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

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

 

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

We look forward to hearing your feedback.

Best wishes

Mark Voce
Director of Education and Standards

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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We welcome comments on this article which has come out of the Reclaim Social Care Campaign. It is not SHA policy, but it raises important questions relevant to both social care and the NHS.

This is a wide field in which a variety of species flourish, some of which are dangerous invasives. We need to cultivate systematically to ensure that what grows in this field is healthy, productive, and not a threat to other growth. We need to be able to classify, in order to isolate rogues, and then eradicate them. We need to be able clearly to identify some of the more rampant plant life, in order. maybe, to consider techniques of pruning.
I come to this view of the wider challenge from an interest in cultivating a little patch in this field – one area that I think is growing some special and healthy new life. My patch is occupied by a Community Interest Company. This organisation safeguarded one local piece of our National Health Service, by propagating it and preserving it from being hybridised – merged– a with a completely different plant that would have taken us over. We have created an organisation that is of our community, for our community, and owned by our community.
I am a fervent supporter of the NHS, especially having, for 15 years, suffered under the US excuse for a health system. I have been a member of the Labour Party since 1972. The principles of the NHS, as promoted by the Labour Party from 1948, are not negotiable, but there are different ways to organise to support those principles. I believe that there are freedoms in a CIC organisation that make it easier to maintain some aspects of health and social care in conformity with those principles – not everything in the way the NHS organises itself and runs its staff and services is perfect. My purpose in writing this paper is to try to distinguish the different types of possible organisation, to identify the healthy growth points, and also rogue growth.

I start with a straightforward definition:
“A simple definition of “public sector provider” in this context is: one that is constitutionally owned by the community or the State and operates not for profit.”

If one were to operationalise that definition, one would be able to draw a line across one large sector of our field – often called “The Third Sector”. If I understand that term correctly, it contains both charitable bodies and the range of different social enterprises. My simple definition, once operationalised, would separate those two parts of that Third Sector: charitable bodies are accountable through Boards and the Charity Commission – they are not “constitutionally owned by the community or the State”.
The largest part of our health field – diminishing and under threat, but the revered sector whence proliferate (or struggle) the heirloom crops – is defined by the phrase “constitutionally owned by the State”. It should not be hugely difficult to operationalise this definition, in which “State” could be national or local.
That leaves, I think, the cultivators of two sections of field to be pinned down: commercial cultivators and the social enterprises. The word “enterprise” – a word sullied with muck in some horticultural circles – creates a confusion for some, but I think my first definition, with its reference to “constitutionally owned by the community”, serves to draw a line between private enterprise and “mutual enterprise”. I think that an operational definition of private enterprise is achievable.
That leaves the mutuals, or social enterprises. That is a field with subdivisions. Those dividing lines have been traced by Geraint Day and Mo Girach, among others -The semantics of the ‘Big society’: Social enterprises, mutuals and co-operatives, NHS Alliance, August 2010. One subdivision contains CICs, like the one I am associated, whose constitutions place ownership in the hands of not just the workers in the mutual, but the whole community.
There is a programme in this for a whole load of research, I guess:


I would like to ask readers of this paper:

a) If they find the subdivision of the field proposed above useful
b) If they know of any work that pushes forward on defining some of the boundaries in a way that generates precise facts
c) If they know any facts that would give a more accurate version of the numbers guessed in the left-hand part of the diagram above

Once we have divided up the field in a manner that commands some agreement, we can then consider different ways of dealing with different plant species. Even the more aggressive plants might have their uses, if we can refine our horticultural techniques. I believe that there is a lot of mileage in looking at this horticulture from the point of view of risk management. If one can be clear about the risks involved in handling each type of plant, one can be more confident of training each plant to grow to maximise its useful productive capacity. Leaving this (rather seductive) metaphor behind – what one needs to aim at is to understand the types of contract each type of organisation can sustain in a way that optimises their capacity for good, and minimises the risk of bad.
I believe that we can get a long way by distinguishing between contracts in which the best way forward is to share risk between commissioner and provider – those are not safely handled outside public sector partners. But there are also opportunities for what I would call “segregated risk” contracts, where we might watch private enterprise do what it is best at, without massive risk.
But that is another discussion.

