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    Summary

    The current National Health and Care System has shown the fact that a system can run on the basis of an ethic of altruism and public service, not profit.

    The hospitals have always held primacy in our system, and reorganisations have tried to rebalance the system in favour of community health and primary care.

    Public Health has been weakened by the 2012 Act and enjoyed more prominence during the period of Primary Care Trusts when it was integrated with Primary Care. This situation needs to be restored

    Health and Care need to be integrated regionally and the paper argues for Combined Authorities to be given overall control.

     

    No, the title was not a typo. There is more to healthcare than the NHS which we all know and love. Health Care includes Public Health, Social Care, Pharmacy and Dentistry, and they all need to work together. The present crisis has shown this. This is something which many experts in the field have acknowledged for years; doing something about it has proved elusive and difficult. This present crisis has shown not only the heroic dedication and commitment of the staff, but also the gaps and problems which need to be rectified, so perhaps this is the time to try and do it.

    In this paper I have tried to set out some sort of roadmap of the problems we need to tackle. That is why I have called the objective a National Health System, rather than the current NHS, but have preserved the iconic brand which is known all over the world. I once met mountaineers in a foreign land who praised the NHS.

    I am not an academic. I have taught about how the Health System works, but more practically I have been a councillor, worked for the NHS, served on a Clinical Commissioning Group and now Health Education England. I wrote a book about how the NHS should be organised with Sunderland University, and I will draw on bits of that in this paper, but my knowledge comes mainly from my practical experience. (“What Sort of NHS do We Want?”, Searching Finance, 2012)

    How we arrived at the present position

    There is much ignorance amongst the public as to how the NHS actually works. It is certainly very fragmented, but still able to respond as a national system, which has been shown by the present crisis. Many fondly think there was a “golden age” back in the 1950’s when the NHS was first established.  Aneurin Bevan boasted of a national system where the “sound of a bedpan dropped in Tredegar would reverberate around the Palace of Westminster”.

    We all know establishing the NHS was a political struggle and what emerged was a messy compromise. The immediate problem was sorting out hospitals which needed investment after the war. I can remember seeing pictures of my Grandmother, who was a hospital almoner, lining up the nurses to go out with the collection tins. Hospitals seem to have dominated ever since although they deal with a minority of the people who use the system. There are more patient contacts with GPs, carers, Public Health programmes ,  and Social Workers. Local Government had played an important role in health before 1948, and Directors of Public Health were important people. Much of what we would now call primary care was still run by local authorities up until the major reorganisation of 1974.  Strong central control was the way things worked in 1948, a legacy of the war – the NCB, British Railways, The National Grid and even the New Towns. The new NHS was no different.

    Initially Governments thought that a strong NHS would improve health and once the backlog of bad health had been dealt with, costs would reduce. This of course did not happen, so managing the NHS became a constant struggle between improving the service and keeping a lid on costs. In 1974 all health services came under Regional Health Authorities and this remained until the next major reorganisations at the end of Thatcher’s period in power. This was when the concept of the “market” was introduced into the NHS.

    At that time the model of the big top-down organisation was being challenged both in the public and private sphere. Although big organisations were still centrally controlled from the top, they wanted more flexibility locally to restructure and adapt to changing conditions at the bottom. Even the army now operates like this. The idea was that those who planned a service would commission it from who could provide it best. Commissioning meant what the service was going to be had to be evaluated and planned. The NHS had to think exactly want it wanted and the best, and most cost-effective way, of achieving it. This does not necessarily mean using the private sector. Other NHS and not for profit organisations are often involved. But it was never a free-for-all. The NHS was still in charge. Resulting from the Thatcher reforms there was a privatisation of many ancillary services such as cleaning, maintenance and catering. For clinical services there was still a preference to commission NHS and not for profit organisations. One consequence of these changes was that local authorities outsourced much of their social care provision, mainly for economic reasons.

    The Labour Governments after 1997 modified the model, introducing both Foundation Hospitals and Primary Care Trusts. In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTS, and also prioritised deprived areas such as Easington in County Durham. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    The Black Report in 1979 pointed out that despite large investment in the NHS, health inequalities persisted.  Professor Townsend, one of the main authors, mentioned Easington in a later report and visited Peterlee to explain his ideas. The dominance of the Hospitals in the system had led to a neglect of both social care and the promotion of health in the community. To reduce inequalities meant placing far more emphasis on how people lived, the conditions in which they lived and looking after them in the community when they were frail or unwell. Successive reports re-emphasised what the Black Report had said.

    The Primary Care Trusts were an attempt to redress the power balance with the hospitals. More resources were given to community and public health, which were now integrated. GPs had a major role. The PCTs were coterminous (horrible NHS word) with local authorities, and the Director of Public Health was now appointed jointly between the local authority and the PCT.  Cooperation was much easier. Many PCTs had councillors on their boards. The PCTs now had more power to negotiate with the hospitals to get better deals, and work with them. At this stage commissioning was mainly for other public sector and voluntary organisations. The NHS was the “preferred provider”.  The PCTs made considerable progress in improving public health, such as the reduction of smoking and teenage pregnancies, and set up many community initiatives.

    In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTs, and deprived areas were prioritised. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    I think I should make a few remarks about commissioning.  Many on the left regard it as synonymous with privatisation. This simply is not so.  As explained above the NHS is not monolithic and contains many different sections and specialities. Some of commissioning is straightforward – estimating the number of routine, predictable operations required in a year, like hip replacements. Then it is about negotiating the best deal with a provider.  But some is more complex, such as public and community health which requires constructing alliances between different organisations. Using a private provider is not a necessary part of this at all.

    All this was changed by the infamous Social Care Act of 2012 which established the Clinical Commissioning Groups. It compelled contracts to be put out for public tender, so private providers could apply, and often threatened to sue if they thought they had not been fairly considered.

    Councillors were not allowed to be involved, and their only oversight was through Scrutiny Committees. Public Health was handed back to local authorities. A strong national agency, Public Health England was created to exercise many of the responsibilities which PCTs had previously done including disaster planning and campaigns to reduce smoking and other habits deemed to be harmful to health. I will say more about the consequences of that later.

    The CCGs were a result of lobbying by a minority of GPs who wanted to commission directly without the NHS bureaucracy and pressure from private providers who wanted a bigger slice of the action. The Government thought they could use them to reduce costs. The whole enterprise was ill thought out and very disruptive. It is a useful lesson in the sort of “creative destruction” advocated by the likes of Dominic Cummings. The idea being that somehow once the bureaucratic shackles of the NHS and local government had been thrown off, GPs would somehow emerge as the heroes of the NHS and challenge the dominance of the Trusts. I can remember attending seminars before the new act was implemented where it was even advocated that two GPs could form a commissioning group. How they would work out the necessary plans and calculations was not thought about. I can remember a seminar about the changes entitled “Breaking Though”.

    In reality it was only a minority of GPs who wanted to run the NHS.  Most of them simply wanted to get on with their jobs which were demanding enough. Much of the pressure came from private providers, aided and abetted by members of the government anxious to reduce costs and eliminate, as they saw it, unnecessary bureaucracy.  Andrew Lansley, in many other ways a fairly level-headed man, seemed carried away by it all, and David Cameron and Nick Clegg did not really understand it. The only contribution by the Liberals was to ensure lay representation on the new CCGs. The reorganisation was described by one critic as “visible from space” and disrupted the NHS for several years.  Patterns of cooperation between agencies, carefully established over time were either disrupted or had to be carried on “under the radar” in the new competitive model. A new bureaucracy had to be established from the PCT staff to perform commissioning.

    One hospital (Hinchinbrooke) was taken over by a private company which could not cope and had to hand it back to the NHS.  Many private providers attempted to run the new 111 services, but now most of them are organised by Ambulance Trusts.

