Category Archives: Economics of healthcare

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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Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’

 

Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.

 

Reduction in prevention, cytology and mental health services

Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.

 

STI screening and HIV testing

More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.

 

PrEP availability and reproductive health

The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.

 

Impact of separation of HIV and GUM on staff and services

Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.

 

Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”

ENDS

Editor’s notes:

  1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
  2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
  3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or simon.whalley@mandfhealth.com or Jo Josh, BHIVA, on 07787 530 922 or jo@commsbiz.com.

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Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

 

A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

 

We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

And here is Health Campaigns Together on the subject at this link.

As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

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 Court of Appeal grants NHS campaign group permission to appeal against NHS England’s new Integrated Care Provider contract

Some very good news – which also means NHS England is consulting on an ACO contract that may be unlawful.

They knew full well that was a possibility, despite their protestations in the consultation document that both Judicial Reviews had ruled in their favour.

(They have rebranded the ACO contract the Integrated Care Provider contract and their consultation runs until 26 Oct.)

We shall be putting out more info shortly about this.

 

The Court of Appeal has issued an order granting campaign group 999 Call for the NHS permission to appeal the ruling against their Judicial Review of the proposed payment mechanism in NHS England’s Accountable Care Organisation contract.

The Accountable Care Organisation Contract (now rebranded by NHS England as the Integrated Care Provider contract) proposes that healthcare providers are not paid per treatment, but by a ‘Whole Population Annual Payment’, which is a set amount for the provision of named services during a defined period. This, 999 Call for the NHS argues, unlawfully shifts the risk of there being an underestimate of patient numbers from the commissioner to the provider, and endangers service standards.

In April, the High Court ruled against the campaign group’s legal challenge to NHS England’s Accountable Care Organisation contract – but the group and their solicitors at Leigh Day and barristers at Landmark Chambers found the ruling so flawed that they immediately applied for permission to appeal.

Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the Accountable Care Organisation contract – now renamed the Integrated Provider Organisation contract.

The consultation document asserts that the payment mechanism in the ACO/ICP contract is lawful, because:

“The High Court has now decided the two judicial reviews in NHS England’s favour.”

Steve Carne, speaking for 999 Call for the NHS, said

“It beggars belief that NHS England is consulting on a contract that may not even be lawful.

And a lot of public funds is being spent on developing the ACO model – including on the public consultation.

We are very pleased that 3 judges from the Court of Appeal will have time to consider the issues properly.

We shall shortly issue our stage 5 Crowd Justice appeal for £18k to cover the costs of the Appeal.

We are so grateful to all the campaigners and members of the public who have made it possible for us to challenge the lawfulness of NHS England’s attempt to shoehorn the NHS into an imitation of the USA’s Medicare/Medicaid system.

We will not see our NHS reduced to limited state-funded health care for people who can’t afford private health insurance.”

Jo Land, one of the original Darlo Mums when 999 Call for the NHS led the People’s March for the NHS from Jarrow to London, added,

“All along we have been warning about the shrinkage of the NHS into a service that betrays the core principle of #NHS4All – a health service that provides the full range of appropriate health care to everyone with a clinical need for it, free at the point of use.

Since we first started work two years ago on bringing this judicial review, there have been more and more examples of restrictions and denials of NHS care, and the consequent growth of a two tier system – private for those who can afford it, and an increasingly limited NHS for the rest of us.”

Jenny Shepherd said

“NHS England’s rebranded Accountable Care Organisation contract consultation is a specious attempt to meet the requirement to consult on a significant change to NHS and social care services.

We don’t support the marketisation of the NHS that created the purchaser/provider split and requires contracts for the purchase and provision of services.

Integration of NHS and social care services, in order to provide a more straightforward process for patients with multiple ailments, is not aided by a system that essentially continues NHS fragmentation.

This new proposed contract is a complex lead provider contract that creates confusion over the respective roles of commissioner and provider. It requires multiple subcontracts that are likely to need constant wasteful renegotiation and change over the duration of the lead provider contract. This is just another form of fragmentation, waste and dysfunctionality.

