Category Archives: Liverpool

This is a talk given by Public Matter’s Deborah Harrington at an NHS event held jointly by NEON (New Economics Organisers Network) and Health Campaigns Together for The World Transformed in October 2018 in Liverpool.

The brief was to speak for no more than 7 minutes and ‘not to dwell on the history’ but on how to move forward.

The talk began with a quote from the novelist Milan Kundera:

“The struggle of man against power is the struggle of memory over forgetting.”

“We allow our futures and our present to be reshaped by others against our interest if we forget what’s important in our own collective history.

Every NHS campaign meeting contains powerful stories from campaigners – on resisting service closures and cuts, fighting for pay and conditions and more. But I would like to make my first point about what we can learn about building a movement from right at the start of the life of the NHS. From Bevan, in fact. I think this has great relevance to what we are talking about today.

In the first half of the 20th century (don’t worry, it’s not a history lesson) the country as a whole suffered from two world wars, an appalling flu epidemic that wiped out whole communities and the Great Depression. The people didn’t need to be lectured about the Big Society to realise they were all in it together (well, almost all).

The fight was between different political factions at government level about what services were to be delivered and how to deliver them.

Doesn’t that sound familiar?

The arguments were fierce, but Bevan won the day (with a few compromises along the way). But it only lasted 3 years before the principles upon which the NHS was founded were under attack.

If you have never read Chapter 5 of Bevan’s set of essays written in 1952, In Place of Fear, you should. Essential reading for two very important reasons: first he counters the arguments put up against his NHS and secondly he makes his case for his vision of the NHS stand out powerfully against the opposition. If you haven’t read it, you may well be shocked to see him facing all the same arguments we face today: the necessity of having out of pocket payments, the cost of immigrants, the unaffordable burden of the old and the excessive demands made on the system ‘because it is free’. I want to stress from this is that there was general support amongst politicians and public alike that the issue was not over whether there would be a National Health Service, but what form it would take. And Bevan held out for his vision – a socialist enterprise in a very rich capitalist society.

So we move on to the second point – which is defining what a vision of a public service NHS should look like today and what are the threats facing it. I would argue that cuts and closures are the symptoms of the threat, not the threat itself. The threat is from a globalised free market vision of public services as divisible into those which can provide a profit stream and those that can’t.

It’s across the services, not just the NHS and it is across the world, not just in the UK.

But the questions which are thrown out at the public – it’s the old/it’s the immigrants/it’s too much demand/it’s unaffordable – are the way in which the corporate sector frame the situation to cast doubt on the future existence of the NHS in its current form.

And that’s where the catch lies – because the corporate sector which is the engine of this change does have a vision of what the future form should be (effectively to turn it into a UK version of Medicare) and they are doing a hard sell on it. And their sales pitch is seductive.

In it they say that in order to have high quality services we must bring them together, in fewer locations. Surplus land can be sold to help pay for the transformation and the new buildings to house new services can be rented from the private sector ‘bringing investment’ into the NHS. They say the new services will utilise new technology to fit modern lifestyles, that personal health vouchers for those with long term or complex conditions will empower them with choice, that the service will be personalised, focused on you, the patient.

They say it’s the quality of care and the joined up nature of the care that matters, not whether the provider is public or private. So the second take home message is to understand the opposition’s arguments, learn how to demolish those arguments quickly and efficiently and to move on to promoting our shared vision. Because our struggle today is not for any old NHS but for a universal, comprehensive, equitable, public service NHS. Because ‘free at the point of need’ only matters if the service you are getting is worth having. And because every word of their seductive sales pitch is designed to hide the destruction of the NHS’ values of universal and comprehensive care and its ethos of public service, not corporate profit.

And so to my third and final point. Across the country we have individual campaign groups who are extraordinarily knowledgeable about their CCGs, STPs, and all the NHS in England acronym soup. We have umbrella groups which link them together which allows lessons learned in one place to be shared with others. But we also have a wide variation in the individual groups. At the grassroots level look at any group on social media and you will see pro-NHS campaigners arguing from a racist and xenophobic perspective that ‘our’ NHS can’t cope with the demand from ‘non-contributors’. Time and again someone will say that ‘the NHS is what they pay their National Insurance for’ (spoiler alert: it doesn’t). And others (whether well meaning and mis-guided, or simply trolls) saying that the NHS needs to change if it is to continue at all.

At the political and opinion forming level (think tanks, politicians, main stream media) there appears to be a consensus that the Health & Social Care Act (2012)  ‘failed’ and that, whilst parliamentary time is so bound up in other matters, it is good that Simon Stevens is working around that legislation to put the NHS in England back together again. My colleague Jessica and I had a meeting with an MP from the North West who said that this view pervades all political parties and indeed it is reflected everywhere from the cross party Health Select Committee to the recent publication from the Labour Party ‘A Picture of Health’.

