Category Archives: Health Care

Health care and treatment in the UK

The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

  1. Global crisis

This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

  1. The public health system

We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

  1. Local government and social care

Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

  1. The NHS

In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

  1. Maintaining people’s standard of living

We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

  1. Conclusion

At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

24th March 2020

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20/03/2020

 

OPEN LETTER TO THE PRIME MINISTER FROM THE SOCIALIST HEALTH ASSOCIATION

Dear Mr Johnson,

The pandemic has exposed the steady destruction of our public services and welfare state which has happened over the last 10 years.

This is the most unprecedented health challenge in 100 years which is complex and difficult – but as voiced by many experts in the field, we have significant concerns about the way the UK government has hitherto been approaching this national emergency. We hope from now on this will be better co-ordinated. We support frontline staff at this worrying time.

However the public is finally waking up to the fact that, as a result of government austerity and privatisation policies, we are ill-prepared – with too few ICU facilities, NHS beds, healthcare staff and equipment – to offer a safe and effective response to the virus. Those most at risk also have to use a threadbare social care system which is already bending under the strain.

The UK should be in a relatively strong position on public health with a comprehensive service, considered one of the best in the world. However, Tory reforms in England destroyed the health authority structure below national level and has slashed budgets but at least Public Health England has a regional organisation and Local Government have Directors of Public Health. We wish to make some key points:

  1. You are placing staff at risk

There is not enough personal protective equipment (PPE) for clinicians/frontline staff who are now personally at risk every time they go to into work.

There is insufficient testing of staff who, having been put off work with minor illness and then return to the front line, do not know whether they have had the virus or not.

  1. You are placing patients at risk

There are too few beds and too few trained intensive care staff and equipment such as respirators. The government appears to have acted too late. We should be requisitioning beds from the private sector, not paying them £2.4 million a day.

Covid-19 testing has been wholly inadequate. It appears that a combination of inadequate preparation and misguided policy is responsible.

  1. You are placing communities at risk

Undocumented people, for instance migrants and refugees, have long felt unable to use the NHS for fear of being referred to the police or the Home Office. This will increase risk. Legislate on charging and reporting undocumented migrants must at least be suspended.

Those precariously employed, particularly gig economy workers, are still not financially protected and may be compelled to continue working inadvertently spreading infection.

Thousands of excess deaths have occurred in the last few years as a result of the slowdown and reversal in life expectancy. Austerity policies have been a significant cause. It confirms international evidence that cutting the welfare state while at the same time introducing austerity, kills people.

This pandemic is likely to add to that grotesque toll.

  1. You are placing the NHS at risk

Government policy has split hospitals from general practices and from each other. It has created an industrial approach to care where staff and patients are increasingly seen as economic units. The newest redisorganisation has opened up the English NHS planning process to the private sector and to the US, especially if we have a trade deal. In addition, it has the potential to split the English NHS into 44 independent units – exactly what we do not want as we fight a global pandemic. If your government’s Long-Term Plan had already been fully implemented doing exactly that, we would not have been capable of a well-coordinated national response to the Covid-19 crisis.

  1. You are placing Social Care at risk

Too little funding for Local Authorities has put social care on life support. Those most at risk receiving personal or residential care appear to receive the least advice and the least support to combat the virus. Those with Direct Payments, organising their own care with Local Authority funding, appear to be entirely on their own if their carers get ill.

  1. You are placing democracy at risk

The most recent reorganisation of the NHS has made both formal and informal democracy more difficult. Just when we need all communities to collaborate and contribute to responding to this global challenge, NHS organisations have become more distant and poorly responsive.

It has been frustrating and confusing to have changing government advice without any formal presentation of the data and evidence behind it. It was patronising and did not inspire confidence.

 

WE EXPECT YOUR GOVERNMENT TO:

  • Treat us like adults – show us the evidence on which you base your decisions
  • Protect frontline staff right now with clinically appropriate protective gear and systematic testing. Bring testing in line with the WHO recommendations.
  • Protect the population of the UK by permanently increasing NHS staff in hospitals and primary care, increasing hospital beds, increasing respirators.
  • Roll back privatisation and austerity across public services.
  • Seize the opportunity of this pandemic to invest for the long-term in the welfare state, recognising that a thriving society requires a thriving state.
  • Suspend now legislation on the charging and reporting of undocumented migrants.
  • Invest permanently in social care, making it free at the point of use, fully funded through progressive taxation, promoting independence for all and delivered by a workforce with appropriate training, career structure, pay and conditions.
  • Protect those in precarious employment from financial meltdown from the pandemic. All those who should not be at work should have an living income.
  • Ensure that people across the UK have equitable access to the help they need, through their Devolved Administrations
  • Review the Long Term Plan

 

Faced with this international emergency, we need to combine medical expertise – including support from abroad, with technical investment with practical solutions and community engagement along with emergency economic measures to fight this together.