    The idea behind the 2012 Act was that there would be a free market. The CCGs would commission the most efficient service, public or private.  Collaboration, whether between hospitals and other parts of the NHS was not, in theory, allowed. Private providers could take the NHS to court if they thought the NHS had an unfair advantage. In practice, however, the national NHS kept a firm grip on things. There is always the need in the NHS to pool risk.  If there is an outbreak or crisis in one area the whole system has to pitch in.

    The 2012 Act led to an extremely costly and disruptive reorganisation. Many health professionals soon realised that it did not work. In reality the bureaucracy expanded, and much energy had to be expended negotiating between different parts of the NHS. The majority view was that if the NHS was going to cope, two things were necessary. Firstly, more resources needed to be directed to promoting good health, and thus reducing those diseases which were caused, or exacerbated, by a bad lifestyle, such as diabetes. Secondly an ageing population meant more people would need care in the community, rather than treatment in hospital. If they did not receive this care, then they would end up in hospital, as so called “bed blockers”.  Hopefully if policies to address these objectives could be put into place it would reduce unnecessary hospital admissions.

    Local health professionals have tried to negotiate arrangements for CCGs, Hospitals and Local Authorities to work together.  These were originally called Strategic Transformation Partnerships, abut have now morphed into Integrated Care Systems.

    Simon Stevens, Chief Executive of the NHS, said in the Five Year Forward View

    “The government will not impose how the NHS and local government deliver this. The ways local areas integrate will be different, and some parts of the country are already demonstrating different approaches, which reflect models the government supports, including: Accountable Care Organisations such as the one being formed in Northumberland, to create a single partnership responsible for meeting all health and social care needs; devolution deals with places such as Greater Manchester which is joining up health and social care across a large urban area; and Lead Commissioners such as the NHS in North East Lincolnshire which is spending all health and social care funding under a single local plan.”(Implementing the five Year Forward View 2017)

    More detailed plans for ICSs have been set out last year

    The NHS Long-Term Plan set the ambition that every part of the country should be an integrated care system by 2021. It encourages all organisations in each health and care system to join forces, so they are better able to improve the health of their populations and offer well-coordinated efficient services to those who need them.(The NHS, Designing Integrated Care Systems in England 2019)

    It is important to notice the word “Systems”. These ideas rely on different organisations working together. They do not pool budgets, and have no one accountable management, just committees who liaise.

    The trouble is all this is against the 2012 Act. Manchester eventually commissioned other NHS organisations to deliver its community health services, but was threatened with court cases from private providers. All that would have wasted a considerable amount of public money.

    The Conservative election manifesto recognised the system was not working in 2017 and proposed changes to the rules.  All this has since been forgotten about with the dominance of Brexit but will eventually have to be addressed.

    Some on the left see the ICS’ as some sort of conspiracy, implying that there is a secret plan to fragment the NHS and then sell off parts of it. Simon Stevens is often portrayed as being some sort of ogre who is using his American experience to somehow smuggle American health companies into this country.  Remember that health is largely organised on state lines in America, and the insurers who pay for much of it want single organisations whom they can work with. I think the reality is somewhat different. Many think Simon Stevens is a shrewd operator who managed to secure additional funding for the NHS.

    Ever since I have been involved with the NHS there have been efforts to join up health and social care at a community level, and to challenge the dominance of the hospital Trusts.  In the early 2000’s the former Sedgefield Borough Council worked with their Primary Care Trust and Durham County Council to effectively integrate services by putting social workers, district nurses and housing officers in the same room, and Easington PCT considered integrated care initiatives.  The Sedgefield initiative worked at a grassroots level because it did not involve redesigning systems.  As soon as you tried to set up a new structure people retreated into their bunkers.

    It is much easier to set up an integrated system in theory than in practice. One senior insider I spoke to recently said that negotiations to set up an integrated care system locally were not getting very far because of vested interests. Different organisations have different hierarchies and systems of accountability.  They are also keen to hang onto their budgets.  It looks like a solution will only be reached if the NHS imposes it, and they do not have much spare energy for that at the moment.

    I remember the days before local government was reorganised in Northumberland and Durham, and District and County Councils were merged into the present unitary ones. The Government asked councils to work out ways of working together. There were interminable liaison meetings between the different councils which got precisely nowhere, each one wanting to preserve its own interests. Eventually the Government imposed a solution.

    Insiders also tell me there is very little interest from councils in the new arrangements.  Although in practice working relationships between the local authority and the NHS in most areas are good, some councillors appear to prefer the scrutiny role than actually being responsible for the service.

    So overall I think the problem is not so much a conspiracy to carve up the NHS as some on the left seem to think, but rather getting our fragmented system to work together for the benefit of all of us.

     

    Where we are now

    Most people on the left believe in a publicly run health service, free at the point of use. They also value the dedication of the staff and think they should be better rewarded.

    Socialists also dislike privatisation.  There is a difference between having to use the private sector if nothing else is available and the obligation to put services out to tender regardless of whether they are functioning properly as happens now. Efforts to integrate services are also hampered if parts are privately owned, as private providers may not disclose their information and not cooperate. (I remember my efforts on the CCG to get Capita to produce its accounts to the Audit Committee for a service they provided.)

    Privatisation often results in poor staff conditions and pay.  I think nearly all Labour Party members would wish a future Labour Government to repeal the 2012 act and restore the NHS as the preferred provider.

    That is the easy part.  Now we get to the difficult issues of how we organise an integrated service in the future and ensure it is accountable. Let me stress now that I do not want another major reorganisation. Our NHS staff do not deserve that. Rather we must think about how what we have now can be made to work better.

    I have not said much about Social Care, either personal, which is delivered at home, or residential in care homes. It is widely accepted that the situation is at crisis point. The paper by Professor Paul Corrigan is an excellent starting point. A recent briefing by the Nuffield Trust emphasised the dimensions of it. (Nuffield Trust, Election Briefing Nov 2019.)  Here are a few statistics:

    We believe the scale of the workforce challenge has so far been underestimated: our new calculations show that just providing a basic package of care of one hour per day to older people with high needs would require approximately 50,000 additional home care workers now. To provide up to two hours would need around 90,000 extra workers. ( Then there is the question of where they would come from if Brexit is implemented)

     

    A decade of austerity has seen government funding for local authorities halve in real terms between 2010–11 and 2017–18,* which has led to councils tightening the eligibility criteria for care. It is known that there were 20,000 fewer older people receiving long-term social care services in 2017/18 than in 2015/16, but this is likely to understate the problem – estimates of unmet need go as high as 1.5 million.

    Constraints on public sector finances in recent years have meant that fees paid by councils to the organisations that provide home and residential care have been cut repeatedly. The predominant approach used for buying services from providers incentivises organisations to provide a bare minimum of services and nothing more. Some 75% of councils report that these organisations have either closed or handed back contracts in the last 6 months, creating enormous disruption and discontinuity for those receiving care.

    The problems of Care Homes have been highlighted by the current pandemic. There are roughly 11,300 care homes in the UK who look after 410,000 residents. Most of their income comes from fees paid by residents or their families, with a minority provided by local authorities.  In practice the private fees subsidise the public ones which are often insufficient to cover the costs of the residents. Sally Copley of the Alzheimers Society says “The whole system hasn’t been working properly for some time”.  Many staff are on zero hours contracts and staff shortages are endemic as Professor Corrigan pointed out. Staff are paid far less than they are worth and do not receive adequate training nor professional recognition.

    We all have formative experiences which make us socialists. One of mine was in a care home where a member of my family was a resident. I knew two married members of staff well. Both were dedicated to their work and the residents.  They were always cheerful.  I can remember them saying with great enthusiasm how they had saved up enough to take their young family to Great Yarmouth for a week in the summer.  Their work deserved far more reward than that. I though “something has to be done about this”.