But we need to remember what is at the heart of our campaign and keep our message simple and strong. And for that I will quote Jessica’s grandfather, the late Julian Tudor-Hart, who wrote in his essay ‘The Inverse Care Law’ in 1971 ‘the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is exposed to market forces, and less so where such exposure is reduced.’

Because I would argue that the 2012 Act has not failed.

It has done its intended job of ripping the NHS into fragments so that its pieces can be reassembled like jigsaw pieces. It absolutely leaves the NHS exposed to market forces and they are being embedded at every level from decision and policy making to running services. The evidence from across the world proves the Inverse Care Law right. So my last take home message would be to remember that this is a struggle that goes further than England’s boundaries. And it also goes across time.

There is a short term and very urgent battle to be won but it is in a broader and ongoing battle of ideals and ideology that isn’t going away any time soon.”

On the platform with Deborah was Bonnie Castillo, Executive Director of the National Nurses United Union in the USA. The NNU is part of the fight for universal healthcare in the USA. Bonnie explained how important the NHS is as a beacon of hope for them, “Your fight to defend the NHS is our fight’ she said.

From this Saturday there is to be a week of cross-Atlantic campaigning as described here in the Guardian. They want Britons to join in with the NNU’s National Medicare for All week of action, running from 9-13 February. NNU is the largest union representing bedside nurses in the US.

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General comments:   It was wonderful to be amongst such an enthusiastic group of diverse people, of wide age range, varied skin tones, many dressed relating to the country of their family origins, with and without disabilities (wheel chairs were very much in evidence); they seemed to reflect the diversity of our population as I experience it on the street. There was a joyful atmosphere despite almost all the topics reflecting the distress amounting to cruelty imposed by this current government on those least able to fight back; the hunger for change, just the prospect of being able to work in a co-ordinated and supportive way to do something about it is palpable. It’s always so stimulating to be amongst people who are energised to tackle the job for which we know there is such urgent need, although the practicalities of undoing the effects of this long austerity will not be easy. It was also useful to encounter organisations of which I was only vaguely aware previously. All the events out of the main hall in both the main conference and the World Transformed were jammed with people, seats quickly taken, standing room also gone and people bulging into the corridor, leaning one ear towards the door to catch as much as they could.

Women’s Conference:   The SHA Motion supporting Abortion Rights across the UK was not taken forward to the main conference. Coral Jones seconded this motion with a strong statement, and spoke of the dilemmas facing Northern Ireland GPs forced by the 1861 law to make decisions they wouldn’t choose in non-professional circumstances, and that Ulster women choosing an illegal abortion might face imprisonment for the rest of their lives. There is also the situation of BAME women who cannot speak openly for cultural and patriarchal reasons. The other motions were Childcare, Women’s Health and Safety and Women and the Economy. The motions, presentations and supporting contributions from the floor were so persuasive, I would have found it difficult to choose which one to support for the main conference had I been a voting delegate.   All of these motions indicate a deteriorating situation for women and therefore the health and well being of future generations too since such adversities cascade down the generations; problems introduced in one generation may never, or take many generations, or take many generations to be resolved. I suggest SHA takes up the 3 motions which were rejected for the main conference at an early date. Domestic violence, the silenced experience of 1 in 3 women is commonplace, whilst specialist supportive services for women and children have been lost since 2010. Two women killed each week in the UK is not a trivial matter; these murders are about male power and coercive control of ‘his’ woman and a new campaign ‘Level Up’ aims to get more informed, responsible, less sexist, reporting of these situations in which the woman is usually ‘blamed’ for promoting his violence. Support is being given to address male violence (which seems good), but takes funding from the woman and children and often gives the man access to his family again without having reformed his abuse of them

World Transformed – SHA, Health Campaigns Together and NEON (New Economics Organisation Network) combined presenting the debate on ‘Saving the NHS’. Speakers including Jean Hardiman Smith and Deborah Harrington ( made excellent cases with many references back to Nye Bevan’s ‘In place of fear’, how the arguments and threats raised in chapter 5 of this pamphlet in the 1940s are very relevant today, services being unaffordable, people living too long, demand too high etc… and to Julian Tudor Hart’s Inverse Care Law applying throughout the World. There was a pertinent reminder that services free at the point of need only matter if they’re of good quality. Bonnie Castillo, a nurse from the US – National Nurses United ( – pointed out that most and rising ill-health in the US is from preventable diseases, US neo-natal mortality is the highest in the developed world, and that though grass roots demand ‘Medicare for All’ is huge, it’s frustrated by corporate donor pressure blocking supportive Democrats from voting for it. It’s a timely reminder for us in England as corporate lobbying of politicians erupts volcanically here; conflicts of interest seem never to be challenged now and politicians switch easily between well paid corporate and governmental posts.

