Category Archives: Patient Choice

Introduction

 

The  SHA Council agreed to pull together some of the existing policies on prevention and public health, introduce new proposals that have been identified and put them into a policy framework to influence socialist thinking, Labour Party (LP) manifestoes and future policy commitments. The SHA is not funded by the industry, charitable foundations or by governments. We are a socialist society which is affiliated to the Labour Party (LP) and we participate in the LP policy process and promote policies which will help build a healthier and fairer society within the UK and globally. An SHA working group was established to draft papers for the Central Council to consider (Annex 1).

 

The group were asked to provide short statements on the rationale for specific policies (the Why?), reference the evidence base and prioritise specific policies (the What?). Prevention and Public Health are wide areas for cross government policy development so we have tried to selectively choose policies that would build a healthier population with greater equity between social groups especially by social class, ethnicity, gender and geographical localities. We have taken health and wellbeing to be a broad concept with acknowledgement that this must include mental wellbeing, reduce health inequalities as well as being in line with the principles of sustainable health for future generations locally and globally.

 

The sections

 

These documents are divided into five sections to allow focus on specific policy areas as follows:

 

  1. Planetary health, global inequalities and sustainable development
  2. Social and the wider determinants of health
  3. Promoting people’s health and wellbeing
  4. Protecting people’s health
  5. Prevention in health and social care

 

The working group have been succinct and not reiterated what is a given in public health policies and current LP policy. So for example we accept that smoking kills and what we will propose are specific policies that we should advocate to further tackle Big Tobacco globally, prevent the recruitment of children to become new young smokers, protect people from environmental smoke and enable smokers to quit. We look to a tobacco free society in the relatively near future. Whether tobacco, the food and drink industry, car manufacturers or the gambling sector we will emphasise the need to regulate advertising, protecting children and young people especially and make healthy choices easier and cheaper through regulations and taxation policies.

 

Wherever appropriate we take a lifecourse approach looking at planned parenthood, maternity and early years all the way through to ageing well. We recognise the importance of place such as the home environment, schools, communities and workplaces and include occupational health and spatial planning in our deliberations.

 

We discuss the NHS and social care sector and draw out specific priorities for prevention and public health delivery within these services. The vast number and repeated contact that people have with these servces provides opportunities to work with populations across the age groups, deliver specific prevention programmes and use the opportunities for contacts by users as well as carers and friends and relatives to cascade health messages and actions.

 

The priorities and next steps

 

In each section we have identified up to ten priorities in that policy area. In order to provide a holistic selection of the overall top ten priorities we have created  a summary box of ten priorities which identify the goals, the means of achieving them and some success measures.

 

This work takes a broad view of prevention and public health. It starts with considering Planetary Health and the climate emergency, global inequalities and the fact that we and future generations live in One World. A central concern for socialists is building a fairer world and societies with greater equity between different social classes, ethnic groups, gender and locality. We appreciate that the determnants of such inequalities lie principally in social conditions, cultural and economic influences. These so called ‘wider determinants and social influences’ need to be addressed if we are to make progress. The sections on the different domains of public health policy and practice sets out a holistic, ecological and socialist approach to promoting health, preventing disease and injury and providing evidence based quality health and social care services for the population.

 

The work focuses on the Why and What but we recognise the need for further work to support the implementation of these priorities once agreed by the SHA Council. Some will be relatively straightforward but others will be innovative and we need to test them for ease of implementation. A new Public Health Act, as has been established in Wales, but for UK wide policies would make future public health legislation and regulation easier.

 

The SHA now needs to advocate for the strategic approach set out here and the specific priorities identified by us within the LP policy process so they become part of the LP manifesto commitments.

 

Dr Tony Jewell (Convener/Editor)

Central Council

July 2019

The complete policy document is available below for downloading.

Public health and Prevention in Health and Social carefinaljuly2019

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Tell us your views

We are the regulator for pharmacists, pharmacy technicians and registered pharmacies in Great Britain. We set standards for pharmacy professionals.

We are consulting on guidance for pharmacist prescribers which sets out the key areas they should consider when prescribing to ensure they provide safe and effective care. Pharmacist prescribers can diagnose conditions and prescribe medicines to patients. They often work in GP practices as well as in other healthcare settings, and can also work as part of an online prescribing service.

 

Read our proposals and tell us your views now

 

We want to understand the impact of these proposals on patients and the public. Help us spread the word by encouraging your members to take part. To help, we have a toolkit of materials which you can download from our website.

We look forward to hearing your feedback.