The way to integrate the NHS and social care is through legislation to abolish the purchaser/provider split and contracting; put social care on the same footing as the NHS as a fully publicly funded and provided service that is free at the point of use; and remove the market and non-NHS bodies from the NHS.

Such legislation already exists in the shape of the NHS Reinstatement Bill.”

The campaign team say they are determined in renewing the fight to stop and reverse Accountable Care. Whether rebranded as Integrated Care or not, they see evidence that it is the same attempt to shoehorn the NHS into a limited role in a two tier healthcare system that feeds the interests of profiteering private companies.

Steven Carne emphasised,

“It is vital that we defend the core NHS principle of providing the full range of appropriate treatments to everyone with a clinical need for them.”

999 Call for the NHS hope the 2 day appeal in London will happen before the end of the year. The Appeal will consider all seven grounds laid out in the campaign group’s application – with capped costs.

Details on the first instance judgment can be found here, and the judgment itself here.
David Lock QC and Leon Glenister represent 999 Call for the NHS, instructed by Rowan Smith and Anna Dews at Leigh Day.

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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Deborah Harrington’s interesting posting on “The Myths and Legends of Hypothecated National Insurance” (March 29 2018) in particularly relevant in the light of media speculation about hypothecated taxes or National Insurance contributions to pay for health or social care.

In Wales there is a further variation on this general theme with Professor Gerry Holtham (Dept. of Regional Economics at Cardiff Metropolitan University ) proposing the establishment a social care levy for Wales. (See link below)

The levy, based on weekly payments between £1.75 and £7, would differ from a tax in that the receipts would not go into a general government budget but rather into a separate social care fund with its own independent trustees. “A portion of ..(the fund) receipts would go to local authorities to expand social care provision straight away. The greater part of the receipts would be held back for future needs and meanwhile invested to grow over time and enable even greater social provision to be made in the future as the population ages.”

And following the National Assembly for Wales having secured its own tax raising powers at the beginning of October 2017 the Welsh Government Finance Secretary, Mark Drakeford, signaled that a levy to support social care was one of the new tax ideas he was considering.

Solving Social Care. And more besides

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A new, independent and broad-based citizens’ initiative – the People’s Plan – was launched in Greater Manchester last October and has now published its findings.  This extract covers health and care  – but other parts of the plan would also impact on health. 

People's plan

Since 2016 Greater Manchester has responsibilities for managing and integrating hitherto separate, centrally funded NHS services and local authority adult care services. Both services are in crisis: in adult care, austerity budget cuts have reduced numbers receiving home care by some 20% nationally; and in health services, the halving of the number of hospital beds over the past thirty years has created a fragile system that suffers with demand peaks or delayed discharges. The National Audit Office has questioned whether integration of health and care will save money or reduce hospital admissions; and this finding is ominous when Greater Manchester has a predicted £2 billion shortfall in health and care expenditure within five years. Against this background, it is unclear how Greater Manchester will find the policy levers, financial resources and political will to tackle prevention of ill health and low life expectancy in deprived localities.

Challenge 1:How to lever in more financial resources for health and care services, where social ownership and operation of free services should be defended

Event participants recognised that “services cannot be run without proper funding” and the first priority of survey respondents is levering in more public funding. In health, as in housing, what citizens want is public provision that depends on reversing austerity cuts. By implication, the Greater Manchester mayor and other Greater Manchester politicians need to change central priorities as much as manage local services; as a Bury event participant put it: “make it the Mayor’s job to fight for more money for local services”.

The other clear theme is that public funding should support socially owned and operated services. While voluntary and other third-sector providers are often complimented, references to private providers in health and care are mostly negative: “Resist the influence of the private sector, because it takes money out of the system”; other respondents had concerns for poor pay and conditions in outsourced adult care.

Pointers on what to do:

  • Lever in more public funding.

83% of all survey respondents agreed that ‘Greater Manchester should urgently seek a better funded deal for health and social care’ – with just 2% opposed. Here again, as in other policy areas, like housing, what respondents want the Greater Manchester mayor and other Greater Manchester politicians to do is not just manage the system within existing funding limits but claim more resources. For example, investment in training for ongoing supply of nurses in Greater Manchester services is an area where consequences of cuts to bursaries are a serious concern.