Fringe meetings on the Future of Care and Universal Credit (in association with the Trussell Trust) were predictably bleak. Barbara Keeley MP said all aspects of care is in crisis, (services, informal family and paid care); care itself had become more intensive and complex as people live for longer, sometimes with profound disabilities and requiring much more intimate intensive personal support often than before. The hollowing out of social care had led to 25% of caring situations now rated as poor resulting in ever more responsibilities being left to involuntary ‘volunteer’ family / friends. The Government’s promise of a Carers Action Plan (vague at best) and extra support for young carers had been forgotten, whilst Local Authorities, deprived of funding could not meet statutory responsibilities, so many people in England now never even approached their Councils for help, thereby contrasting with Scotland where Social Care is still funded. A commission to investigate the range of problems consequent to unpaid care in England would raise the profile of family carers and point out its impact on neglected matters like their entitlement to a pension; a pension is only available to those on the meagre Carers Allowance. The lack of training for unpaid and newer recruits to paid care also needs addressing; insofar as it works currently, the care system relies on an older workforce teaching the younger recruits voluntarily. Re-ablement, helping people to recover care for themselves is of very low priority. It would be useful to publicise the Dilnot Commission Report on Social Care (2011) and its recommendations and to take government to task for its failures. Why call it a caring system when it clearly isn’t?

The many flaws of Universal Credit and the damning report of July 2018 were aired. The numbers of food banks increased by 13% in the last year, 52% in areas where they were fully established already. The Left Behind Report has highlighted the brutality of the immediate problems of 70% of claimants who go into debt whilst waiting to gain access to support. No-one at these meetings could ever doubt the urgent need for reform of Universal Credit and re-instatement of a proper supportive welfare state providing the safety net it used to do with benefits linked to needs. Work coaches are primarily about implementing cuts. It’s not ‘just about managing’, but a question of survival now with 66% of benefit spent on food and the rest on utilities and never forgetting that this situation applies to 1 in 6 families where at least one member is in work and in work poverty has risen from 13 to 32% in recent years.

There were 2 SHA fringe meetings, both held at the Quakers and chaired by Jean

Emma Dent Code, MP for Kensington and Chelsea claimed it was the most unequal borough in Britain, with care homes run by a well known provider, it has 4 of the worse in the country according to the CQC, it has 4 food banks and has had the greatest fall of life expectation ever recorded – 6 years since 2010. She gave the example of a male in one part of the Borough with a life expectation of 63 years, whilst another living near Harrods would have 92 years. She reported many Grenfell related horror stories.

Judy Downing of the Relatives and Residents Association gave an outstanding presentation of the Labour Party’s failure to highlight the lack of standards and needs of the work force in care homes, many of which were run by small providers for profit. She claimed 1.4 million paid carers in care homes had no qualifications, (whilst this is a situation worse than operated in kennels, the same is true for informal family carers). Staff turn-over in care homes is about 28% (costing an estimated £3 – 5 billion), many leaving in less than a year, and about 50% of care homes are inadequate. Currently, US companies are making 12% profit from care homes in exchange for ‘crap’ care.   She suggested CQC should be nationalised to address these horrors with mandatory regulations and training elements.

Eleanor Smith MP called for re-nationalisation of the NHS, with a proper training budget again. Social care and care for the elderly budgets had plummeted since the 1980s, and the NHS would soon be in the same state if nothing was done. Private providers, international hedge fund managers (‘vampire capitalists’) would soon be able to affect health budgets – a clear conflict of interest – and Local Authority care workers are being warned off speaking about what’s happening. 60% of care homes don’t do health checks, there have been 3 times as many cuts in residential home beds as in the NHS. A Mental Health Capacity Amendment Bill if enacted would allow a care home manager to make the decision to deprive someone of his liberty – a privatisation of liberty! There is a financial incentive NEVER to discharge a patient when it is so profitable to keep him, as has happened for decades in private mental health care homes.