Best wishes

Mark Voce
Director of Education and Standards

 

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Patients still make enquiries at busiest hours, despite 24/7 online access

· University of Warwick publishes first independent evaluation of one of the main providers of online consultation platforms

· Targeting services at younger patients and those with general administrative enquiries could be most effective

· “In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes.” Says supervising author.

Patients are using online consultations in the same way they would arrange a consultation via traditional means, a new independent evaluation by the University of Warwick reveals.

Despite this, the study identifies several opportunities to tailor online platforms to specific patient requirements and improve their experience.

Primary care researchers from Warwick Medical School have today (26 March) published the first independent evaluation of one of the main providers of online consultation platforms in NHS general practice. Published in the British Journal of General Practice, it provides independently analysed information on the types of patients that are using online triage systems, how and when patients are using this platform, and what they think of it.

Online triage is a system in which patients describe their problems via an online form and subsequently are telephoned by a GP to conduct a telephone consultation or arrange a face-to-face consultation. Practices aim to respond within one hour of receiving the request.

The researchers examined routine information from 5140 patients at nine general practices using the askmyGP platform over a 10 week period. Highest levels of use were between 8 am and 10 am on weekdays (at their highest on Mondays and Tuesdays) and 8 pm and 10 pm at weekends, mirroring the busiest time for patients contacting their practice via telephone.

Supervising author Dr Helen Atherton, from Warwick Medical School, said: “With online platforms there is an assumption that having a 24/7 ability to make contact with a general practice will cater to those who wish to deal with their health problem at a convenient time, often when the practice is shut, and that being online means they will perhaps share different problems than they would over the telephone or face-to-face.

“In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes. This suggests that patients’ consulting behaviour will not be easily changed by introducing online platforms. Therefore practices should be clear as to exactly why they are introducing these online platforms, and what they want to achieve for themselves and their patients in doing so – the expectation may well not meet reality.”

The NHS Long term plan sets out that over the next five years all patients will have the right to online ‘digital’ GP consultations. The main way these are being delivered is via online consultation platforms. The online platforms claim to offer patients greater convenience and better access and to save time and workload for GPs, however there is currently a lack of independent evidence about their impact on patient care and care delivery.

Patient feedback analysed as part of the study showed that many found the askmyGP system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting.

The study found that two thirds of users were female and almost a quarter were aged between 25 and 34, corroborating existing evidence. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list.

The researchers argue that practices should avoid a ‘one size fits all’ approach to implementing online consultations and should tailor them to suit their practice populations and model of access, considering whether it is likely to add value for their patient population.

Dr Atherton adds: “Individual online consultation platforms are uniform in their approach, patients are not. We found that patient satisfaction is context specific – online consultation is not going to be suitable for all patients and with all conditions and that one approach is unlikely to work for everyone.

“Practices could focus on encouraging people to deal with administrative issues using the platform to free up phone lines for other patients. It could be promoted specifically to younger patients, or those who prefer to write about their problems and not to use the telephone. Clear information for patients and a better understanding of their needs is required to capture the potential benefits of this technology.”

· ‘Patient use of an online triage platform; a mixed-methods retrospective exploration in UK primary care’ published in the British Journal of General Practice, DOI: 10.3399/bjgp19X702197

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Chipping Barnet CLP notes that access to contraception is a fundamental human right underpinning equality, impacting on the health, structure and prosperity of both society and families. The 2012 Health and Social Care Act disadvantaged women, separating much of the funding for contraceptive care from the NHS by moving the responsibility for commissioning into Local Authorities, with NHS providers competing for contracts. As a result, the commissioning of contraception is now separate from the commissioning of other aspects of women’s health, including abortion. From both a woman’s and a clinical perspective, this is illogical. Compounding this, the impact of austerity on Local Authorities has led to a reduction in services, reduced access and to a postcode lottery for contraception in England.

Chipping Barnet CLP believes that contraceptive services need to be fully funded and accessible in all areas of the UK, with co-operation replacing competition. It welcomes the commitment of the Shadow Health Department to abolish competitive tendering for these essential services, and to work with clinicians to establish centres of excellence alongside regular accessible clinics to which women have free and easy access to confidential care.

Chipping Barnet CLP calls on the Labour Party to resolve to deliver fully funded contraceptive services in all areas of the UK, setting up a working group whilst still in opposition, composed of experienced clinicians and commissioners, to write a blueprint for delivery which will be implemented within the first year of the Labour Government.