  • Use public funds to support not-for-profit and publicly owned and operated services.

Survey respondents and event participants were against further outsourcing or privatisation. Health and care services need new ‘step down’ facilities for discharged hospital patients who cannot go back to their own homes and do not have a care home bed; but 67% of all survey respondents believed such facilities should be built and operated by NHS providers and 74% also supported provision by other not-for-profit providers, with only 10% supporting private for-profit providers.

People's Plan

Challenge 2: Build a new kind of NHS as a civic institution which offers a wide range of stakeholders more participation in decision-making as well as providing more user-friendly services

Citizen attachment to the NHS is not all sentimental and uncritical. Ministers and managers have sought to restructure health and care services so that they meet user demands more effectively, but citizen critics go further and ask for a redefinition of the NHS as a new kind of civic institution where a wide range of local stakeholders would have a major influence over decision-making.

At a café-style event conversation about ‘Devo Manc’, participants posed a challenge to “find ways to put health and social care close to communities”. There is widespread dissatisfaction with current forms of consultation that are too often about changes already decided by service managers.

Pointers on what to do:

  • Experiment with direct public participation in decision-making.

65% of all survey respondents wanted direct participation by the public for proposed changes, through means such as online polling, for example, whose results could not be easily ignored.

  • Create an advisory board representing wider interests.

More traditional forms of representative democracy have even wider support. 77% of all survey respondents wanted a wider advisory board representing different stakeholders including voluntary and community organisations as well as provider groups. For example, representation for those with learning disabilities and their many challenges was strongly featured in the Health and Care themed event.

  • Provide more user-friendly services on a local community basis.

This is the point where citizen priorities align with those of politicians and service managers. At a Greater Manchester Older People’s Network event and in surveys, the GP and hospital appointments systems were described as “barriers” to access, with specific criticism about the availability of “on the day” appointments; and at a Wythenshawe event the complaint was that “public transport never lines up properly with health services”

Challenge 3: How to put more resources into prevention and into the inadequately funded ‘Cinderella’ services of mental health and adult care, which have now been damaged by austerity cuts

Many of the open survey responses and comments of event participants highlighted the problem of ‘Cinderella’ services. Some event participants thought hospitals were claiming resources that should have gone to prevention, primary and community provision; all agreed with the survey respondent who wanted “greater emphasis on prevention not cure” and worried about how austerity cuts in mental health and adult care had aggravated long standing problems about service provision. The result is pervasive insecurity about service availability, crystallised by the question at one Tameside event: ”will it be there when you or your family members need it?”.

Pointers on what to do

  • Stop cuts to mental health services and increase funding.

This connects with prevention because, as one survey respondent argued, with more funding for primary care, GPs should be able to prescribe more one-on-one counselling and for more than six weeks.

  • Revalue the workforce in adult care.

Some open responses registered the point that care workers are paid and trained worse than health service workers, although they had an increasingly important role in an ageing society. As one respondent argued: ”properly trained care assistants would help people to stay at home”.

David was  one of the people involved in contributing/drafting/editing/finalising the plan, but he is not the sole author

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The House of Lords Select Committee on the Long-term Sustainability of the NHS has slammed the ‘short-sightedness’ of successive governments for failing to plan effectively for the long-term future of the health service and adult social care.

The long-term future of the NHS is an increasing public concern, with a record 55% of people saying they expected the NHS to deteriorate over the longer term.

The Committee makes it clear that a tax-funded, free-at-the-point-of-use NHS is the most efficient way of delivering health care and should remain in place now and in the future. For that principle to remain, however, many aspects of the way the NHS delivers healthcare will have to change. 