    A proper care system would assess people on the basis of clinical need, not ability to pay.  At the moment there is continuing health care, provided by the NHS, which is free,  for those thought to have health issues, but domiciliary and residential care largely has to be paid for by the clients or their families except for the minority who benefit from a stringent means test. Dementia is not classified as a medical condition.  Many people feel this system is unfair. A senior commissioner I spoke to said she would rather commission “care” which would be provided by professionals trained by the NHS, rather than try and distinguish between continuing health care and social care.

    At the last election the Labour Party promised free personal care for those over 65, as in Scotland.  As the Nuffield Report points out this does not include assistance with cleaning and general supervision.

    One of the best assessments of the cost of integrating health and social care was done by Kate Barker and associates for the Kings Fund in 2014.  They looked carefully at what social care involves, and how it could be paid for. There are different levels of social care, and they conclude that the same principles should apply as to the NHS.  Afflictions can strike anyone, rich or poor, so care funding should come from the public purse. The costs of care and treatment should be publicly funded, although this might not include the actual “hotel charges” for residential care. The authors suggest various ways to raise the extra funding, such as means testing free TV licences, and requiring those (usually better off) who continue to work after the retirement age to pay national insurance.  There would of course be a need for those on higher incomes to pay more tax, possibly after the age of 40, and the Government should consider a wealth tax which in reality for most would be a tax on your home. There are various avoidance schemes and tax loopholes for the wealthy which could be closed.

    There would probably be agreement amongst socialists that health and social care should be integrated and paid for out of taxation, but it is no good thinking only the rich would have to pay.  Everyone would have to pay something.

    Finally, there is the issue of Public Health. Transferring it to local government has not been a success. The budget, supposedly ring fenced, has been diverted to other local government departments because of the squeeze on local authority finance, and last year some of the poorest authorities took a very big hit. Durham lost almost 40% of its public health funding. Yet even in its diminished state, The Centre for Health Economics at York has estimated that expenditure on Public Health is four times more effective in promoting health than that spent on the NHS. Simple common sense tells us that keeping people healthy is better than curing them once they are ill.

    Several distinguished epidemiologists, including Professor Allyson Pollock at Newcastle, have argued that the marginalisation of Public Health locally has severely reduced the country’s ability to deal with the coronavirus epidemic. Back in PCT days Public Health had the resources and plans to deal with disasters, often pooling risk with others.  Now that has been transferred to Public Health England, leaving local authority public health departments to deal mainly with schemes to keep people fit. Worthy enough, but nothing like the resources they used to have.   A regional public health response might have led to better testing and efforts to contain the virus. The Government’s response has been “one size fits all”. Restoration of the importance of Public Health and its reintegration with the NHS should be a major aim of policy.

     

    Policy Objectives

    Our policy objectives will be ambitious. We might need a five year, or even ten year forward view to coin a phrase.

    We seek an integrated National Health System, encompassing the National Health Service, Social Care, Public Health, with links to Pharmacy, which has a role in primary care, and Dentistry, which is not a totally public service although the NHS controls the training. But we do not want a major reorganisation again. Our dedicated health and care staff do not deserve that. What we want to do is give the present system more resources and steer it in the right direction. Repealing the 2012 Act would be a priority.

    We must ensure that particularly in social care staff are paid a decent wage and given proper access to training. The present system which relies on the minimum wage and zero-hour contracts must end.

    The first thing we know is that all this will cost more than it does now, although integration may produce some savings. A future Labour Government has to be honest about this. It is no good promising a few rich people will pay, as the public simply will not believe it. It is a good principle that everyone should contribute to something which is part of national solidarity, so all feel that it is theirs, but contributions have to be proportionate to the ability to pay.  A proper revaluation of properties, which is akin to a wealth tax, would raise money through the community charge to make a substantial contribution to social care.  An increase in National Insurance, earmarked for the NHS should be considered, provided that it became more progressive.

    Then we come to the whole issue of Governance.  Despite showing little enthusiasm, local government needs to be involved in the whole strategic planning of the NHS. But they must not see it as simply concerning their own territory, so to speak. The present structure of Foundation Trusts should stay, but Public Health and Commissioning Services should be reintegrated into Primary Care Trusts, in my opinion one of the most successful NHS organisations in its long history of restructuring. The PCTs would have oversight of Pharmacy and Dentistry. Many of the responsibilities transferred to Public Health England should be restored to the PCTs. Their boards should contain both professional and local government representation.

    There is a need for a regional dimension in all this.  When the Northumbria Trust reorganised its A&E provision to build a super emergency only hospital at Cramlington it did not consider the effect on major hospitals in Newcastle like the RVI. Patients in Hexham, for example would find it easier to go there than to Cramlington. This is just one example of where a regional perspective would have been useful.

    Local authorities’ power over social care providers need to be strengthened. At present there is a real mixture of providers, commercial companies, charities, cooperatives and individuals who provide personal care as a small business. There is a strong argument for integrating the private sector, which is virtually bankrupt anyway, into area trusts responsible to local authorities. Standards and remuneration need to be strengthened.

    Trying to merge different organisations would be very difficult and disruptive. The result could be some unwieldy bureaucracy which would be difficult to manage and slow to react to changing needs and priorities. Accountability should be pushed upwards. We need to have some sort of accountable umbrella which ensures that hospital trusts, PCTs (coterminous with local authorities) and Social Care, which is regulated by local authorities, all work together. There will always be oversight from NHS England, NHS Improvement, and the Care Quality Commission, but these bodies are mainly regulatory.  There needs to be a more local system of Governance and Oversight.

    Nationally the country is moving to a system of Combined Authorities which at present oversee economic development and transport.  Manchester has also had community health added to its powers. A combined authority does not take powers away from local authorities.It has power and oversight over services provided by other organisations. Its membership is delegated from existing councils, with a mayor if that is agreed. It would seem logical for a combined authority to exercise oversight over the Foundation Trusts, PCTs and Local Authority Care in its area and produce a plan to ensure they work together. The CCGs now cooperate to cover larger areas in any case. That way we preserve flexibility within the system without adding another layer of bureaucracy,and move towards the integrated National Health System we want.

    I want to end by stating that as socialists we owe a great deal to the NHS and Care Services. They are an example, much admired elsewhere, of how a publicly run system can be successful, and that duty and altruism more important motivators of human conduct as making a profit.  It is our duty to ensure it is funded and run properly.

    David Taylor-Gooby, author on the NHS and member of the Socialist Health Association

    May 2020
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    The United Kingdom has overtaken Italy with the highest official death toll from the coronavirus, Covid-19 in Europe. New figures released on Tuesday, 5th May 2020 show that this is the trend, we ask, what does this mean for London and Inner London Local Councils?

    London is a vast geographical area and has a complex demography. The inner London boroughs are more diverse, in general and the outer London boroughs are more suburban.

    The incidents of coronavirus in the capital have been measured by the Office for National Statistics.

    The ONS reports that overall, London had 85.7 Covid-19 deaths per 100,000 population, almost double the rate of the next worst-affected region which is the West Midlands at 43.2 deaths per 100,000.

    Nick Stripe, head of health analysis and life events at the ONS, said: “By mid-April, the region with the highest proportion of deaths involving Covid-19 was London, with the virus being involved in more than 4 in 10 deaths since the start of March.”

    The figures for the top ten London Boroughs are:

    Borough SMR
    Newham 144.3
    Brent 141.5
    Hackney 127.4
    Tower Hamlets 123
    Haringey 119
    Harrow 115
    Southwark 108
    Lewisham 106
    Lambeth 104
    Ealing 103

    If we look even closer within each London borough, we can see the how each Super Output Area is affected. Super Output Areas are a small area statistical geography covering England and Wales. Each area has a similarly sized population and remains stable over time. You can take a look at the ONS interactive map here: 

    The Index of Multiple Deprivation (IMD) is an overall measure of deprivation based on factors such as income, employment, health, education, crime, the living environment and access to housing within an area. [NB There are differences between England & Wales]

    Age-standardised mortality rates, all deaths and deaths involving COVID-19, Index of Multiple Deprivation, England, deaths occurring between 1 March and 17 April 2020

    Looking at deaths involving the coronavirus (COVID-19), the rate for the least deprived area was 25.3 deaths per 100,000 population and the rate in the most deprived area was 55.1 deaths per 100,000 population; this is 118% higher than the least deprived area.