Published by Jean Hardiman Smith with the permission of Sarah Pillai ( Chipping Barnet CLP )

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Nick Bostock reports at GPonline that:

Under-pressure GPs are delivering ‘remarkable outcomes’ on cancer

You can read the complete article here. Nick reports:

GPs ‘can take a lot of credit’ for marked improvements in early cancer diagnosis and reductions in the proportion of cases detected as an emergency, according to a cancer expert.

In the year to March 2018, the proportion of cancer patients who first presented at hospital as an emergency fell to 18.8% – down from 21% in the year to December 2012.

Over roughly the same period, cancers detected at an early stage increased significantly – rising from 46% in 2013 to 52% by mid-2017, according to figures from the National Cancer Intelligence Network (NCIN).

However: GPonline reported earlier this year on research showing that GPs were as good as consultants at making appropriate use of cancer diagnostic tests – and yet pledges to give GPs direct access to four key diagnostic tests – blood tests, chest X-ray, ultrasound and endoscopy – have not been delivered in many areas.

Isn’t it about time that GPs were also given access to the new technology for GP consultations via mobile and Skype? This is currently being ‘rolled out’ by GP at Hand. Here’s a transcript of the R4 Today programme 13 September at 6 mins to 9:00 am (I made this transcript and I believe it’s a fairly accurate job – but any mistakes are mine):

(Int) Interviewer

AP (Ali Parsa, CEO Babylon – parent company that runs GP at Hand)

RV (Dr Richard Vautrey, Chair GP Committee, British Medical Association)

SoS = Secretary of State

 

(Int): So Ali Parsa just explain to us how your App works.

(AP): So, we have a very simple service. So, what it does is allow patients to check their symptoms whenever they want. To make an appointment with a doctor within seconds, to be able to see a doctor within minutes. In fact, I was just checking my App and it says that if I want to see a doctor I can see one at 9 o’clock today, in the next few minutes.

(Int): You mean ‘see’ over the phone?

(AP): Over the phone. And if you want to see somebody physically then, you can go see them that very same day. It is open 24hrs a day, 365 days of the year. And it is available for the same price the National Health Service pays any other GP. What we have done is to solve the problem of accessibility and the continuity of healthcare – using technology and what the SoS and the NHS is doing today is celebrating that and promising it for the whole country.

(Int): And Richard Vautrey, this is something which patients complain about again and again, isn’t it, access to their GP, so is this kind of App the solution?

(RV): We have real concerns, as well as patients do, about the inability of many practices to be able to offer enough appointments and that’s simply because we haven’t had the funding over the last decade to support the expansion of the health service to be able to meet the growing needs of our patients. What General Practices are doing right now is seeing thousands and thousands – if not a million – patients today offering, you know, face-to-face consultations and seeing them in their surgeries, so that’s when patients approach them today. So that’s happening right now. What we haven’t got is the resources to be able to offer some of the IT technologies in every single practice. And the SoS’s commitment to IT is welcome, but we need to see that commitment translated into resources provided to enable every practice to offer this type of consultation.

(Int): But could this kind of technological approach actually help some of the pressure on GPs because people would consult a doctor over the phone rather than going to the surgery.

(AP): Well many practices, if not most practices, already offer telephone consultations. What they haven’t got is the IT kit to be able to offer smart phone consultations, or Skype-phone computer consultations, any many would like to be able to do that, if the technology was provided to them. But the other big difference is that every Practice that is open today will see any and every patient who lives within their area, and we have concerns about the model of which GP Hand has been built, which is primarily about looking at some of the relatively mobile healthy patients and not accepting every single patient who lives within their area.

(AP): I’m afraid Richard that is simply factually not true. We will ask when patients started the service, to ask patients to seek advice if they want to change their GP Practice to our Practice, if they have any clinical issues. Most patients seek advice and join us – we look after them, young, old, sick, healthy, our patients are across the border, and we don’t do that just in Britain, remember we look after one third of the population in Rwanda, and we do so in the United States, we do this in Canada. . .

(Int): But specifically, on this idea of whether you cherry pick patients, it’s likely that patients who don’t have very serious health problems, and maybe younger, are more likely to want to use an App on their mobile.

(AP) . . . but, why is that? If the patient is not very mobile, if the patient is very old, if the patient can’t wait a few weeks to see their GP, they’re significantly more likely to use a service that is continuously available. Many of our patients have mental health issues – they can’t wait for a few days or a few weeks to see their GP. That’s why they switch to us. A thousand patients today will choose to apply to GP at Hand, and then switch their GP Practice – one every three minutes.