The Committee concludes that “a culture of short-termism” seems to prevail in the NHS and adult social care and that the Department of Health has been unwilling or unable to look beyond the next few years. It recommends that a new, independent Office for Health and Care Sustainability should be established to look at health and care needs for the next 15-20 years and report to Parliament on the impact of changing demographic needs, the workforce and skills mix in the NHS and the stability of health and social care funding relative to demand. A political consensus on the future of the health and care system is “not only desirable, it is achievable” according to the Committee and they call on the Government to initiate cross-party talks and a meaningful \”national conversation.”

The Committee says that in the past funding has been “too volatile and poorly co-ordinated between health and social care.” This has resulted in poor value for money and resources being allocated in ways which don’t meet patient needs. In the future health funding will need to increase at least in line with growth in GDP, and NHS financial settlements should be agreed for an entire Parliament to enable effective planning.

Pressures in social care now pose a significant threat to the stability of the NHS so the Government needs to embark on a far more ambitious three-year programme to stabilise publicly-funded social care. The Committee asserts that, beyond 2020, a key principle of the long-term settlement for social care should be that funding increases reflect changing need and are, “as a minimum, aligned with the rate of increase for NHS funding.”

The report says that the failure to implement a comprehensive long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need is, the “biggest internal threat to the sustainability of the NHS.” The report highlights the problems of over-burdensome regulation, unnecessary bureaucracy, a prolonged period of pay restraint, low levels of morale and retention problems.

The Committee points out that service transformation is at “the heart of securing the long-term future of the health and care systems.” They argue that the model of primary care will need to change, secondary care will need to be reshaped and specialised services consolidated further. A renewed drive to realise integrated health and social care is badly needed. 

The Committee makes 34 recommendations for change including: 

·    The health and social care systems are interdependent but poorly-coordinated. To allow money and resources to be used more effectively the budgetary responsibility for adult social care at a national level should be transferred to a new Department of Health and Care.

·    The traditional small business model of GP services is no longer fit for purpose. NHS England should engage with GPs to examine alternative models including direct employment

·    Policy is now increasingly focused on integrated, placed-based care and so NHS England and NHS improvement should be merged to create a new body with simplified regulatory functions and strong local government representation.

·    There is an indisputable link between a prolonged period of pay restraint, over-burdensome regulation and unnecessary bureaucracy and low levels of morale and workforce retention. The Government should commission an independent review to examine the impact of pay on morale and retention of health and care staff.

·    There is a worrying lack of a credible strategy to encourage uptake of technology and innovation in the NHS. The Government should do more to incentivise the take-up of new approaches and make clear that there will be funding and service delivery consequences for those who repeatedly fail to engage.

·    Cuts to funding for the public health budget are short-sighted and counter-productive. National and local public health budgets should be ring-fenced for at least the next ten years. We also need a new nationwide campaign to highlight the dangers of obesity.

·    The Government should be clear with the public that access to the NHS involves patient responsibilities as well as patient rights. The NHS Constitution should be redrafted to emphasise this.

Commenting, Lord Patel, Chairman of the Committee, cross bench peer and eminent obstetrician said: 

“The Department of Health at both the political and official level is failing to think beyond the next few years. There is a shocking lack of long-term strategic planning in the NHS. This short sightedness stems from the political importance of the NHS and the temptation for politicians to reach for short-term fixes not long-term solutions.

“To solve this we need a new body that is independent of government and is able to identify clearly the healthcare needs of a changing and ageing population and the staffing and funding the NHS will require to meet those needs. This new Office for Health and Care Sustainability should be a trusted, independent voice as the Office for Budget Responsibility has become on economic forecasting and on public finance matters. It will need to look ahead and plan for 15-20 years into the future.

“We also need to recognise the NHS will need more money. NHS spending will need to rise at least as fast as GDP for 10 years after 2020. One area where more spending will be required is on pay for lower paid staff. We are in an increasingly competitive international market for health professionals and a decade of pay constraint in the NHS has damaged morale and made it difficult to train and recruit the staff we need.

“We have heard much about the need to integrate health and social care and we think the best way to do that is make the Department of Health responsible for both health and adult social care budgets. We also think it is time to look at the way care is delivered. This may well involve changing the model where GPs are self-employed small businesses.  Delivering health care fit for the 21st century requires improvement in primary care to relieve pressure on hospitals. That change should be delivered by GPs.”