In the Health Inequalities session we were reminded of the Black Report of 1980 which linked health inequalities and poverty and was ignored by Mrs Thatcher so that since then, services have been lost and deaths have risen. How many more tragedies will happen before it is realised that we need a properly funded NATIONAL Health Service? The process has been to carve up the NHS, give powers to the Local Authorities then slash their funding. This has resulted in public health, drug and alcohol services, sexual health clinics, mental health rehab facilities, women and child welfare and support facilities, preventive medicine of all kinds, life expectation and quality of life all plummeting. Staff see a daily erosion of their service, they are subjected to constant pressure, unrealistic targets, so that many at all levels leave ill. Cuts and privatisation are rife. This is a quote from a nurse who can’t wait to leave ‘I did not become a nurse to make profits to line wealthy pockets.’ The NHS is for the people NOT profiteers. NHS Well-being terms are needed to address the injustice and assess the impact of all these changes on the lives people live including those with chronic and disabling health conditions (not forgetting mental ill-health), the unemployed, especially women’s and BAME’s lives

On the last day, Denis Skinner’s contribution was welcomed with a standing ovation. He described being inspired to leave mining and become an MP by the Atlee government of 1945. He has seen an inclusion at the Conference just not seen in everyday life. A fairer society should be judged by the obstacles it overcomes. He was there at the birth of the NHS, mentioned the various surgical procedures without which he wouldn’t now be addressing us. One was a heart by-pass performed by a United Nations team, and he listed all the countries from which the various medical staff had come – it was huge, as was his reception with laughter, clapping and cheering as the list went on and on.

Judith Varley   11.10.18.

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Ray Tallis is an active member of Keep Our NHS Public and a strong defender of the NHS. This should be a very interesting lecture

Public Lecture: The Royal College of Physicians and the Politics of Healthcare 2018

8 November 2018
Liverpool Medical Institution, Mount Pleasant, L3 5SR

6pm: Welcoming drinks
6.30pm: Lecture

Raymond Tallis is a philosopher, poet, novelist and cultural critic and was until recently a physician and clinical scientist. In the Economist’s Intelligent Life Magazine (Autumn 2009) he was listed as one of the top living polymaths in the world.

Born in Liverpool in 1946, one of five children, he trained as a doctor at Oxford University and at St Thomas’ in London before going on to become profritic and was until recently a physician and clinical scientist. In the Economist’s Intelligent Life Magazine (Autumn 2009) he was listed as one of the top living polymaths in the world.
Born in Liverpool in 1946, one of five children, he trained as a doctor at Oxford University and at St Thomas’ in London before going on to become professor of geriatric medicine at the University of Manchester and a consultant physician in healthcare of the elderly in Salford. Professor Tallis retired from medicine in 2006 to become a full-time writer, though he remained visiting professor at St George’s Hospital Medical School, University of London until 2008. He was visiting professor of English at the University of Liverpool until 2013.
Over the last 20 years, Raymond Tallis has published fiction, three volumes of poetry, over two hundred articles and 23 books on the philosophy of mind, philosophical anthropology, literary theory, the nature of art and cultural criticism. Together, these works offer a critique of current predominant intellectual trends and an alternative understanding of human consciousness, the nature of language and of what it is to be a human being.

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I can’t recommend this film – which focuses mainly on older political activists campaigning for the NHS – too highly.
(Statement of competing interests: I feature briefly in the film)

Pensioners United

Directors: Phil Maxwell, Hazuan Hashim

Country: UK

Running Time: 75′

Year: 2018

A potent account of a passionate group of pensioners who unite together to fight for a better life for themselves and those who will follow them. Starring Jeremy Corbyn, Harry Leslie Smith, the late Tony Benn, and thousands of inspirational pensioners from across the UK.
~ Allyson Pollock

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You may find this video of a meeting held in Birkenhead Town Hall on September 27 of interest. The meeting set the current situation in Wirral, of an accountable care system at a fairly advanced stage, in its national context.

The meeting began with a short contribution from a local GP, Dr Mantgani, who has in the past worked closely with Virgin; he expressed his concerns regarding the threatened closure of five walk in centres.

I then spoke – about 12 minutes into the video – about the historical and current context of NHS cuts, rationing and privatisation.

After a very interesting Q and A, there was a contribution, starting 56 minutes in, from Yvonne Nolan, a former director of social services in Manchester who now lives in Wirral. Yvonne described her work in Manchester, which in effect involved a long period setting up the de facto accountable care organisation which now operates across Greater Manchester. She related this to the current situation in Wirral.

This was followed by further questions and comments; all in all, a fascinating session

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Waiting for Jeremy: Wavertree Chair Alex Scott-Samuel and other invited Merseyside activists on stage awaiting the Leader’s Speech at #Lab18

Note the SHA tee-shirt.


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For those who were unable to attend Conference, here is Dr Coral Jones speaking at the conference.