(Int): Richard Vautrey, some GP Practices are worried about the fact that if their patients sign up to GP at Hand they then lose that funding, don’t they?

(RV): That’s exactly right. And the way that General Practice is funded at the moment is a balanced mechanism, so those patients who use the service less, and there are many patients that use the service more, and that overall, that compensates one for another. What we have concerns about is that this would effectively replace a personal service with an anonymous call centre and patients don’t want that.

(Int): And finally, Ali Parsa, this was something that commissioning groups in Birmingham were worried about and that was clinical safety – isn’t it better to see a doctor the next day.

(AP): No, it wasn’t clinical safety, you do see a doctor, not a call centre, face-to-face on your mobile and then see one in one of our surgeries. We will open up across the country physical surgeries, their issue was not that. It was an IT hitch that doesn’t allow its screening to be done with your local hospital and that IT hitch has been fixed. This is the future, and I encourage more and more patients to join it.

(Int): Okay thank you both, we’ll leave it there, let us know what your think via twitter.

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Dear chums

As you may have heard the Wirral Clinical Commissioning Group (CCG) has announced that it wants to close five local NHS clinics because Wirral residents “were confused about where to get help with urgent care”. The CCG, which is the local arm of NHS England, says it wants to “move care closer to home”.

Are YOU confused? Will YOUR care be closer to home if they close centres which are used by THOUSANDS of Wirral residents every week of the year?

Eastham Clinic; Victoria Central, Wallasey; Miriam Medical Centre, Birkenhead; Parkfield Medical Centre, New Ferry; Moreton Medical Centre

All these are due to close. Will a proposed ‘urgent treatment centre’ at Arrowe Park be closer to YOUR home?

You can find a petition from Defend Our NHS here:

https://www.change.org/p/defend-our-nhs-save-our-wirral-walk-in-centres?

Please sign and share with friends.

Thanks

Kevin

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For everyone who couldn’t make the Conference, here is Alison Scouller’s ( Vice Chair ) speech. An audio file is also posted.

Jean Hardiman Smith

Hello Alison Scouller here, sorry I can’t be with you. These are my thoughts to accompany the SHA discussion document before you. We decided to write this policy as part of our wider policy work, as we had no statement of the SHA’s perspective on maternity care.
I’m a retired midwife who worked in hospital, community and latterly as a midwifery lecturer in South Wales. To devise a policy I took inspiration from the Save Liverpool Women’s Hospital campaign’s manifesto for maternity and worked initially with two Welsh members, Billie Hunter, Professor of Midwifery and Gill Boden who is a campaigner for AIMS, and another Midwifery Professor Mavis Kirkham from Sheffield as well as liaising with our secretary Jean Hardiman Smith. Since then we have revised the policy considerably, following suggestions and contributions from Central Council members.
We have taken on board the particular concerns of the Liverpool campaigners in the context of the creeping privatization of the English NHS, but in writing this policy we had to have a policy which is applicable across the UK. Therefore the first paragraph sets this out. .
We decided that the right to access contraception and abortion that should form part of another document about reproductive rights, including fertility treatment, and that here we should focus on care for pregnancy.
As you can see in point 1) we put the importance of addressing poverty centre stage, and the overarching importance of good nutrition from pre to post pregnancy, in fact throughout everyone’s life! We decided not to be too specific on particular public health measures, as our policy has to be applicable in different versions of the NHS and the wider context. We also included the issue of other forms of stress and their detrimental effect on pregnancy outcomes, both in terms of women and babies.
The next 2 points emphasize the importance of those at the centre of maternity care needing to be listened to, whether it’s about their own individual situation or in terms of general observations about how care should be. Planning for care should of course reflect diversity in all communities. In order to address inequalities in society, whilst all should receive the same level of care, extra provision should be there for some, as was recognized by previous Labour Governments in projects such as Sure Start.
We went on to identify issues related to specific stages in pregnancy itself, having covered the pre pregnancy period. In point 6) Antenatal care is clearly crucial to ensure that women are aware of as many aspects of their health as possible, such as family history, normal physiological changes of pregnancy, Body Mass Index , any pathological conditions already present or precipitated by pregnancy, and how these may impact on their pregnancy outcomes. It needs to be accessible as early in pregnancy as needed. It should be as local to women as possible and include at least one home visit, unless the woman does not wish for this, with her named midwife.
When we talk about antenatal education this does not mean in a formal, school type environment but can range from physically meeting in a group setting with a midwife to having education available on CDs, online and via social media. It’s not just about being given information for example about how labour may progress but also learning practical skills to cope with it, such as exercise and relaxation. It’s also about what happens after the birth and coping strategies for parents. The social and support aspects of women and family members meeting with others going through a similar experience are usually the most valued by those enjoying group education. Of course specific needs have to be catered for, so that some women may prefer to attend women only groups and prefer less formal settings.
The evidence for the effects of adverse childhood experiences on people’s ability to be good parents is now quite compelling, hence point 7)
In relation to point 8) We know from research and experience that women’s wishes in relation to place of birth are determined by many factors, and these are very varied. Health care professionals must strive to provide as much evidence based information to enable women and their families to make the right choices for them. All places of birth carry some risks, with home birth and stand alone birth centres there are always concerns about access to ‘back up’ in emergencies. On the other hand there are risks associated with unnecessary intervention (mistimed, inappropriate and even dangerous) in childbirth, both in terms of mortality but also morbidity of mothers and babies I think Lesley page coined the phrase ‘too much too soon, too little too late’ to summarise the problems unfortunately still occurring. The other thing to bear in mind is the importance of antenatal care and education in ensuring safe outcomes. If that care is as it should be, then women at risk of complications are less likely to have poor outcomes because care will have been tailored to mitigate those complications.
Moving on to point 9) we identify the importance of continuity of care. This can be difficult to achieve in cash strapped services but has been consistently shown in research and other feedback to be a key concern for women and promotes positive outcomes.
Finally we put in relation to after birth, points 10) and 11). Physical, emotional and mental health are equally important here. Increasing breastfeeding rates would make a huge difference to children’s health, yet initiation and continuation of breastfeeding rates in the UK remain low. Once again peer support has been shown to be critical to breastfeeding success, as well as support from midwives and health visitors.
In the past, care of women’s mental health has lacked coordination between midwives, health visitors, GPs and community mental health nurses. Equally where babies have been compromised by maternal complications before or during birth and/or being born preterm then neonatal special and intensive care cots should to be available as needed.