 

Chair SHA

Dr Brian Fisher, London

Vice-chairs SHA

Dr Tony Jewell

Tony Beddow, Swansea

Norma Dudley, London

Mark Ladbrooke, Oxford

Secretary

Jean Hardiman Smith, Ellesmere Port

Treasurer

Irene Leonard, Liverpool

Co-Chair KONP

Dr Tony O’Sullivan, London

 

Co-signatories

Dr John Carlisle, Sheffield.

Terry Day, London

Carol Ackroyd, London

Corrie Louise Lowry, Wirral

Caroline Bedale, Oldham

Hazel Brodie, Dumfries

David Taylor-Gooby, Newcastle

Peter Mayer, Birmingham

Dr Alex Scott-Samuel, Liverpool

Dr Jane Roberts, London

Dr Judith Varley, Birkenhead

Vivien Giladi, London

John Lipetz, London

Jane Jones, Abergavenny

Dr Kathrin Thomas, Llandudno

Dr Louise Irvine, London

Dr Jacky Davis, London

Dr Coral Jones, London

Dr Nick Mann, London

Dr John Puntis, Leeds

Brian Gibbons, Swansea

Anya Cook, Newcastle,

Alison E. Scouller, Cardiff

Punita Goodfellow, Newcastle upon Tyne

Parbinder Kaur, Smethwick

Gurinder Singh Josan CBE,  Sandwell

Jos Bell, London.

Steve Fairfax Chair SHA NE, Newcastle upon Tyne

 

The Socialist Health Association is a policy and campaigning campaigning membership organisation. We promote health and well-being and the eradication of inequalities through the application of socialist principles to society and government. We believe that these objectives can best be achieved through collective rather than individual action.

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Our response to Government guidance on COVID and self-isolation
Our Senior Legal Officer, Katie Wood, has compiled initial guidance on COVID and pregnant women’s rights at work in light of the Government guidance. It covers health and safety, working from home, sick pay, maternity leave and pay, dismissal and redundancy. Please read and share the blog.We have written to the Chancellor of the Exchequer, the Rt Hon Rishi Sunak MP, about the Government guidance on social distancing and vulnerable adults, including pregnant women. The guidance to self-isolate has clear implications for the income of pregnant women in the workforce during their pregnancy and maternity leave, and for retention of their job. We urge ministers to make a clear public statement that the dismissal of a pregnant woman simply for self-isolating, in line with the Government’s advice, would amount to unlawful pregnancy discrimination. See our letter here and help us share it and demand immediate response from the Government.We are preparing a list of FAQs on COVID, maternity and employment rights. We shall release it as soon as it is ready. Please check our website for regular updates.

 

Our advice lines are open
We provide free legal advice on maternity and employment rights to pregnant women and new parents and will carry on throughout this crisis. Please note that receive a huge number of calls under normal circumstances, we are experiencing a spike at the moment. Please check our information sheets first, they cover a comprehensive range of questions.Our National Maternity Rights Advice Line is 0808 802 0029. It is open all weekdays from 10 am to 1 pm for all callers who live outside London.For London residents, please call our London Maternity Rights Advice Line 0808 802 0057, open all weekdays except Wednesdays from 10 am to 1 pm.For those with questions about NHS charging for maternity care, our Maternity Care Access Advice Service is 0808 800 0041, open Tuesdays, Wednesdays and Fridays 10 am to 12 noon.

Please share this information with your networks and direct your contacts to the right advice line number. If you are unable to get through, please be patient. This is an unprecendented situation and we have limited capacity. We are doing our best and we shall deal with all the calls we can handle.

Posted by Jean Smith on behalf of Maternity Action.

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“Like everyone else, we feel helplessness, anxiety, and fear.”

by Dan Robitzski / 8 hours ago

As they try to fight the COVID-19 outbreak, medical staff in China are suffering from the seemingly endless slog of work, new cases, and the coronavirus itself.

Nurses in Wuhan, the city where the outbreak began, are fainting on the job, developing painful rashes, sores, hypoglycemia, and psychological exhaustion — and that’s why two of them published an impassioned plea for help from the rest of the world in the journal The Lancet on Sunday.