 

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A repeated claim made by politicians and a justification for the Health and Social Care Act 2012 is that the NHS is ‘unsustainable’ in its present form because the UK’s ageing population is increasing costs to levels that we can no longer fund from taxation. But this is a myth. While the proportion of the population aged over 65 years is increasing in most of the developed world as people live longer, there is no evidence for the claim that ageing itself will lead to a funding crisis. Rather, the NHS funding crisis is due to cuts in funding for the NHS and social services coupled with the high costs of marketisation and privatisation leading to service closures such that NHS funded services including GP services and out of hours services and hospital services are no longer meeting needs.

Reductions in funding and budgets for social services and long-term care and reductions in local authority provision add to the strain on NHS services. The volume of services provided is shrinking and these are not keeping pace with need. The amount spent on social care services for older people has fallen nationally by £1.4 billion (8.0%) from 2010-11 to 2012-13. The number of people receiving state-funded care fell from 1.8 million in 2008-9 to 1.3 million in 2012-13.

According to Age UK, in the three years between 2010-11 and 2013-14:

  • Numbers of older people receiving home care have fallen by 31.7% (from 542,965 to 370,630).
  • Day care places have plummeted by 66.9% from 178,700 to 59,125.
  • Spending on home care has fallen by 19.4% from £2,250,168,237 to £1,814,518,000.
  • Spending on day care has fallen even more dramatically by 30% from £378,532,974 to £264,914,000.

Older people are living longer, healthier and more productive lives

The extent, speed, and effect of population ageing has been exaggerated by the government because the standard indicator—the old age dependency ratio  ( The old-age dependency ratio is the ratio of people older than 64 to the working-age population, aged 15-64) — does not take account of the fact that people aged over 65 years are younger, fitter and healthier than in previous decades. In fact older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years.

Currently over one million older people are still working, mostly part time, many with valuable experience or specialist knowledge. The spending power of the ‘grey pound’ has risen inexorably. Many do volunteer work vital to the third sector or look after grandchildren.

Older people aged over 65 contribute more to the economy than they take out. It is estimated that taking together the tax payments, spending power, caring responsibilities and volunteering effort of people aged 65-plus,older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. It is not age itself, ‘but the nearness of death’ or health status of the individual in the ultimate period in the last few years or even months before death that matter most. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ In fact, it is those dying between the ages of 50 and 60 who cost the most. If the cost of death declines with age then an ageing society could lead to lower health care costs.

Life expectancy is an estimate of average expected life span, healthy life expectancy is an estimate of the years of life that will be spent in good health. The trend for healthy life expectancy at 65 in England for males and females has increased approximately in line with overall life expectancy at 65. For example, between 2006 and 2009, healthy life expectancy increased by 0.8 years for females and 0.5 years for males while overall life expectancy grew by 0.6 years for females and 0.7 years for males. This suggests that the extra years of life will not necessarily be years of ill health. There are important socio-demographic differences in healthy life expectancy. Not only can people from more deprived populations expect to live shorter lives, but a greater proportion of their life will be in poor health.

When measured using remaining life expectancy, old age dependency turns out to have fallen substantially in the UK and elsewhere over recent decades and is likely to stabilise in the UK close to its current level. It is not age but nearness to death that accounts for health expenditure.

Increased life expectancy means more years lived in good health.

Politicians must stop blaming older people for their decisions to cut funding and close services

The false premises of the ageing hypothesis provide a technical rationale for starving the NHS of funds. In July 2013 NHS England warned of a funding gap ‘of around £30 billion between 2013-14 and 2020-21’. A Lords select committee , the Office for Budget Responsibility , the Nuffield Trust and the Institute for Fiscal Studies published health spending projections on the assumption that ageing is a main driver of cost rises. The studies mainly relied on simple population projections. The connection between ageing and costs and chronic illnesses was simply assumed. They did not consider the fact that people are living longer, healthier and more productive lives.