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For everyone who couldn’t make the Conference, here is Jessica’s speech to our Fringe meeting on the future of Women’s health that I referred to earlier in a members email.

Jean Hardiman Smith

 

Thank you for inviting me to speak to you today. My name is Jessica Ormerod. I run a research and information organisation called Public Matters with my lovely friend and colleague Deborah Harrington.
Although we write about all aspects of the NHS and other public services, I have a particular interest in maternity. I have been writing about maternity issues for seven years since I was the chair of the maternity services liaison committee for Lewisham Hospital which coincided with our fight to save our maternity services. We won that fight but we have by no means won the war because as you know maternity services up and down the country are being closed and downgraded.
But before anything else I want to paint the picture of what is happening to the NHS as a whole. Because every closed maternity ward, service or reduction in staff is the direct result of changes to the NHS that have been happening since the 2012 Health and Social Care Act. These changes are having a devastating impact on access to care. It is no exaggeration to say that we are witnessing the reversal of 70 years of universal, comprehensive and equitable care.
The 2012 Health and Social Care Act put into place all the major elements for a step change in the privatisation of the NHS.

A QUANGO called NHS England was formed as the Commissioner-in-Chief of the service, with over 200 subordinate local commissioning units. These commissioning units broke with the tradition of planning services, replacing it with buying in from public, private and voluntary sector providers. Areas of work are subdivided into contractable units and NHS public providers are obliged to compete. The loss of a contract means loss of income, which has a knock-on effect on the viability of the public sector, which is left with high cost acute care and a reduced income.

In 2014 a new CEO was appointed to run the NHS in England. He created a new plan for the NHS, the Five Year Forward View and this was greeted by the establishment as a welcome antidote to what was seen as the fragmented mess left by the 2012 Act (this was only a mere 18 months on from it being enacted). But it’s important to recognize that far from being an accident, the Act achieved the fragmentation necessary for privatisation to be embedded at an organisational level, including many major health industry players taking key roles in the commissioning and policy-making process.

At the heart of NHS England’s Five Year Forward View is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care are relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services.

We could say the scope of this aspiration is far reaching or we could say it is pie in the sky. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service with much of the change becoming the responsibility of local authorities.

The process of transforming the NHS in England, is based on close co-operation between successive politicians and Department of Health managers over many years with the US Health Maintenance Organisation or Accountable Care Organization principles of managed care. This process is continuing without any checks and balances of substance within the formal organisational structures of government. Politicians go to great lengths to deny both privatisation and US influence on the current changes.