Jean Hardiman Smith

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To all members, comrades and friends on behalf of the Officers and Executive:

First, I would like to thank Judith Varley for the tremendous support she gave me at the Conference as a disabled companion. It was extra good having an active and interested SHA member as a plus to our usual allocation of 2. Judith was invaluable in discussions, and in looking around the wider fringes and events at conference. I hope she will have her own tale to tell. Thanks also to my SHA fellow delegate, Coral, who was just great to work with. Missing her already.
SHA had a wonderful presence at the Labour Party Conference this year (2018). There was a slight disappointment from the perspective of the Socialist Health Association in that the Conference focus was on Brexit. In the Women’s Conference our own delegate, Coral Jones, spoke well and persuasively on our motion on the issue of abortion, and how it is still technically a criminal matter. Coral will tell us more about this in her own words. Although the motion was not chosen to go forward, one on Women and the economy being favoured, all was not lost. Coral managed to speak to it eloquently, persuasively, and at some length, at the end of the main Conference, after Central Council member Norma Dudley proposed a reference back to our SHA motion on NHS renationalisation. Norma was speaking on behalf of her CLP, but she mentioned us warmly, and was speaking for us too. I cannot praise her ability highly enough, she is a real asset, like Coral.
I discovered, if I didn’t already know, that there is a wealth of talent amongst SHA women. Even when they were not speaking on the platform, or chairing sessions, they were showing their understanding and passion on health and care issues from the floor. I will try to remember some names, but everyone I heard was amazing, so if is an oversight if you are not mentioned:
Saturday/Sunday: Myself and fellow SHA member Felicity Dowling were speaking at The World transformed on the way forward for the NHS on Sunday. I hope I did us proud, Felicity certainly did. I am hoping she will let us have a copy of what she said to put on our website. Jessica Ormerod, and Nicholas Csergo were present to support us, as were other members and friends. If you read this, please add to the debate, and add your name to the people present. As speakers we didn’t get to take part in the round table discussions, and it would be good to hear about them.
Other members were speaking at, and supporting the Conference fringes and events on Sunday, and I hope Felicity will also let us know about the Women’s March to save the Royal women’s Hospital in Liverpool on Saturday.

Monday: Our first Fringe event was on Women’s Health and was very ably chaired by Central Council member and Chair of Liverpool SHA, Irene Leonard. It was attended by Alex, me, and Andy Thompson and a lot of other members and supporters. It was great to see Andy, Alex, and Nicholas supporting the session on Women’s Health. Of course, it is not just a women’s issue, and their support and friendship is very much appreciated. Our members Jessica Ormerod, Felicity Dowling and another local activist with a great depth of knowledge (Alex can tell us more about her, and I hope we meet up with her again – and recruit her), spoke so eloquently and passionately on the subject, and members of the audience were able to make very knowledgeable and worthwhile contributions. I hope Irene will say a few more words on this session.
Tuesday: Coral, myself and Judith mostly stayed in the Conference, but in the afternoon, Brian Fisher our Vice President arranged a meet up to talk about Care in the Community. Judith and I attended, while Coral and Norma both covered the Conference.
Tuesday Evening: Our second Fringe meeting on care and the renationalisation of the NHS Bill. We were very lucky with this, as MP Emma Dent Coad, who is the MP who ensured Grenfell did not pass unnoticed, and Eleanor Smith, the MP who is supporting the Renationalisation Bill through Parliament were both able to be present for almost the whole of the session. We also had our SHA member Judy Downey, possibly the foremost expert in the country from SHA perspective, and who is honest, and passionate. Last, but not least, Brian Fisher our Vice President spoke well and passionately about the issues, and a truly Socialist solution. I had the honour of chairing, but with a whole roomful of energised, knowledgeable and passionate people, both speakers and audience, it chaired itself. Again, Nicholas and Alex were there to support, as were Norma, Corrie Lowry, another Central council member, and great speaker, and Felicity. Our own Kathrin Thomas was also there in support. We all agreed that we could not let care be relegated to the long grass, as it seems to be in great danger of doing, and I hope we will get the opportunity to work with the MPs again. Gilda Petersen, from HCT, with whom we (SHA via Brian and me) are working on a Conference in November (details to follow) brought leaflets to the meeting room. I hope everyone will support this. It is in Birmingham on the 17th November and will be another chance to hear some wonderful speakers again, meet with new ones, and spend a whole day thinking about these complex issues.

Judy spoke about the privatisation of Liberty and will do so again in November.

Today I collected our material from the stall, and listened to a great speech from Jonathan Ashworth, and, to come full circle, the debates to which Coral and Norma made such a great SHA contribution.

To all members and friends, I won’t know what everyone did, and your contributions are all important. Please send me your information and opinions, so that all voices are heard

Jean Hardiman Smith Secretary and proud SHA delegate

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Saving the NHS: Planning Our Fightback
Sunday 23rd September, 10.45 – 12.45
organised by Health Campaigns Together and NEON.

Venue: Black E (sometimes described as Liverpool’s third cathedral) at
1 Great George St, Liverpool L1 5EW

This is part of a series of events, alongside the Labour Party Conference,
organised by The World Transformed.