    In the least deprived area (decile 10), the age-standardised mortality rate for all deaths was 122.1 deaths per 100,000 population. In the most deprived area (decile one), the age-standardised mortality rate for all deaths was 88% higher than that of the least deprived, at 229.2 deaths per 100,000 population.

    The bar chart shows how much higher each decile is compared with the least deprived decile for all deaths and deaths involving COVID-19.

    For deciles 4 to 9, the percentage increase in age-standardised mortality rate of deaths involving COVID-19 is similar to that of overall deaths.

    The rate of deaths involving COVID-19 is more than twice as high in the most deprived areas compared with the least deprived

    Local responses will involve contact tracing. This graphic from Public Health England gives a brief description of the process.

    contact tracing is part of a public health approach

    Professor Allyson Pollock of Public Health at Newcastle University has been campaigning to raise the profile of a more localised approach, in a letter she has said that a massive increase in testing and tracing should be the next phase, but decades of cuts and reorganisations have whittled away the necessary regional expertise.

    In the letter the dynamic nature of the pandemic across the country is aptly described as “not homogenous. It is made up of hundreds, if not thousands, of outbreaks around the country, each at a different stage.”

    Her approach champions “classic public health measures for controlling communicable diseases such as contact tracing and testing, case finding, isolation and quarantine. They require local teams on the ground, meticulously tracking cases and contacts to eliminate the reservoirs of infection. This approach is recommended by the WHO at all stages of the epidemic.”

    The history of public health is important including the recent changes in the Health & Social Care Act 2012. This abolished local area health bodies, created Public Health England to fulfil the Government’s duty to protect the public from disease and charged local authorities with improving public health.

    As public health returned to local government, with a sleight of hand, the Government introduced the current programme of public health funding cuts. In 2019/20, the London’s share of the Public Health Grant had fallen to £630 million, representing a per head funding reduction from £80.75 in 2015 to £68.61 in 2019, a fall of 15% and the biggest regional reduction in England.

    “Investing in public health is also hard for governments because the benefits accrue to their successors and there is little to show for spending at the end of the five-year election cycle.”

    “Cutting public health funding would be an act of self-mutilation. If controlling spiralling demand is the priority, for goodness sake don’t cut public health.”

    Luke Allen
    Researcher, Global Health Policy, University of Oxford in the conversation

    A localised response requires political will, expertise and attention to detail.

    Public Health funding and status needs to be revitalised and restored. It is a matter of life and death.

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    Boris Johnson’s Queen’s speech includes this statement:

    “New laws will be taken forward to help implement the National Health Service’s Long Term Plan in England.”


    A Camden New Journal article ‘Beware false prophets’ published last month, reports:

    “The most alarming feature of the Long Term Plan, however, is that it completely locks in the contracts on offer through the adoption of Integrated Care Partnerships (ICPs).

    “These ICPs are the planned outcome of NHS England’s Sustainability Transformation Plans and Accountable Care Organisations, and are non-state organisations with a single management structure. Included within them are hospitals as well as primary and commun­ity care services – and possibly social care too.

    “These giant five to 10 year multi-million-pound commercial contracts will be open to bidding, and they will not be subject to public scrutiny (information is routinely withheld on grounds of commercial confidentiality). This will open the way to bids from giant international health corporations that already run similar de-skilling of healthcare in the US and elsewhere.”

     

    Jeremy Corbyn’s Labour speech in Northampton is clear:

    “For a decade our NHS has been run down, carved up, and prepared for privatisation. A Labour government will reverse this. We’ll repeal the Tory-Lib Dem privatisation Act of 2012. We’ll give our NHS the resources, equipment and staff it needs. That means more GPs and nurses and reduced waiting times. And under Labour prescriptions in England will be free.

    “And we’ll make life-saving medicines available to all by ensuring Big Pharma can no longer hold our NHS to ransom. The prices pharmaceutical companies demand don’t reflect the costs of the drugs they make. They simply charge as much as they can get away with.

    “We’ll use compulsory licensing to secure generic versions of patented medicines and create a publicly-owned generic drugs manufacturer to supply cheaper medicines to our NHS, saving our health service money and saving lives.

    “Only Labour can be trusted with the future of our NHS.”


    Please see Mariana Mazzucato’s The Value of Everything, especially Chapter 7 “Extracting Value through the Innovation Economy”. It explains value extraction by Big Pharma.

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    This article was first published by Simon Collins at HIV i-Base on 2 September 2019.

    On 2 September 2019, leading HIV charities including HIV i-Base and the UK-Community Advisory Board (UK-CAB), published an open letter to Rt Hon Amber Rudd MP in her capacity as Minister for Women and Equalities, calling for an urgent intervention to include sexual health in the upcoming Government Spending Round. [1]

    In England, the responsibility for sexual health was disastrously shifted from the NHS to local authorities, whose public health budgets have been cut in real terms by £700 million over the last five years.

    These cuts have directly reduced access to sexual health services, where many people are unable to routinely access treatment and testing due to limitations in allocation of daily appointments.

    Many of these cuts disproportionately affect lesbian, gay, bisexual and transgender (LGBT+) and black and minority ethnic (BAME) communities, and young people.

    A similar joint letter calling for increased funding for sexual health was also sent today by LGBT+ groups from the Labour, LibDeb and Conservative parties.

    Last year, a review of services in South London reported that 1 in 8 people with symptoms were being turned away from sexual health clinics. This included 40% who were under 25 years old and 6% who were under 18.

    References

    1. Green I et al. Urgent request to intervene: Funding for sexual health services. 2 September 2019.
      http://www.tht.org.uk
    2. Collins S. Almost 1 in 8 people with symptoms turned away from sexual health clinics in SE London: 40% are under 25 and 6% under 18 years old. HTB 01 May 2018.
      http://i-base.info/htb/33968

    Please see this Press Release from BASHH (British Association of Sexual Health and HIV) and BHIVA (British HIV Association) from October 2018: Government funding cuts leave sexual health and HIV care at ‘breaking point’

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    The title of the new GP contract is “ Investment and evolution: A five- year framework for GP contract reform to implement the NHS Long Term Plan.” 31.1.19 (Framework)

    The main aim of NHS England’s ‘NHS Long Term Plan’ 7.1.19 (LTPlan) is to establish Integrated Care Systems (ICSs) throughout England by 2021. And for these to evolve into Integrated Care Providers (ICPs) (Ps 29 – 31 LTPlan) ICSs and ICPs were previously called Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs). It was against the latter that Judicial Reviews were fought by NHS campaigners from 2017.

    In January 2018, Pollock & Roderick exposed the potential for single contract organization ACOs to be run by private companies to make profit out of commissioning and providing health and social care for large populations of NHS registered patients, on huge longterm contracts. (1.) The purpose of ICSs and ICPs it to totally transform 1) the payment systems and 2) the commissioning and delivery systems of health and social care in England, along the lines of US Accountable Care. (1.2.3.) In the latter, providers of healthcare are incentivized to work together, to commission and provide the vast majority of healthcare for a whole population, on a capitated budget. The commissioner and provider align objectives to make a surplus on the budget, whilst pledged to achieve quality standards.

    The basic principle is that of American Health Maintenance Organisations (HMOs); “ the less care you provide, the more money you make.” Methods used to commission and provide care below budget are to; develop keen leaders, risk segment the population, sophisticated digital systems to promote virtual consultations, share patient data and collect data on health service use and cost, and ‘integrated Multidisciplinary teams” of mainly non-doctors adherent to managed care pathways providing 24 hour continuity of care to keep patients out of hospital substituting for doctors as often as possible. Ruthless imperatives are to *reduce ‘skill mix’, *continually redesign care to cheapen and cut it and *stop patients accessing hospital care.