There is, however, a groundswell of resistance to the damage being done to the NHS and there is a lot of knowledge surrounding individual service contractions and closures, but little in the public domain about the overall programme of change. And that is what I am here to talk about today.

The National Maternity Review, aka Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.
44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems. Unlike the Integrated Care Organisations which are now under consultation, they have been put into place with very little fanfare or institutional opposition.
As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England consistently refers to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.
In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.
But what makes maternity different from other services?
Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.
Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.
Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP. They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.
Currently women can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ – that’s a midwife-run facility on hospital grounds, or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services which is blood, air and surgeons. A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.
Put this into the context that since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.
Who is driving the changes to maternity?
Surprise, surprise, Better Births panel includes private health providers and those private companies are working with government to re-write policy.
Although most current providers are NHS hospitals, private providers are now being strongly encouraged. Local Maternity Systems set their own payment systems. This means that they can choose whether they pay via their geographical population or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.
NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations – I don’t need tell you about this because you’re part of it! The sites were told to be bold and radical. Another incentive is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site.
LMSs are encouraged to work alongside private providers in order to offer women a wider choice. As most women have previously been cared for by the NHS this simply means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this does actually reduce the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.
Better Births tells us it is working on a new accreditation scheme for maternity providers. But in a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard.
Private providers are required to have a contract with the NHS in order to receive payment via a Personal Care Budget. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will apparently encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. But it is decidedly unclear about how this can be achieved. The guidance talks about using Personal Care Budgets for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.
Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.
What does this all mean?
Scale and pace have taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of this new policy.
This is a top-down reorganisation of a national service with little to no consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.
The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction!
Clearly long gone are the years of epidemiological study, of public health planning, of consultation with experts.
Better Births is based on consumer choice issues around personalised maternity care. There is a serious lack of evidence that this restructuring will give women the vital services they need. There are fewer services, obstetric departments are being stretched even further and technology is replacing face-to-face clinical care.

On the other hand, it embeds private care and fee-for-service. And, most importantly of all this is not how a national public service works.

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Update 2/5/17: If you are concerned about GP records, see this post


In matters of health and care, your relationship with your doctor is based on a very human spirit of confidentiality. Not the cold law of data protection.

Any large, formal system is bound to breach the Hippocratic Oath; “First, do no harm”. Data doesn’t care. In a purely digital world, a thing either is or it isn’t – with no nuance. Smaller systems, talking to each other, offer more discretion for the humanity of your situation. It is  why fax machines still work better than e-mail for the NHS.

Patients routinely find themselves in one of the following three real-world scenarios. Human situations get ignored by the database designers’ visions, forgetting the real world::

  • When a doctor cannot tell their patient the full story without causing distress – such as when at test returns a  likely false positive result.
  • When a doctor cannot tell another doctor something – such as where  they’ve been asked not to by their patient.
  • When institutions cannot tell doctors relevant details – e.g. in situations where there is “too much data, but no clear information”.

When you are between diagnosis and treatment, which (if any) of these three apply may change hour-to-hour. Human choices are a reality, usually ignored by by those who want to copy records across a lifetime.

medConfidential defends the confidentiality you desire for your medical records.

Why is Confidentiality more than Data Protection?

“Data Protection” was a 1980s response to the advent of new computers and the copying of data. Transparency was the balance intended to ensure that processing is “fair”. When copying was limited to “faster photocopiers”, organisational boundaries were maintained, and confidentiality questions rarely engaged.

Modern communications has created the capacity to copy medical records at a scale that shatters confidentiality.

Confidentiality, and trustworthiness, is based on patients’ expectations of boundaries. And so, as data subjects, any processing that breaches duties of confidence cannot be considered Fair – so cannot be lawful.

medConfidential defends the confidentiality you desire for your medical records.

If you do have concerns, it is still safest to opt out now to exclude your data. You can always opt in later. For more information on what you can do, please visit our How to opt out page.

We also take donations.

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David Cameron notoriously claimed at the April 2014  Welsh Tory Spring Conference that Offa’s Dyke had become “the line between life and death” due to the performance of the Welsh NHS. However fortunately for the truth and honest debate, almost to the day the Nuffield Trust published its comparative study “The four health systems of the United Kingdom; how do they compare?”. It reported :- However, this latest study ….. reveals that while there are few indicators on which a devolved country does better than England or its North East region, the performance gap between England and the rest of the UK has narrowed in recent years. There is little sign that one country is moving ahead of the others consistently across the available indicators of performance.