So the most remarkable thing about the ageing hypothesis or ‘demographic time bomb’ is its survival. The Canadian economist Robert Evans has described it as a ‘zombie theory’, one that refuses to die. It survives today only as a reason for explaining politicians’ bad policy decisions which have resulted in pressures on the NHS: as an alternative to the real reason which is the cutting of health budgets, and services for health care.

In the UK, both the Royal Commission on Long Term Care (the 1999 ‘Sutherland report’) and the Wanless Inquiry (2001-04) rejected the ageing thesis. The 1999 Royal Commission found that, even though ‘the population aged 80 or over is growing rapidly and appears likely to continue to do so’, the UK was not on the verge of a “demographic time bomb” as far as long-term care is concerned and as a result of this, the costs of care will be affordable.’

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’

In Canada the Evans paper on the Romanow report into future health care costs declared: ‘All studies come to the same conclusion. Demographic trends by themselves are likely to explain some, but only a small part, of future trends in health care use and costs and in and of themselves will require little, if any, increase in the share of national health resources devoted to health care.’

The European Commission report of 2010 found that it was ‘the health status of an individual (and – in aggregate terms – of the population), rather than age itself, which is the ultimate driving factor’ behind cost rises. Furthermore, ‘Over time, there is no clear link at the aggregate level between levels of spending on health care and the demographic situation of societies. In fact, several studies have found that the impact of ageing on increase in health expenditures is limited to as little as a few percentage points of this increase.’

The connection between ageing and health care costs has also been rejected in studies and parliamentary reports in the USA, Canada, Germany and Australia.

Examples of the ‘Zombie theory’ and how it is used to justify policy choices:

“We’ve got a growing and ageing population now and this is having a significant impact. It’s down to the policy-makers to decide whether to change the policy or not.”  Rupert Egginton, director of finance at the Nottingham University Hospitals NHS Trust

“An ageing population with more chronic health conditions, but with new opportunities to live as independently as possible, means we’re going to have to radically transform how care is delivered outside hospitals.” Simon Stevens, Chief Executive of NHS England

“However, if the NHS is to meet the needs of an ageing population we need it to be more efficient so it can provide more and better treatments.” Lord Howe, Parliamentary Under-Secretary of State for Health

Trends in numbers of people aged over 65 years and mortality rates and number of deaths:

ageing population

Figure 1: Age-Specific Mortality Rates, 1963 and 2013, England and Wales (Source: ONS24

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS25)

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS)

ageing population

Table 1: Number of deaths registered in England and Wales, 2004-2013 (Source: ONS)

Age structure of the UK: 2011 Census data

  • Aged 65 and over: 10.376 million
  • Aged 85 and over: 1.394 million
  • Total population: 63.183 million

This was first published by the Campaign for the NHS Reinstatement Bill

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The health care industry nationally and internationally is vast and expensive. Insurers and governments worldwide spend a lot of effort seeking to control expenditure growth using rhetoric rather than evidence to improve the efficiency with which health care is delivered.

Everybody now believes in “integrated care”. The Americans are obsessed with focusing their reforms on “value” i.e. improvements in the length and quality of life. All funders use the repetition of the religious cant of “prevention is better than cure”. There is agreement that primary care is “important” and should be funded properly.

These “ideals” permeate all public and private health care systems. In the case of the English NHS they take the form of ill digested newspaper columns, superficial TV news and current affairs diatribes and a flood of Department of Stealth initiatives and NHS England missives about plans, and “innovations” galore. There is a ferment of advice and advocacy.

All this effort is characterised by a reluctance to use evidence and add to the knowledge base by high quality evaluation. Earnest policy makers and daft politicians create floods of un-evidenced verbal diarrhoea. This wastes societies’ resources and create observable opportunity costs e.g. Lansley’s barmy NHS reforms of 2012 cost several billion pounds, thereby imposing avoidable mortality and morbidity on thousands of patients.

The cry must be “where is the evidence?” when well-intentioned policy makers and managers commit scarce resources to “improve” the health service. Instead of believing in un-evidenced magic solutions, let’s “confuse” policy making with facts.

Here are some popular policies which require much more careful evaluation.