“While we are professional nurses, we are also human. Like everyone else, we feel helplessness, anxiety, and fear,” the authors, Yingchun Zeng and Yan Zhen, both from hospitals in Guangzhou, wrote. “Experienced nurses occasionally find the time to comfort colleagues and try to relieve our anxiety. But even experienced nurses may also cry, possibly because we do not know how long we need to stay here and we are the highest-risk group for COVID-19 infection.”

Nearly 2,000 medical workers helping COVID-19 patients in China have been infected, and at least nine have died. Meanwhile, the nurses write that the safety measures they have to follow, like quadruple-layering gloves and constantly wearing and washing tight respirators that are giving them bedsores, are simultaneously making them sick and rendering them useless as caregivers.

For instance, unpackaging medical supplies and giving a patient a shot while wearing four layers of latex gloves is particularly difficult.

“Due to an extreme shortage of health-care professionals in Wuhan, 14,000 nurses from across China have voluntarily come to Wuhan to support local medical health-care professionals,” the nurses wrote. “But we need much more help. We are asking nurses and medical staff from countries around the world to come to China now, to help us in this battle.”

 

 

 

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One on International Trade dispute settlements and the other on Social Care.

These are not official SHA policy.

Issues for the NHS during UK Trade deal Negotiations

As socialists we have an almost irreconcilable set of principles

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The long-running Lincolnshire health visitors’ dispute is coming to an end with a pay victory that sees the vast majority of the workforce being upgraded.
Unite, Britain and Ireland’s largest union, today (Thursday 5 December) hailed the victory, which will see most of the union’s members move onto the grade 10 pay scale, as ‘highly significant’.
Unite regional officer Steve Syson said: “Thanks to the tremendous solidarity that our members have shown since this dispute started in the summer, we have achieved a highly significant and welcome victory.
“The health visitors’ determination against what they considered as a gross pay injustice was buttressed by the firm backing from the people of Lincolnshire and from supporters across the UK.”
The dispute had centred on the council’s insistence on different contracts for grade 9 and grade 10 health visitors, while Unite has consistently argued that as all health visitors have the same qualifications they should be paid the same.
The health visitors have now suspended their month-long strike action while the authority upgrades the health visitors; however, Unite reserves the right to reinstitute strike action if the council does not abide with the agreement. Besides the grade 10 job roles, the health visitors will receive between £2,000- £6,000 in a one-off transitional payment.
More than 70 Unite health visitors voted for the month-long, now suspended, strike that started on 18 November. Of those, about 58 will now be fast tracked to the grade 10 posts with 16 further Agenda for Change (AfC) staff awaiting confirmation; about 13 have left or are departing to take up alternative employment within nursing, which leaves a handful of relatively new health visitors on grade 9.
Unite pledged today that it would explore every avenue to get those still on grade 9 uplifted to grade 10 as soon as possible.
Unite regional secretary for the East Midlands Paresh Patel added: “I think that a number of factors contributed to this positive outcome, including the fact that the council was, and even now, is continuing to lose highly skilled health visitors at the rate of knots, as our members are offered alternative roles elsewhere in recognition of their experience.
“There was also the stark realisation by council bosses that our members were prepared to take further strike action on top of what they had already taken in the summer, after a second ballot confirmed they were prepared to continue on with further industrial action.
“This victory should be seen in the context of a broader campaign for a fully-resourced health visiting service across England – that fight will continue across the country in 2020.”

Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

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The life long member of the Socialist Health Association, Dr Julian Tudor Hart died on July 1st 2018. The following is the funeral tribute paid to him by Dr Brian Gibbons who worked with Julian in the Upper Afan Valley Group Practice  in south Wales.

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There is no great forest that is made up of a single tree, no great river made from a single tributary or no great mountain range with single peak.

And as we come here to remember and commemorate the life of Julian Tudor Hart—we realise what a multi-faceted individual he was.

He embraced and embodies such a broad range and depth of
subjects, knowledge and skills, accomplishments and life experiences

 

To say that Julian was interested in politics and the life of the community that he served for almost three decades would be like saying that Gareth Bale was known to be able to kick a football.

Julian’s politics were principled, passionate and undiminishing right up to the final months and weeks of his life.

Even then he was involved in the Labour Party, Swansea Labour Left and in the affairs of the Upper Afan Valley — in campaigns to keep the key community facilities open such as Cymer Swimming Pool open.