Despite being  being caught out, the Prime Minister continued to misrepresent the state of the NHS in Wales. By October 2014, when challenged about the state of the English NHS, he demanded that “ …Let’s have an OECD inquiry … I want a comparison between the Labour NHS in Wales (and England)..” He went on to say that Labour was “ ..totally terrified of (its) .. failures in Wales on the NHS.” Indeed Monmouth Tory MP, David Davies, went so far as to suggest that the Welsh Government was doing everything it could to delay the production of such a report.

However despite all this rhetoric the report, “OECD Reviews of Health Care Quality: United Kingdom 2016”, was published in February 2016. And it concluded that from the limited country specific data available “… no consistent picture emerges of one of the United Kingdom’s four health systems performing better than the other.” In short, again, there was no evidence to support Cameron’s claims about the relative performance of the Welsh NHS.

The line between fact and fiction.
In his response to the publication of the review the Welsh Health Minister, Prof Mark Drakeford said “This report is the line between fact and fiction. Any claims of one nation having a second-rate NHS compared to others simply do not reflect the facts. The time has come for a real, mature debate about the future of our health services.” Can we expect Mr Cameron please take note?

While the OECD showed that each administration needs to improve its performance, in relation to Wales it concludes that continuously improving quality of care is deeply established and widely shared across the Welsh health system. And where things are not going well, the Review felt that the Welsh Government’s “Escalation and Integration Framework” was a robust tool for quality assurance and intervention.

These are important messages as for most of the last half decade Welsh Tories have been arguing for a total “Keogh style” review of the NHS in Wales with the implication that the NHS in Wales is in some sort of systemic melt-down similar to the situation in Mid Staffordshire NHS Foundation Trust. The OECD review shows no evidence to support this denigration of the Welsh health service.

How the planning system is working.
In stating that all of the UK shows an improving picture, there are still a number of areas where the NHS does need to do better. This applies in different measure across all of the four administrations not least in Wales.

The OECD Review reports that Wales no longer operates an internal market but uses a “planned” system underpinned by the principles of “prudent health care”. While the prudent health care principles give an important sense of direction to the Welsh NHS, the under-performance of health boards linked to an imbalance in favour of local autonomy means that there is room for improvement in planning health care delivery.

A greater sense of national purpose is needed which could be achieved by butressing the prudent health care approach with a clear action plan and by strengthening the use of the three year Integrated Medium Term Plans (IMPT).

Inequalities and primary care.
Welsh Health Boards are still adjusting and learning about their new planning role. The Review believes there is a need to give an increased emphasis to primary care as part of a wider agenda of tacking health inequalities. Both these areas have been judged to suffer from relative neglect under the new “planing” regime. This could be a consequence of the relatively weak role that the primary care sector and patients have in the planning system e.g. there are no GPs on the Health Boards by right.

Developing the role of primary care clusters (PCCs), covering populations of 50-250,000, could have a significant potential in this regard. And the latest investment by the Welsh Government in PCCs is an important step forward. The clusters will provide opportunities to broaden the range of services and expertise that patients may access in a primary care setting. In addition the clusters provide a workable population base for more sensitive health care planning where the local expertise of front-line clinicians can be usefully captured by the planning system.

Patient power.
The OECD seems to take the somewhat ideological view that the lack of a market in health care in Wales  diminishes patient choice and influence compared to English. However, in making this point, it is acceptes that the geography and demography of Wales does not allow for a ready translation of the English experience.

Faced with this lack of “patient power” it recommends a strengthening of patients’ voices. More effort should be spent on capturing the patient experience. While coming at it from a different perspective, this is in line with the SHA Cymru view that we should “ use the visible hand of public accountability to improve standards rather than rely on the invisible hand of the market”.

Wales has retained its Community Health Councils as the patients’ voice within the NHS. It has been through a number of changes to improve its effectiveness down the years thought it is still debatable that they are fully fit for purpose. The Review recognises the need for CHCs to be more effective in the way they hold the service to account and articulate the views of patients. In improving its focus on these tasks there is a question as to whether CHCs add any value to NHS quality by continuing with their on-site inspection activities.

Collaboration rather than abusive rhetoric.
The four health administrations are doing things differently across the UK. New and innovative ways of doing things are being developed. The OECD acknowledges that this diversity provides an important learning opportunity that is being neglected by all four administrations. In part the lack of an agreed set of performance parameters and a lack of professional and political will is preventing this from happening.