 Primary care spending

NHS England has announced increased spending of over £2 billion in the next five years. GPs, according to a recent survey, are not overly disenchanted with their pay or administrative burdens but are thoroughly disenchanted with the quality of their working lives.

No wonder! Go and re-read the results of e.g. the Symphony work in Somerset to see how many patients have multiple morbidities and associated complexity and high costs. When I walk into my GP’s office with my multiple morbidities he has to catch up with my latest “events”, diagnose what is bugging me now and treat me. All to be done in 10 minutes! Quite a task and the risk is either corners are cut or appointment times go to pot. Hence GPs disillusionment with the pressures created by changing clinical needs of increasing numbers of patients who survive serious health events and proceed to make high demands on the NHS.

So what to do with £2 billion plus from NHS England? More GPs, if they can be recruited from India and Poland, and slowly from UK medical schools, could reduce waiting lists and give more appointment time.

Be careful! If the supply of GPs is increased will they detect increased need for hospital diagnostics and bed care? Supply creates its own demand as there is significant unmet need in all health care systems: the disguised iceberg of illness. But will increased supply of GPs always increase activity and costs? By how much? Where is the evidence?

So maybe fund more practice nurses instead or as well as GPs? There is evidence, dating back to the 1970s that nurses can substitute for maybe 50 to 70 per cent of a GP’s workload. But again practice nurses can be economising substitutes for GPs or complements to them who increase the quality and quantity of care. Will more expenditure on practice nurses increase the demand for hospital diagnostics and bed care?

The challenge for Sir Galahad Stevens is evidence based design of efficient ways of investing in primary care. Whatever policies are selected, evaluation would be valuable?!

However efficient evaluation of primary care funding is impossible given the appalling lack of data about what transpires when GPs and practice nurses are busy caring for patients. If Sir G is spending more on primary care he and his merry fellow workers need to reduce our ignorance about what goes on in this “black box”.

Competition and Hospital Mergers

Venerable academics such Carol Propper in England and Zack Cooper with work in England and the USA have shown monopoly is associated with poorer outcomes and higher costs for patients. Competition challenges local monopoly making it a better deal in some contexts for patients, insurers and the NHS.

However part of NHS rhetoric is the belief that hospitals should merge and form up into chains. Industrial economics indicates that take overs and mergers often fail to produce the improved efficiency projected by their advocates. Are NHS hospitals different? Where is the evidence?

One effect of mergers will be that the potential for competition will be reduced. Dear policy maker how would you trade off the potential gains from mergers, if they exist, against the losses from reduced completion? Time for some joined up thinking comrades!

‘Prevention is better than cure.’ Is it?

There have been some notable successes in prevention. The work of Sir Richard Doll over 50 years ago led to significant subsequent falls in smoking and the production of avoidable cancers and heart disease. The UK is now leading in its advocacy of e-cigarettes on the basis of some evidence that they are less harmful than tobacco “cancer sticks”.

Excessive alcohol consumption continues to create ill health, particularly amongst pensioners. Scottish attempts to introduce minimum pricing is opposed by industry and the EU has “paused” the policy because of completion rules. As with the tobacco industry, alcohol producers resist the erosion of their markets with highly effective lobbying of political institutions

Mortality from colorectal cancer has declined due to screening, complemented by improved treatments and the reduced incidence of the disease. In the USA where ‘poo screening’ reaches only 50 per cent of potential beneficiaries, death rates have fallen by over 45 per cent since the mid-1980s   (Welch and Robertson, NEJM, April 2016).

But how should policy makers deal with excess salt and sugar in diets, and the consequent ill effects on obesity, kidney disease and hypertension? What are the likely costs and benefits of the proposed partial sugar taxation policy? Are these effects superior or worse than regulation of producers? Will the  Mars Corporation’s decision to put “health warnings” on some of their products result in loss of market share with few health gains, or lead to health inducing emulation?

Sir Galahad’s Five Year Forward Plan rightly advocates vigorous prevention policies. But politicians, lobbied by corporate interests, move as slowly as investment in evidence production.