    The favoured payment systems are; a) capitated budgets ( whole Population budgets ) b) performance related rewards e.g QOF and CQUINs in England c) ‘Shared Savings Schemes’ All of the above characterize “ A new Service Model for the 21st Century” promoted in the LTPlan ( Chapters 1 &7) and the Framework.

    But the confusing way they are written disguises the US style Accountable Care being smuggled in.

    The reference to ICS boards on Page 30 LTPlan actually refers to the STP boards (Sustainability and Transformation Partnership boards) already imposed in 44 areas of England in 2016.
    Their remit, known from STP plans, is to make huge cuts, reconfigure care out of District General Hospitals, develop a ‘local system workforce’ with ‘new roles’, divert elective care into the private sector and get GPs into ‘scale’ integrated primary care systems.
    The barrier to the latter, despite all the super practices, federations and primary care networks that have been created in the last five years by NHSE, is the fear amongst GP principals that they would lose their independent NHS contractor status and their life long General Medical Services (GMS) contracts. This would be the case in ICPs.
    GPs are right to be worried. The strategy is to ‘supercede’ so called ‘ cottage industry’ GP practices, with ‘post industrial’ care, through ‘family care networks’. (4) The Framework is being hailed as the solution. NHSE is happy that GPs are being herded into new Primary Care Networks ( PCNs ) enabling the establishment of ICSs, allover England by 2021. The BMA applauds the Framework as a victory for saving GPs’core primary medical services contracts for now.
    But the title gives the game away. It is five-year GP contract reform “to implement the NHS Long Term plan.” GPs are being told to sign up to a Network Contract DES ( Directed Enhanced Services ) (5) as an “extension” to their core practice contract AND a Network Agreement, which is a legal integration agreement. “ The PCN is a foundation of all integrated care systems;…” ( P 30 p4.28 Framework)

    The practices, in agreeing to the Network Contract DES, AND the Network Agreement are bound to work together, share patient and other data, carry out network specifications, share network funding for new non- doctor network staff ( >22,000 of them over 5 years ) and deliver other urgent care and extended hours services.
    The network agreement requires that providers of other medical and social care, join the new PCN, e.g. community providers such as dentistry, optometry, Virgin run nursing, charities, acute and mental health trusts and local authority social care, over time. In this way the new PCN becomes an integration machine.

    In signing the Network Contract and Network Agreement ( and agreeing an area covering 30 to 50,000 or more population, giving their patient list numbers, choosing a Clinical Director to sit on the Sustainability and Transformation (STP) board, and deciding which NHS contracted body will receive central network funds,) the member practices would form a new PCN.

    Practices are being jumped into joining new PCNs by 30.6.19. Although this is supposed to be voluntary, pressure is being applied for 100% coverage.
    The new PCNs would work under the direction of the STP via the Clinical Director and must deliver LTPlan and STP directives and protocols, i.e. commissioner diktats, or network funding stops.

    In this way the STP in the area ( 1-2mn population) would become REAL.- in the sense of running GPs and patient lists as their delivery arm. ICSs = STP boards + PCNs. ICSs cannot function without NHS registered patient lists.
    Astonishingly, whether practices join the new PCN or not, their patients will belong to the Network anyway (P 28. p 4.19) and network services would still be provided to those patients.

    Two critical consequences flow from this Framework; 1. Patient lists will in future belong to the practice AND to the network.
    The ownership of NHS patient lists will in this way be acquired by the ICSs. 2. GPs will be working to their original practice contracts AND to the Network contracts. The two contracts would be double running.
    GPs are being assured that as they still retain their core practice contracts, – all be-it overlayed by the Network Contract DES, and the network integration agreement – that they are safe and their original GP primary medical services duties would remain the same.
    But for those with eyes to see, -with the augmentation of network funds over five years, ( £1.8bn nationally compared to £1bn for the core practices ) the flooding -in of new non -doctor network staff to do GP work, requirements to perform new ways of working, and redesign care, and diktats to reduce hospital referrals and cut hospital care to achieve ‘shared savings’ for the ICS, – that GPs would lose their autonomous leadership role of patient advocate, prioritizing optimal care for their patients. GPs would find themselves driven by perverse incentives to endorse the constant cheapening of care and denial of hospital treatment.
    GP practices would become entangled in the Networks physically and financially and find it difficult to get out again. They would be better to not sign up. Over half of GPs are now salaried sessional or locums and the BMA GP membership has not had a vote.
    This Framework is a thousand times worse than the GP contract change in 2004. It aims to herd GP practices into new integrating networks which form the basis of giant ICSs throughout England. Through multiyear GP Network contract changes, the Framework enables ICSs to ‘evolve, and paves the way for fully integrated ICPs on single long term NHS contracts, tailor-made for international corporate takeover.
    The American model has been pursued in England by successive governments since Enthoven recommended HMO Kaiser Permanente to Mrs Thatcher in 1990. Simon Stevens, (Blair’s health advisor 1997 – 2004, vice president of UnitedHealth the biggest US health insurance company 2004 – 2014) was appointed CE of NHSE in 2014 by David Cameron, and then advocated ACO style ‘new models of care’ in the Five Year Forward View. (6) American accountable care methods are now being imposed in England from within by NHSE, well before President Trump opened his mouth about more US trade deals.
    These proposals should be exposed and opposed by all who treasure the NHS publicly provided according to clinical need, comprehensive and free at the point of use.

    Anna Athow

    annaathow@btinternet.com

    9.6.19

    references;

    1.  “ Why we should be concerned about accountable care organisations in England’s NHS.” 30.1.18 BMJ 2018; 360 doi: https//:doi.org/org/10.1136/bmj.k343
    2. UnitedHealth Center for Health Reform & Modernisation “ 2012FAREWELL TO FEE-FOR-SERVICE A “Real World “strategy for Health Care” Dec 2012: https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2012/UNH-Working-Paper-8.pdf
    3. “Accountable Care’- the American import that’s the last thing England’s NHS needs.” Stewart Player, 1.3.16 https://www.opendemocracy.net/ournhs/stewart-player/accountable-care-american-import-thats-last-thing-englands-nhs-needs
    4. “Commissioning and funding general practice Making the case for family care networks.” 2014 Rachael Addicott & Chris.P 38 https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/co mmissioning-­‐and-­‐funding-­‐general-­‐practice-­‐kingsfund-­‐feb14.pdf
    5. “Network Contract Directed Enhanced Service” NHSE 29.3.19  https://www.england.nhs.uk/wp-­‐content/uploads/2019/03/network-­‐contract-­‐des-­‐specification-­‐2019-­‐20-­‐v1.pdf
    6. “The Multispecialty community provider ( MCP ) emergingcare model and contract framework” July 2016 Gateway 05637 https://www.england.nhs.uk/wp-­‐content/uploads/2016/12/1693_DraftMCP-­‐1a_A.pdf
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    Integrated Care is the most recent re-naming of Accountable Care: the system currently being implemented in the NHS in England and which is derived from the US. This blog addresses issues arising from this implementation and whether or not Integrated Care is fit for public purpose.

    The narrative that comes from Westminster, echoed by parts of the media and even some campaigners, is that whilst cuts and closures, underfunding, understaffing and poor NHS management at the highest levels are all contributory factors to the problems the NHS faces, there is no overarching concern with Integrated Care itself.

    On the contrary, the bringing together of commissioners (purchases of services) and providers of services is viewed as getting rid of the hated ‘purchaser-provider split’ which is isolated in this narrative from all other structural components and becomes a proxy for the market system. On this point alone the move to Integrated Care is seen as a stepping stone to a return to public service. There is even some movement to reclaim ‘integrated’ as a term of public service.