We plan a lively session that asks participants to think forward and think strategically.
Speakers include John Lister from HCT, Public Matters, National Nurses United, Save Liverpool
Women’s Hospital, Wigan Outsourcing Campaign, Socialist Health Association, Just Treatment.

See you there!

Keith Venables, HCT and George Woods, NEON.

Lastly, ahead of the event we’d really appreciate you helping us promote it and get the word out.

You could retweet the @TWT_NOW tweet here
You could add something like this to the tweet:

‘We’re going to be at the session on a mass movement to save the NHS at @TWT_NOW this year!

Join us to help build a practical plan to defeat privatisation and cuts s/289263841860031/

Join and share the Facebook event page here s/289263841860031/

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My priorities for Health Behaviours …

  1. Change the language!
  2. More controls on junk food marketing to kids
  3. Minimum unit pricing for alcohol is a must
  4. Start taking cycling seriously
  5. Betting. When the ‘fun’ stops


This is my city

It is not a rich city!

Do not blame us about how we live or tell us it’s about our lifestyles or our behaviour but do something about our environment so that it’s easier for us to live healthier and longer.

Premature Deaths from Cardiovascular Disease are significantly higher in Liverpool City Region – 80% could be avoided through behaviour change:

Deaths from Cardiovascular Disease

DSRs = Directly Age-Standardised Rates

But for behaviour change to happen we need less emphasis on the individual more on the environment

  • We are surrounded by junk food and bombarded with messages to buy sugary drinks and processed food
  • It’s sometimes cheaper to buy alcohol than bottled water
  • Our traffic systems are built around cars when bicycles are the environmentally healthy choice
  • And a growing habit-forming behaviour that is leading to public health concerns
More controls on junk food marketing to kids

More controls on junk food marketing to kids

A Labour Government should close existing loopholes to restrict children’s exposure to junk food marketing across all the media they are exposed to. This should include updating current broadcast regulations with a 9pm watershed on advertising of food and drinks high in fat, sugar and salt to protect children during family viewing time and taking action to ensure online restrictions apply to all content watched by children. In addition rules should be extended to cover sponsorship of sports and family attractions and marketing communications in schools”  – Obesity Health Alliance Manifesto, April 2017. Emphasis my own.

Cheap lager

Minimum Unit Price of Alcohol. Ok in Scotland and Wales. How about the UK?

  • Low prices lead to increased alcohol consumption and alcohol-related harms
  • The cheapest products are favoured by the heaviest drinkers
  • A minimum unit price will reduce consumption and harms and will do this more effectively and more fairly by targeting the heaviest drinkers

Congested street

Have things changed from the ‘90s? This is Liverpool

People will only turn to cycling in great numbers when there is a significant investment in safe infrastructure.  

“Doctors should care about cycling, as it’s one of the best preventive health interventions we have. Active commuting, including cycling, is associated with reductions in mortality, cardiovascular disease, and cancer. Body mass index and the percentage of body fat are lower in active commuters …

And it’s not just the individual cyclist who benefits. Car drivers who switch to a bike will reduce air pollution”.

Dr Margaret McCartney, BMJ, October 2017

Go by bike

Cycle commuting is associated with a lower risk of CVD, cancer, and all cause mortality. Walking commuting was associated with a lower risk of CVD independent of major measured confounding factors.

Gambling – How has it got to this?

Gambling sponsors football

Gambling is a Public Health Issue

  • It was the Labour Party who deregulated gambling in 2005. It has damaged the health of the nation
  • It’s a problem that goes beyond simply dealing with Fixed-Odds Betting Terminals
  • The Gambling Commission estimate that the number of British adults with gambling problems is in excess of 400,000 with a further two million at risk of significant health and social problems
  • Let’s ban shirt sponsorship by gambling companies in football
  • And let’s have a radical overhaul of gambling regulation
Benjamin Franklin 1706-1790

Benjamin Franklin 1706-1790

Prevention demonstrates a substantial RETURN ON INVESTMENT – most published health interventions are substantially COST-SAVING

Public Health Priorities for Labour – How Far Do You Dare To Reach?

  1. Change the environment so the default option is healthier.  Lay off on the victim blaming!
  2. We must do more to prevent junk food marketing to our kids which in turn fuels childhood obesity
  3. The evidence is there for Minimum Unit Pricing for Alcohol. Please act
  4. Cycling can and should be for everyone but there must be significant  investment outside London
  5. There should be a radical overhaul of gambling regulation

This was presented at our conference Public Health Priorities for Labour

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Accountable Care Organisations” are mentioned 18 times in the Cheshire & Merseyside Sustainability and  Transformation Plan with no details or background. Massive reorganisation plans are now surfacing in Warrington, St Helens, and West Cheshire. Management consultants PwC, who helped write the STP itself, are guiding developments.