And he was revived and renewed with Jeremy Corbyn’s victory in the Labour leadership election and the outcome of the last year’s general elections which showed that British elections no longer had to be won from the middle ground of politics.  And that it was possible to offer people, and particularly the young, a radical alternative for change

And, I’m sure, Julian was not only pleased to see a leader from the left at the helm of the Labour Party.
But he would have also been pleased that that leader shared another of Julian’s great passions — gardening.

If Julian had a chance to speak to Jeremy Corbyn he would have talked not only about politics but also runner beans, carrots, radishes and lettuce.

And those discussions would have given a new meaning to the idea of “organising a left wing plot “ !!!!

 

Julian’s politics came from the heart

But it found expression in the head and in the hand.

He investigated and analysed and applied the scientific method to his political beliefs.

And Julian respected all those who did the same even those who took a diametrically different point of view from him.

It was all the more than painful for him, therefore, to see over recent years to see that ignorance, prejudice and bigotry is too often used as evidence in much of the present political debate.

Karl Marx said, and I am sure that to quote him here this morning at a humanist funeral for Julian Hart is in order.
“The philosophers have only interpreted the world, in various ways. The point, however, is to change it.”

And this is what exactly what Julian did.

Yes he used the scientific method to interpret the world but not with some sort of detached view of the ivory tower academic or to provide frothy intellectual fodder for the chattering classes.

But to intervene to make a difference, to make society a fairer and more equal place for us all to live, a place where we can all work together for our own mutual benefit and the common good, where we all live a more enriching and enjoyable life.

Where all would contribute according to their ability and receive according to their need.

 

Julian was a man of action.
From campaigning side by side with the people who lived in Glyncorrwg and the Upper Afan Valley, through writing papers, pamphlets and books, giving interviews and partaking in debate, peaking and organising meetings,

He was an active, conscientious and creative member of many organisations as diverse as the Socialist Health Association of which he was the first honorary president and the Royal College of General Practitioners of which he was a council member for many years – where he constantly took the view that high professional and clinical standards, particularly for those with the greatest health care needs, were the natural ally of a thriving NHS.
He advised national political parties and governments in various parts of the world.
And he had a particularly important role in the development of health policies in the run up to and in the early years of Welsh devolution.

In short he walked the streets with the people of Glyncorrwg in their campaigns and he also walked on an international stage.

And in mentioning all of this, we do need to remember the support he received from his wife Mary and his children whose home was often a cross between a Heathrow terminal and Piccadilly Circus as people dropped in from far and near from the Afan Valley to the Appalachian Mountains and even further afield.

He also brought his activism and creative thinking to many local campaigns.And we can see the physical legacy of that in the Upper Afan Valley – the South Wales Miners Museum, Glyncorrwg Ponds and Glyncorrwg Mountain Biking Centre.

Of course Julian would agree that none of this would have been achieved without the co-operation in local community efforts and a massive amount of hard work and effort by many local people.
But equally I am sure that there are few who would disagree that none of these projects would have achieved what they did without Julian Hart.

 

Julian Hart was an unrepentant socialist …but he was most particularly committed to promoting and protecting the NHS.

He saw the NHS as being the embodiment of the values of a socialist society, where people contribute, through their taxes, according to their ability to pay – unless you are Google or Amazon, of course — and you receive according to your need.

Nye Bevan was, apparently, once asked how long he thought the National Health Service would last and he is reported as saying “ The NHS will last as long as there’s folk with faith left to fight for it.”

But one of our most resolute fighters for the NHS has left us.

Already many people have started to consider what sort of monument or memorial would be fitting to commemorate Julian Hart’s life work.

But I am sure that Julian would be first to say – the greatest of all memorials would be the continuing campaign to protect the NHS and the work to allow it to innovate and expand, to develop and to flourish as an even greater public service than it is now.

One of Julian’s favourite singers was Paul Robson, who was once one of his patients, and one of Paul Robson’s most popular songs was Joe Hill which you will hear later.

Joe Hill was a Swedish immigrant and trade union organiser in the USA who was framed for murder and executed in Salt Lake City.

The song reminds us that even though Joe Hill did die, his spirit lived on wherever there was a the struggle for trade union rights and a campaign for social justice

And Julian’s spirit will live on to be a similar source of
inspiration though he is no longer with us.

Joe Hill said is his last letter – “Don’t mourn, organise!”

Julian would have repeated that message

Organise to protect and build the NHS.
Organise to build a better, more caring and equal society.

That must the first and enduring monument and then we can get on with the rest.

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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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

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