    There are very good reasons why tackling this issue head on may be politically sensitive. Labour is keen to claim for itself not only the creation of the NHS (which it historically deserves) but a current role as the best defence against Trump. The Secretary of State for Health also claims that he will not allow the NHS to be in US-UK trade talks ‘on his watch’. That is understandable, but the love affair of the major UK political parties with United Health and Kaiser Permanente, amongst others, goes more than skin deep. US Integrated Care has been introduced into the NHS piecemeal over the last 30 years and we are now into the full adoption of an NHS ‘version’ being rolled out at speed. It’s here where the argument lies for politicians, think tanks and amongst campaigners . A question mark is raised over its origins and over whether it is irredeemably bad for the NHS or not.

    Our counter argument is threefold:
    1. The Integrated Care System does not in fact remove the ‘purchaser-provider split’, but merely changes it to a different type.
    2. The constraints put upon the NHS to meet the requirements of Integrated Care are set out in terms of restructuring the service in such a way that it will no longer meet the key tenets embedded in it from its creation: delivering all services for everyone within (mostly) easy reach.
    3. “One thing the community cannot do is insure against itself. What it can and must do is to set aside an agreed proportion of the national revenues for the creation and maintenance of the service it has pledged itself to provide.” Bevan’s statement worked on a national level while the ICS model creates a risk and reward system in which profit and loss are to be shared locally between the constituent players of 44 ‘local health economies’. This is entirely upending the basis for financing the NHS.

    Integrated Care
    The concept of Integrated Care is a longstanding method in the United States which was created to try and reduce the healthcare costs which are spiralling out of control. The most expensive part of any healthcare system anywhere in the world is acute care. It needs higher concentrations of staff per patient, more infrastructure – both buildings and equipment – and changes more rapidly than other parts of the service in its response to technological advances.
    It follows from an accounting point of view that any measures which can be taken to ‘reduce demand’ on the acute sector will reduce costs. Part of the cost reduction exercise in the US involves forming collaborative bodies (Accountable Care Organisations aka Integrated Care) which share profit or loss across the different constituent bodies – that is to say the insurance groups who provide the funding from their clients (state or private) plus various hospitals, GP practices and other health services. The profit and loss sharing is designed to provide incentives for keeping people out of hospital and in theory to keep them more healthy in the community.
    From the above, it is clear that purchasing and providing still exist within US Accountable Care and that it in no sense represents a return to the kind of planning required to run a public service NHS. The same is true of the system being implemented in England.

    Restructuring the NHS
    In order to attempt to meet the accounting criteria behind Integrated Care, the NHS’ historical provision of local GP family practices, local District General Hospitals that include full Accident and Emergency and other local services must be dismantled. Acute and emergency provision is calculated to be more cost effective if it is concentrated in hospitals that service a much larger population. Local hospitals then become satellites to the centralised major trauma hospital no longer offering the full service we are used to.
    GPs are being corralled into much larger units which may run the satellite hospital or work from large centralised clinics. Property made ‘surplus’ from these restructurings can be sold as a result.
    These changes are an intrinsic part of the development of Integrated Care. They are not optional, nor do they come about only as a result of the last nine years of below inflation funding.
    None of the descriptions above are based on assumptions. They all come from official NHS England and Sustainability and Transformation Partnership policy documents. The reality is evident on the ground.

    Risk and Rewards
    “Risk and reward sharing is underpinned by a theory of change that expects a provider to adjust its behaviour in response to financial incentives”
    Early adopters of the ACO model in 2012 in the US, known as Pioneers (see our report on ACOs for more details), were allowed to move to a full capitated budget. This represents the full transfer of risks from the commissioner to the ACO and it means the ACO has the incentive to cut costs in order to maximise its profit share from the budget. As in those early pioneer ACOs, NHS England has made it clear that it wishes to pass all financial risks to the Integrated Care Systems. But unlike the US model, an NHS ICS does not necessarily have to include acute hospital services in its provider collaboratives. As the greatest losses fall on acute hospital services this creates the possibility of a collaborative being formed only from those providers who can best make profits.
    Our report into ACOs explains how many of the participants in the early US pioneer programme failed to see many of the implications of a shared savings programme, seeing only its potential benefits. They later discovered that they had serious financial difficulties.
    This question of risk and reward sharing is one of the most important issues for an NHS provider and illustrates how they have moved from being government provided services to government commissioned services. Under this scheme an NHS provider could potentially suffer significant losses risking its financial viability to the point where it may collapse as a business.

    The failures of private sector providers, as we have seen in recent years, causes inconvenience for commissioners and loss of services for patients but the potential collapse of an NHS body would have far more serious ramifications. There is also the case where a majority of an ICS’ services are provided by private sector organisations which opens the door to profits flowing out of NHS funds. Furthermore the arrangements for how both risks and rewards will be shared between providers adds another layer of complexity to the transaction costs of the NHS. This, of course, provides yet more work for management consultancies, big accountancy firms and lawyers.

    What’s to be done?
    We fully appreciate the desire of campaigners to achieve victories in the face of what feels to be overwhelming odds. Each local victory does throw a welcome spanner in the works. However, to ignore the structural changes being brought in and not to recognise the part that each individual closure or downgrade plays in the overall pattern of change is to ignore the elephant in the room.
    That is why we think the slogan ‘Act Local, Think National’ should always be embedded in every campaign. It is important to understand that the national picture gives the corporate sector a major role in the future of the NHS as it has done increasingly over the last thirty years and that the model currently being adapted is specifically based on US Integrated Care.
    This is a system built fundamentally on business principles with competition and the profit motive in its DNA. This is not a system that lends itself to public ownership and provision serving the public interest.
    President Trump’s statement about the NHS being on the table in future trade talks set off a raft of responses including Jeremy Corbyn tweeting, ‘Labour will [..] ensure US private companies cannot lay a hand on our NHS. The NHS is not for sale’ and Matt Hancock saying, ‘not on my watch’. It has understandably provoked a lot of comments on social media and discussions in the press about the importance of keeping the US out of the NHS in the future. But the challenge is to change the conversation so that we openly oppose US corporate interests influencing our NHS now.

    Deborah Harrington

    Who We Are

    4 Comments

    This article was first published in the Camden New Journal under the title, Brexit, and spectre of NHS US sell-off, on 16 May 2019.

    There is much talk at the moment about the prospect of Brexit resulting in a trade deal with the US which will sell off our NHS to American private healthcare providers.

    This fear has also been expressed by Shadow Health Secretary Jonathan Ashworth. [1] But it is critical to understand this “sell-off deal” has been under way for a long time and is fast gaining momentum, argue Susanna Mitchell and Roy Trevelion.

     

    The driver of the “sell-off deal” is Simon Stevens, who in 2014 was appointed head of NHS England, the body that controls all NHS spending. Before this, Stevens had been vice-president and CEO of the mammoth American healthcare corporation the UnitedHealth Group.

    Stevens has proceeded to “Americanise” the service through his subsequent NHS policy, based on a privatisation strategy he had outlined at the World Economic Forum at Davos in 2012. [2]

    From first to last, his NHS policy – the Five Year Forward View, the Sustainability and Transformation Plans and Accountable Care Organisations (renamed Integrated Care Programmes) that back it up, and now the 10-year Long Term Plan – have worked to import the US model into the UK.

    Unsurprisingly, the UnitedHealth Group will make major gains from this transformation. It is now the largest healthcare company in the world, with a 2018 revenue of $226.2 billion. It has many secondary companies that serve more than a hundred-million people globally. [3]

    Over the years it has been prosecuted for fraud and bad faith practices. This included limiting insurance payments to doctors, and not stating its true financial results in reports to shareholders. [4] [5]

    One of its fastest growing subsidiaries is Optum (formerly UnitedHealth UK). This is a leading information technology- enabled health services business. In February 2015, it was one of the commercial organisations approved by NHS England as “Lead Providers” to carry out the financial work of GPs.