Accountable Care is a concept from the US health insurance market. The idea there is that a group of healthcare firms take responsibility for providing care for a given population for a defined period under a contract with a commissioner, such as Medicare. ACOs use market-based mechanisms to lower costs whilst achieving pre-agreed quality outcomes. They ‘align incentives’ between providers and commissioners, sharing any savings between hospitals, doctors and the commissioning Medicare programme itself.

An earlier version is known as the Health Maintenance Organisation, run by the insurers themselves. It involved routine denial of patients’ access to medically necessary treatment, fighting claims, screening out the sick, paying exorbitant CEO salaries, and systemic fraud. Low rent medical care had considerable hidden costs in top-ups and deductibles.

Now, the ACOs have healthcare providers in the lead. But the same insurance firms are driving and developing the process. NHS England boss Simon Stevens’ former employer UnitedHealth already has contracts with more than 800 ACOs across the US, and has just launched a national accountable care organization, NexusACO, which will be available to employers in 15 US markets.

One form of ACO, mentioned in the STP, uses ‘capitated’ or ‘global’ fixed payments to providers for all or most of the care that their patients may require over a contract period, adjusted for severity of illness, and regardless of how many services are offered. Clearly, once the payment is in place, it is open to providers to offer only as much care as required by the contract.

The specified care needs may not be comprehensive, and the defined patients may not be the geographical population. Indeed, as the Cheshire & Merseyside plan states “Greater focus could be paid on ensuring primary care is at the centre of care models and ACOs are built on GP registered lists.”

Two models promoted by the Five Year Forward View come straight out of the ACO playbook: the Multispecialty Community Provider, and the Primary and Acute Care System. The MCP, based on primary care in localities and prevention, aims to reduce avoidable hospital admissions. The Cheshire & Merseyside STP states explicitly “In parts of the system there is some ambition to build the ACOs around multispecialty community providers.”

All ACO plans simply accept the massive NHS funding cuts. They assume that pooling NHS and local authority resources, and expanding new models of care in the community, will justify cutting hospital budgets. The National Audit Office and the Nuffield Trust have recently demolished those assumptions. Warrington ACO

Warrington has agreed to pool CCG and local authority health and social care budgets, and are “determined to move away from a national tariff-based payment system to a defined capitated budget.”

The ACO Board will be established by 1 April 2017 with an independent chair and will comprise:

  • Warrington Borough Council (Commissioning)
  • Warrington Borough Council (Provision)
  • NHS Warrington Clinical Commissioning Group
  • Warrington and Halton Hospitals NHS Foundation Trust
  • Bridgewater Community Health NHS Foundation Trust
  • Five Boroughs Partnership NHS Foundation Trust
  • Warrington GP representatives

Board tasks will include designing plans for:

  • Shared accountability and risk share
  • Pooled/aligned budget arrangements.
  • Contractual (and funding) flexibility through agreed contractual arrangements that bind the ACO.
  • Arrangements for commissioning/contracting from the ACO to the health and care market.
  • An appropriate vehicle for delivery.

Options for the ACO structure include Corporate Joint Venture and (full) Merger, to be determined through an options appraisal workshop.

St Helens is setting up an “Accountable Care Management System” to involve the CCG, health providers and St Helens Council. It is set to go live in April 2018 and intends to transfer these services from Day 1: Adult Social Services, Children’s Social Services (excluding Youth Justice), Public Health, Community health services, Adult Care Services (excluding maternity), Primary Care, Mental Health Services, Community Safety Services, Community fire safety, Mental health street triage, Victim support services, Probation services, Ambulance. Other services may be added later, and the only permanent exclusions are Youth Justice, Community fire protection, and Road safety.

St Helens is now asking itself: Will the ACMS compete for tenders as a collective? Will the ACMS itself issue tenders and procure services from others?

West Cheshire CCG is planning to establish an ACO, whose parties include:

  • NHS West Cheshire Clinical Commissioning Group
  • The Countess of Chester NHS Foundation Trust
  • Cheshire and Wirral NHS Foundation Trust
  • Cheshire East and Chester Council
  • The three West Cheshire primary care localities of Ellesmere Port & Neston, Chester City and Rural

It will “take a distinct approach to segmenting our GP registered population by risk, around which our plans are based”. It will issue a Memorandum of Understanding between providers, who “have been challenged to advise how they can release a material portion of their existing resources to enable this transformation”. It will also issue a “prospectus”.

Liverpool Community Health is being broken up and handed to other providers. The biggest single contract is planned as an MCP with Bridgewater Community Health in partnership with the Liverpool GP Federation and Liverpool City Council, whose bid came in £4.6m below the value of the services it would provide. Cuts in back office staff are anticipated. In November, Rosie Cooper MP asked Bridgewater to confirm or deny plans to set-up a joint venture, pooling all budgets to provide all community health and social care from a single company. I don’t know if she got an answer.