 Integrated care

The fragmentation of primary and secondary health care and local authority social care has been highlighted as a problem for over four decades. Numerous re-disorganisations of the NHS have failed to bite the bullet of “integrated care” in large part because of each sector being reluctant to give up power and budgets to complementary competitors for public funding

Recent investments in “Vanguard” projects and political initiatives such as the integrated Manchester “Poor House” are the latest manifestations of integration. Similar efforts are evident in the USA. In both countries there is investment in evidence, with US studies showing limited success. Given the failures over decade’s progress in developing efficient forms of integrated care remains slow with the need for healthy scepticism about the quantity and quality of evidence.

Conclusions

Beware the high priests of evidence free policy making! They dominate choices about the allocation of scarce resources amongst competing patients. Prepare to be challenged by academic researchers whose role, as Mary Beard noted in the Guardian recently, is to make everything more complex! Simplicity is rarely the characteristic of health care reform!

The health care market is very complex. Simple solutions rarely work. The latest wheeze of vote maximising politicians all too often wastes resources, thereby giving up potential health gains. Such behaviour is not only inefficient it is also immoral. Politicians and managers should think before they spout un-evidenced drivel!

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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.

Sequencing-Money-300x299-300x299Have 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.

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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Andy Burnham has set out his vision for the NHS and at its heart is a commitment to a publicly funded and publicly managed service. The private sector would be confined to a “supporting” role while the voluntary or not for profit sector would be given preferential contractual treatment.

His vision is one in tune with core Labour values and will resonate with the public who want the NHS to remain free at the point of delivery and available to all when and where they need it.  The NHS is a national treasure and is an institution that captures the sense of fairness that can be regarded as the essence of being British.  Its heart and soul should be preserved and be invested in.  But it should not be preserved in aspic.  It must move with the times and be confident enough to embrace high quality services wherever they may be located.

I welcome Burnham’s plan for integrated care based from home and treating the whole person, and I welcome his commitment to greater homecare services for end of life care provided on the NHS.  However there are two serious flaws in his vision.  What does a “supporting” role for non NHS providers mean in practice and why should a voluntary organisaton be given preferential treatment over a private company.

The notion that voluntary or not for profit organisations are somehow deserving of preferential treatment is misguided.  There is nothing intrinsically “better” about the service arm of a major charity than many private companies or statutory sector departments.  At present charities compete ruthlessly for contracts, poach staff from within the public sector and from each other and often have no better, if not worse, terms of employment.  The service arms are rarely delivered by volunteers and many charities are replicating the characteristics of both the public and private sectors.

In my field of home medicines, it is currently only private companies that are able to deliver cost savings to the NHS through reclaiming VAT on medicines; only private companies that can meet the very high quality and governance standards needed for dispensing medicines; and only private companies that have the logistical networks to deliver medicines and services to peoples homes anywhere in the UK.

It is hard to imagine any voluntary organisation being able to provide homecare medicines to the expected standards – it is hard enough for current providers to meet the demands – or to have the financial resources to underpin a high-cost, low-margin business, or to take such a business risk without contravening their charitable objectives. The NHS shows no appetite to directly deliver the service and would be unable to take advantage of VAT generated cost savings if it tried to do so.

Clinical homecare provides high cost medicines and nursing services to people’s homes at no cost to the patient – in doing so it improves patient experience, reduces pressure on outpatient pharmacy and delivers real cash savings on expensive drugs – all of which are top priorities for the NHS.  Currently approximately 230,000 patients receive clinical homecare and while there are many pressures on services the sector is expanding and regularly generates very high levels of patient satisfaction. And it is 100% delivered by the private sector.

Clinical homecare is an example of where using the private sector makes sense – where private firms can deliver a clinical service for the NHS and in doing so improve patient care and make real cash savings.  If the NHS is to become a service where staying at home is the first option then clinical homecare providers should be encouraged to do more not less.

Private is not always bad, voluntary is not always good and an incoming Labour Secretary of State should be sophisticated enough to recognise this.

Dave Roberts

Dave is the CEO of the National Clinical Homecare Association but writes here in a personal capacity

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