    It is now firmly positioned in the system and ready to take away more public money. [6]

    The healthcare system in the United States is hugely more costly, and outstandingly less effective than that in the UK. In terms of funding and wellbeing, there is no rational argument for imposing it on our NHS. The only benefit it brings is increased profits for shareholders in the commercial healthcare sector.

    To take three examples, first comparing cost:

    On average, other wealthy developed countries spend about half as much per person on health as the US – in the US $10,224 compared to $4,246 in the UK. In 2017 the US federal government spent 7.9 per cent of GDP directly or indirectly on healthcare; however in total, taking into account private expenditure, the US spent a vast $3.5trillion or 18 per cent of GDP. This private sector spending is triple that of comparable countries. [7] [8]  This structure excludes many citizens from affordable health­care. Appallingly, one in four adults skipped a medical treatment in 2017 due to an inability to pay. [9]

    Secondly, from the point of view of efficacy and wellbeing, statistics are also devastating. The US has the lowest life expectancy at birth among comparable countries (US 78.6, UK 81.2). Statistics show that life expectancy for both men and women has increased more slowly in the US. It comes 12th in the global life expectancy table. [10]

    Thirdly, the US maternal mortality rate is truly shocking. It stands at 26.4 per 100,000 live births, the worst among all developed countries. [11]

    In the UK the rate stands at 9.2 per 100,000. [12] [13]

    Deaths for African-American women are three to four times higher than for white women. [14]

    The infant mortality rate is also worse. The US rate is 5.79 deaths per 1,000 live births. [15]  The UK rate is 3.8 deaths per 1,000 live births. [16]

    It is clear that if we follow the American model of healthcare it can only reduce wellbeing in the UK. Simon Stevens’ “sell-off deal” simply increases the wealth of global corporations (such as the Mayo Clinic, which has recently opened in London [17]).

    It is time that this fact was “called out” loudly and clearly. All possible measures must be taken to prevent the continuing imposition of this ineffec­tive and costly system.

    Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.
    References, some links, live at the time of writing, may not have been maintained:
    [1] BBC Question Time 25.04.2019  at 47.21 ff  https://www.bbc.co.uk/iplayer/episode/m0004hkk/question-time-2019-25042019 .
    [2] https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/
    [3] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [4] https://www.sec.gov/news/press/2008/2008-302.htm
    [5] https://law.freeadvice.com/insurance_law/insurers_bad_faith/unitedhealth-pays-400-million-in-bad-faith-claim.htm
    [6] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [7] https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
    [8] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
    [9] https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
    [10] https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-le_the-u-s-has-the-lowest-life-expectancy-at-birth-among-comparable-countries_2019
    [11] https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1560004210914
    [12] https://vizhub.healthdata.org/sdg/
    [13] http://digg.com/2017/uk-birth-us-safety-comparison
    [14] https://www.huffingtonpost.co.uk/entry/elizabeth-warren-black-maternal-mortality_n_5cc0e93fe4b0ad77ff7f717b?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACQmWXh6QTnSJI5sjLN1KEdQCuSnVb__LEQLJAyEiK2PZwqnVABYxo500JrU24NHWCooflTZAia50H4OJ-YzSPMUqXyGODWHMGcBXUxhfVY-fau-ViM-Ly9n32SQ1vXD-SGhWXohZRVo2givDSEbM1D3TVs38R5MjmfY_5rGZXuP&guccounter=2
    [15] https://www.cdc.gov/nchs/nvss/deaths.htm
    [16]https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2016
    [17] https://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnershiphttps://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnership.

     

     

    1 Comment

    Peter Beresford, Professor of Citizen Participation at Essex University and Co-Chair of Shaping Our Lives, the user led organisation.

    Nothing less than a root and branch reform of English social care is now needed. Its funding and principles must be radically reviewed. Only this will end its permanent state of crisis. Nothing else will make anything like a reasonable life possible for the millions of older and disabled people and family carers now suffering-  sometimes in extreme – from its gross failure and ever declining reach. Some commentators still wait hopefully for the promised government green paper that never comes, but given this administration is still committed to its same old neoliberal goals, it is difficult to see why. What’s needed is a fresh start.

    According to the NHS’s own figures, since 2009 the number of people receiving adult social care in England has fallen, despite significantly growing levels of need. In 2009 1.8 million people received some adult care services in a 12 months period. Today the figure is estimated just over 1 million, a cut of 44%. People are also receiving less support and in the many cases where they have to pay, paying more. This year Age UK estimated that 1.2 million people don’t receive the care support they need with essential living activities.

    Most people assume that social care is provided on the same basis as the NHS, paid for out of general taxation and free at the point of delivery. In fact the absolute opposite is the case. It is a relic of the old much hated Victorian Poor law. It is both means and needs tested. This coupled with years of arbitrary welfare benefits cuts in the name of ‘austerity’ and combatting ‘fraud’, means that the lives of many older and disabled people have never been so insecure, impoverished or undermined since the creation of the post war welfare state.

    So that’s the first thing that must change. It’s not just that social care needs to be ‘integrated’ with the NHS – a favourite word of current policymakers – in principle and practice – in values and funding base as a universalist service, free for those who need it. It also need to be based on the philosophy of independent living developed by the disabled people’s movement. This means that instead of framing service users in deficit terms – what they can’t do – it is rebuilt on the fundamental principle of making it possible for them to live their lives on as equal terms as non-disabled people, non-service users. And this demands similarly based income maintenance, housing, education, employment, planning, transport and other policies.

    We are not going to see this from right wing governments committed to ‘the small state’, the individualising values of the market, regressive taxation and cutting state spend on supporting people. But this must be the basis for any political party committed for the future to securing the rights and needs of all its citizens (as well as challenging hostility and discrimination against non-citizens).

    To achieve this, advocates of truly radical reform of social care, are calling for an ‘independent living service’, which has the financial backing and overview of the treasury and which brings together the roles and responsibilities of all departments to make possible equal lives for the rapidly growing minority of disabled and older people who can expect to need support. Thus, like the NHS it would be harmonised from the centre, to avoid the problems of the present post-code lottery arrangements linked with the current locally led system.

    The present loss and impoverishment of many user led organisations; that is to say those directly controlled by disabled people and other service users, needs urgently to be reversed and such a national network supported to be a key provider of support and services on a human and local scale for service users, offering a key source of accessible high quality training and employment to service users for whom employment is a positive and realistic choice.

    Finally in an aged of AI – artificial intelligence – social care needs to be reconceived as a major generator of positive relationship-based employment and a net social and economic contributor that can be part of a new sustainable economics and social policy. Here we can see the vanguard of a new planet friendly approach to social policy, that offers the promise of high quality support, high quality employment and truly participatory policy and practice.

    Professor Peter Beresford is author of All our Welfare: Towards Participatory Social Policy, Policy Press. He is emeritus professor of social policy at Brunel University London, professor of citizen participation at Essex University and co-chair of Shaping Our Lives.

    4 Comments

    Background

    The NHS Executive outlined eight groups of suggested legislative changes in the NHS Long Term Plan and, as promised in the Plan, these have now been set out in further detail in Implementing the NHS Long Term Plan: Proposals for possible changes to legislation [1]. The intention is to make it easier for NHS organisations to work together. Ostensibly these proposals are supposed to help the NHS improve its delivery of services but we see real problems here.

    Principal objection

    The Health and Social Care Act 2012 was a package promoting a range of checks and balances on the operation of the NHS, designed to support local commissioning; patient choice and competition at the provider level; governed by arm’s length regulators safeguarding quality and the NHS market; and local authority and consumer scrutiny, consent and supervision.

    It is not easy to change one part of this without unravelling the whole but this is what is now proposed. There are good arguments for the complete revocation of this Act with its muddled thinking, naive faith in competition and GP-led commissioning, and the notion that politicians could shirk their own responsibility for taking difficult decisions by passing the buck to NHS managers and regulators.