Rather than using these differences as a cynical party political ploy, as the Tories have been doing, this form of engagement and collaboration seems a better way for the the National Health Service across the UK.

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you choose

Perfect markets need choice. If providers collude in pricing, say because they aren’t that many of them, the consumer doesn’t get a choice, and often has to pay through the teeth to obtain the product.

For products which are the same, for example a biological detergent, the choice comes from variation in ‘adding value’ such as perfume.

A similar argument holds for paying to have your hernia done. The actual service of the actual operation is effectively the same due to constraints posed by the functional anatomy of the human body. But would you like fries with that?

In the paperwork which surrounded the Health and Social Care Act (2012), there was the proposal that choice would lead to lead to improved quality in the healthcare market.

Healthcare is not a market for a number of reasons.

Prof Michael Sandel from Harvard has framed the complicated issues in a number of ways.

In the Guardian, Decca Aitkenhead writes:

“According to the logic of the market, the matter of whether these transactions are right or wrong is literally meaningless. They simply represent efficient arrangements, incentivising desirable behaviour and “improving social utility by making underpriced goods available to those most willing to pay for them”. To Sandel, however, the two important questions we should be asking in every instance are: Is it fair to buy and sell this activity or product? And does doing so degrade it? Almost invariably, his answers are no, and yes.”

The evidence that competition in markets to do with the provision of healthcare drives up competition is weak. This was finally conceded by the previous CEO of NHS England – but there’s a change of hands at the helm in Simon Stevens, appointed by a Conservative-led government.

That choice is so pervasive in neoliberal health policy is exemplified at the lengths to which people dismiss lack of choice.

To advocate for choice at this precise moment would be utterly surreal, given for choice to operate the system needs reserve capacity. This is clearly not the case if the NHS England masterminds seek £20 billion austerity cuts.

For example, if recent allegations – that the NHS received a shortfall of £8bn in funding for the NHS thus mandating it to make three times the volume of ‘efficiency savings’ it otherwise would have had to have made – are true, can it sensibly argued that austerity brings improved choice?

It is hard to argue against the notion that poverty brings about decreased choice. Likewise, if you run out of money in your personal budget, in effect rationing at the n = 1 level, you will find it difficult to argue that your choice has improved.

Similarly, if against the wishes of many CEOs of NHS Foundation Trusts, a cheerleader for the Government imposes a contract on junior doctors, against which 98% of junior doctors have been balloted to reject, can that really be choice?

The imposition of the junior doctors’ contract is as desperate of course as the imposition of Academy status on schools. There is no evidence that this forced conversion drives up quality.

Try another one – try being locked into repayment of a PFI loan for 30 years, a type of ‘corporate wonga’, where your repayments are at eyewatering unconscionable interest rates. Who benefits from this ‘choice’ apart from the PFI money lenders?

Rather, there is quite a lot of evidence that previous UK governments have encouraged the conversion of a well funded national system over decades into a fragmented cesspit of autonomous units, increasingly being sold a pup by the private sector, with worsening performance despite staff working their butt off.

Parents can’t get their children into schools nearby; and the class sizes are ginormous. And your local A&E is shut down as the current Government says it’s ‘unsustainable’ – i.e. does not wish to afford it.

This is not choice, but an ultimate problem in the exercise of choice is that the ‘choice’ of government we have currently was done by a small proportion of the electorate. As ever then, the resultant choice is illusory, as different newsreaders take it in turns to read the script from their corporate masters.

 

 

@dr_shibley

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I went to an LCC event on resilience. The Council are encouraging people to create Resilience Plans for emergency situations like when it snows and no-one can get in and out of your street for days on end.

Makes sense. We talked in groups about who is most vulnerable in these situations. Naturally I thought about the frail, multi-morbid elderly living alone. What happens if the District Nurse you rely on for your insulin injection can’t get to you? Or if the carer who gets you up and toilets you can’t get through the snow?

I did ask if the County Council were working with Health to ensure that Resilience Planning is part of Advanced Care Planning. Of course they are. Strategically….

But without any kind of integrated record keeping of course.

The Council know, apparently, who is vulnerable in our community (….do I believe them?) but can’t share that information with community leaders until there is a crisis.

Why-o-why-o-why….

…couldn’t a persons Resilience Plan be part of their medical Advanced Care Plan and be attached to a shareable health and social care record?

Look at what they are doing in Ireland using the e-portal “Patients Know Best”.

Answer:-
Too many egos, too many silos and too many managers creating pretty websites and complex information sharing protocols that protect health and social data from the one person who has a right to share it:
You.

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