Currently, the plan is on hold as the Care Quality Commission report on Bridgewater, finally released on 6 February, identified serious clinical failures. Liverpool CCG made clear that locality working and partnership with LCC and the GP Federation was their reason for backing the plan, unfazed by the CQC report.

Bridgewater is part of the Warrington and St Helens plans.

If it does proceed, the Liverpool MCP may later emerge as all or part of a fully fledged Accountable Care Organisation. The obvious question is, accountable to whom?


The NHS is supposed to deliver evidence-based medicine, clinicians are educated on that basis, and new treatments are only licensed after passing rigorous trials and cost-benefit analysis. What’s the point to medical school or nurse training if evidence is tossed overboard?

The St Helens plan purports to list evidence for each of their plans. None of it is referenced. For example “Stand alone telephonic case management has been estimated to reduce admissions by 5%.” Says who? The Nuffield Trust (pp85-6) says there is mixed evidence on case management. Research at the University of Manchester published in 2015 is entitled “Effectiveness of Case Management for ‘At Risk’ Patients in Primary Care: A Systematic Review and Meta-Analysis”. From the abstract:

“This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs.”

St Helens says “Social prescribing has saved Newcastle West CCG an estimated £2 – £7 million”. This is actually the Ways to Wellness programme which started in 2015 and runs for 7 years. It hasn’t been evaluated yet. Nuffield describes it as a “large scale trial”. The actual savings it will achieve are, at this stage, only projected.

Warrington says “Evidence shows that proactive planning using risk stratification is a key tool to improving outcomes”. Again, no reference for that. The Nuffield review found risk stratification tools still struggle to identify ‘at risk’ individuals at the point before they deteriorate.

A virtual ward is a model of home-based multidisciplinary care based on the idea of a hospital ward. Intended to avoid emergency admission or readmission, patients are typically identified using a risk stratification tool. As Nuffield reported, an evaluation of three NHS virtual wards targeting patients at risk of admission found no reduction in emergency hospital admissions in the six months after admission to the ward, but it did find a decrease in elective admissions and outpatient attendances. There was no reduction in overall hospital costs.

Private sector

The private sector are directly involved in formulating the ACO plans. Notorious management consultants PwC, formerly PriceWaterhouseCooper, were paid £300k for their work on the Cheshire & Merseyside STP. They were advisors on 17 other STPs. They are involved in plans for ACOs in Tameside, Wigan, Manchester City, Oldham, Cheshire, St Helens, Hounslow and Richmond, Northumbria, Mid-Nottinghamshire, and Croydon. The Northumbria plan, intended as the first ACO in the UK, has been postponed indefinitely as the CCG is £41m in deficit.

West Cheshire CCG appointed PwC to undertake an initial ‘due diligence’ phase. The consultancy also convened three workshops for the parties to the ACO.

In St Helens, the Project Management Office is “supported and challenged by PwC”. PwC has input into the proposals for Governance, IT, Business Intelligence, Communications and Engagement. A Workstream stakeholder reference group has Specialist /practitioner input from three people, two of whom are PwC staff.

The private sector can also be involved in the Governance structures themselves. In St Helens, the leadership is currently with a People’s Board, including the Council and NHS providers, but also the Community Rehabilitation Company and Helena Partnerships. Helena are a housing management group which took over former council housing. The CRC is a privatised probation service, 75% owned by Interserve, a facilities management company with PFI and other health service contracts.

The private sector is also funding new models of care. The Newcastle Ways to Wellness programme is an outcomes-based contract funded through a Social Investment Bond which includes £1.65m from Bridges Social Sector Funds. Bridges Fund Management describes itself as “Capital that makes a difference”.

The End Game

The implications for wages, terms and conditions of NHS staff when employers merge across care sectors under PwC guidance, with local structures which will threaten national agreements, are immediate. Looking further ahead, no private company is big enough to buy the whole NHS. But once the STP plans are implemented and ACOs are established across England, health transnationals will see discrete local systems with budgets of £1bn or less, with structures compatible with the US health insurance market. They could be bought and sold.

Theresa May is adamant that the NHS will remain free at the point of use. Even if that’s true, a big if, she does not mean a comprehensive, universal service, with decisions on treatment made according to clinical need, publicly provided, publicly accountable, funded out of general taxation. That’s what we’re fighting for.


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With thanks to John Brace, here is a video of the full discussion of the Cheshire and Merseyside Sustainability and Transformation Plans by Liverpool Health and Wellbeing Board yesterday – includes contributions from Mayor Joe Anderson, Sam Semoff, Alex Scott-Samuel and Tony Mulhearn

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