    But such a major change should only be done after full discussion, white papers, consultation and time to debate primary legislation in Parliament. These proposals are nothing more than a way of avoiding full Parliamentary discussion. The danger is that ad hoc tinkering rather than fully thought through reform will do more harm than good.

    Lack of evidence

    The supposedly new ethos promoted in these changes is ‘integration’ of service provision under one body. This may appear a plausible way forward but it is unproven as an operational principle or as a means of delivering improvements in efficiency or quality. The House of Commons Select Committee[2], the National Audit Office[3] and more recently the Nuffield Trust[4] have all produced highly critical reports of the new fashion for so-called integration. As yet these criticisms have not been answered.

    A recent perplexed quote relating to the Greater Manchester (GM) experience sums matters up, “Everyone I’ve spoken to is at a loss to explain why GM’s performance has been so poor, given the progress that’s been made on integration and the transformation investment that’s gone in”, HSJ 25th February. The true lesson here is that integration does not guarantee success. But this is a lesson that NHS bosses do not want to hear.

    We have closely monitored projects in various parts of the country that have been forced to pursue this transformation and integration agenda and, in for example Manchester where massive investment has taken place, there is precious little to show for it. The latest reports from the Nuffield Trust show that integration is a more costly model[5]. These proposals therefore lack evidence that the new policy response will succeed.

    The downside of the proposals

    All new proposals must demonstrate that they will do no harm. But, by making it easier to force mergers and close down acute hospitals in the name of ‘integrating’ services, the NHS is seeking to institutionalise a model that seeks to cut local services for patients without adequate consultation, and push back onto the patient the costs and delays of the failures of care that will result. At least checks and balances were built into the Health and Social Care Act 2012 requiring proper presentation of detailed plans, independent regulator support, widespread local stakeholder support and the right to challenge decisions; these would now be scrapped in favour of a centrally-led structure with NHS England at its heart, leading a purge of NHS capacity as it strives to meet government-imposed arbitrary financial targets.

    These proposals are nothing more than a power grab by NHS England to enable its own transformation and integration policies to be imposed on unwilling communities. This is to be achieved by reducing the role of the independent regulators to mere ‘yes men’ as NHS England becomes the only source of power; by elevating the achievement of financial results to the overriding objective (best value); by being unaccountable to local people by removing the link to local accountability which however faulty was the basis for major decisions; and, by promoting a vague and meaningless slogan (integration) as the main principle justifying its activities.

    Concluding remarks

    This is a power grab by NHS England under cover of the distraction of Brexit to achieve for itself untrammelled power over the future of the NHS. It will then act quickly: a wave of mergers, closures and sub-contracting of new models of care would be unleashed. These changes would be enacted quickly and with very limited means for local people to challenge decisions.

    MPs will find themselves and their constituents faced by a fait accompli with little that can be done. Voters in upcoming general and local elections will express their feelings for local hospitals in the traditional way (by voting against politicians who allowed this to happen). But it will be too late. Hospitals and A&E departments once closed rarely re-open. Services sub-contracted for 10-15 years or more will be difficult to restore. Huge integrated care organisations will be monopolistic in attitude and operation, and impossible to be held accountable effectively.

    Local authorities will be either incorporated into this mess in return for crumbs off the NHS table, or left out in the cold while decisions take place around them that will push the costs and implications of changes onto patients and communities.

    Oppose these changes to legislation. Integration is a smokescreen for NHS England to overrule local objections to service closures.

     

    Roger Steer

    14.3.2019

    [1]

    Implementing the NHS Long Term Plan: Proposals for possible changes to legislation

    Engagement Document  February 2019 Prepared by: NHS England Strategy & Innovation Directorate and NHS Improvement Strategy Directorate

    https://www.engage.england.nhs.uk/survey/nhs-long-term-plan-legislation/consult_view/

    [2]

    https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/650/650.pdf

    [3]

    Health and social care integration NAO February 2017

    [4]

    Shifting the balance of care Great expectations Nuffield Trust March 2017; and

    Doomed to repeat? Lessons from the history of NHS reform  Nuffield Trust October 2018

    [5]

    https://www.nuffieldtrust.org.uk/research/age-uk-s-personalised-integrated-care-programme-evaluation-of-impact-on-hospital-activity

    4 Comments

    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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    Is this the knife poised to finally kill the NHS and the post 1945 social settlement?

    Throughout the 80s under Thatcher, but particularly since the Health and Social Care Act (2012), contract after contract for health provision has gone to the for profit private sector. Sometimes the NHS has won contracts, sometimes the privateer, but overall during this last 6 years, our taxes / resources have been drained from public (NHS) to private providers. Stresses on the NHS have been exacerbated by cuts in financial support and staffing, increased demands and by immigrant doctors, nurses and other staff being unwelcome here following the Brexit vote, and it’s liberating a nasty racism. Remaining staff have been exemplary in trying to cope with these demoralising and exhausting situations, but burn-out is now common, staff are sick with stress, continuing to leave or just hanging on for their retirement. Working life for everyone is just not as good as it used to be. Most Trusts in England are now in deficit. Local Authority Social Care is almost non-existent now, again as the result of Thatcher’s immediate and savage cuts in the 80s, and the situation is worsened as local authority funding from central government has been slashed since 2010, and will disappear entirely by 2020. Yet somehow, these combined deficits are all supposed to transform the red to the black by combining health and social care. The latest vehicle in the alphabet soup of acronyms to assist this introduction is Integrated Care Organisations (ICOs) which come with a small money sweetener. However, this money is temporary; almost certainly a one-off as we know this government does not support the public sector and wants it demolished. As Oliver Letwin, the right wing Tory MP said the NHS will have gone by the next election if we win it.

    So how is this to happen? Since the Health and Social Care Act, Section 75 has REQUIRED commissioners to put out to tender everything that couldn’t be provided by the NHS, so hospital services like cleaning, diagnostics, catering etc… have gone already. Now, under the proposed ICOs, Section 75 regulations create rights for commercial providers to promote their interests by rules written by US corporations; these enable any private provider which FAILS to get a contract to compensation by the government if that service returns to the public sector. We have already a foretaste of this, as Virgin claimed and received compensation when it failed to get an NHS contract in Surrey (? Can anyone provide me with the specifics?)   In the past, the Labour Party, the Royal College of GPs and the BMA have demanded that these regulations be scrapped, since clearly the government could not afford to compensate privateers for every contract which had not been accepted – in fact, it would be a great fail-safe money-spinner to submit silly tenders with guaranteed compensation for no service costs at all, especially if those tenders are for 15 years, as is now commonplace! Do I recognise similarities to PFI? ICOs also require to be paid in full for a year BEFORE they actually provide any service, and that money is fixed irrespective of the number or complexity of the procedures they undertake. It looks very much like a ‘race to the bottom’, safeguarding profits by providing the least and cheapest they can.   Is this another echo of PFI? Originally, the commissioners were assured they would not have to use competition in health services, but this seems to have been forgotten and presumably disappears if Section 75 is implemented. When a public contract has been lost to privateers, the service, personnel, equipment and buildings cannot be mothballed, everything is dismantled, and that’s forever. We have so much evidence that privateers ‘cherry pick’ the services which are predictable, easy, most profitable leaving the complex and difficult to the NHS, and if problems arise at some stage in the private service, patients are immediately transferred to the NHS where comprehensive teams of specialist staff, not available in the private hospital, can meet all emergencies IF there’s a spare bed.

    There is no evidence that private services provide a better quality service, in fact, they are not as accountable, nor are they as monitored as is the NHS. Competition / marketisation has led to greater inequalities, increased inefficiency, higher costs and greater public dissatisfaction according to Robert Evans, the Prof of Economics at the University of British Columbia.

    Judith Varley 19.10.18

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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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