And there is a third related discussion we could have: in addition to an operational – i.e. useful – definition of the concepts discussed above, it would be advantageous to come up with legal definitions of some of these concepts. Here are some of the challenges encountered in searching for legal definitions with reference to a CIC:
• The CIC may be “owned” by the citizens of the community/Borough/town, but …
• What are the implications of “ownership”?
• How is the CIC accountable to the owners?
• Our CIC has a Membership Council – community and staff, but …
• Are the members of the Council representatives?
• … of whom?
• What is the “membership”?
We tried launching a membership drive, but foundered on the fact that there was nothing we could offer “members” that we didn’t want to give them simply as one of our population of potential or actual service users. We eschewed the practice of our Acute NHS Foundation (and many other Foundations) – of simply “signing up” everyone who comes through the door, in order to create an artificial “membership” number.

• What if some services are also offered in other communities? What if the organisation is willing to expand into other places it the circumstances are propitious?
• How does one characterise membership in locations where the organisation plays a minor role in the range of care?
• and on and on
The efforts of the CIC to represent the needs of its community may be completely genuine. The CIC may know that the core, at least, of its community is the citizenship of the community/Borough/town that it serves, and that may be enough for pragmatic purposes. It is better to have a practical rationale for pressing forward with doing good, rather than getting too caught up in definitions.
But, if there are readers out there who can help with legal definitions, or examples, or processes for enacting representative monitoring, then please share.

The risk for some social enterprises is that they can be captured by the profit motive or by the private sector. This is a risk that increases as money gets tighter. There are ways to have insurance against that threat, and not necessarily in terms of formal accountability and representativeness. One approach is to mount a diligent programme to embody the principles of organisation in the whole organisation – all members of the staff – and to ensure that principled continuity is not dependent on a small group of founders.
The CIC of which I am a Community Governor has some very creative approaches to ensuring continuity, principle and direction in this way. But that is yet another story.

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It is over 40 years since the Alma-Ata Declaration asserted the crucial role of primary care in the promotion of the health of people world wide. Since then global health policy has attempted to give effect to the Declaration with varying levels of success. The situation has been no different in Wales.

The Wanless Review in 2003 re-emphasised this message. It stated “ …(t)he current configuration of health services places an insupportable burden on the acute sector and its workforce. This is the most expensive part of the system … (t)he primary care sector in turn is not sufficiently resourced or incentivised to keep patients out of hospital though it is hoped that the new General Medical Services Contract (under discussion at the time of this report) will create such incentives.”

The publication of the final report by the Welsh Parliamentary Review on health and social care ( January 2018) shows that this still remains the main challenge. In response the Welsh Government has published A Healthier Wales and a Strategic Programme for Primary Care. Both these policy statements will have to be matched by a determined political will if they are to prove successful.

In 2018 the Wales Audit office stated that “ (b)etween 2010-11 and 2016-17, total health board spending in Wales …. increased from £5.39 billion to £6.32 billion. However, over the same period, recorded spending on primary care as a percentage of total health board spending in Wales ….. reduced from 25% to 22%.This would suggest that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years is not being achieved.” No amount of smart or new types of working will be able to make up for this basic deficit. If primary care is to thrive it needs resources and investment.

This has been highlighted in the number of GPs working in Wales. Between 2004-05 to 2010-11 the number of GPs rose from 1,800 to 2,000. However since then things have been more or less been static until there was a 4% decline between 2016 and 2017. By way of contrast the numbers of hospital consultants has increased by 40% between 2009 and 2017.

However these headline figures do not tell the full picture. While there are now just under 2,000 GPs listed in Wales. Approximately 1,500 of the listed GPs were contractors with the remaining 400+ being salaried. However there is a concern that the official statistics do not present a fully accurate picture particularly in relation to the number of salaried doctors. And there are, in addition, a further 750 doctors working in system who are classified as locums or sessional GPs . This represents a 10% increase since 2016 when figures were first collected.

Vocational training is central to securing a future workforce. The RCGP estimates that Wales needs to have 184 positions to be on a par with the rest of the UK. There has been an increase of 15% in posts over recent years with to 90% being filled but the overall numbers have still to reach UK levels.

The Welsh Government therefore faces a major challenge to increase capacity in its primary care and general practice service. There is abundant evidence that GP workload is increasing both quantitatively and in its complexity. In response there must be an a substantial increase in the workforce as the Welsh Government itself acknowledges the service is not sustainable if it can only survive by the “heroic” efforts of its staff.

Non-medical practice staffing levels has increased by over 7% in the last half decade with approximately 2,500 clinical and 5,000 administrative staff now being employed. Despite these increases the RCGP reports that there are still 20% of GPs do not have access to a practice nurse, 35% to a practice pharmacist and 50% to a physiotherapist. This is clearly not good enough.

The challenge in recruiting and retaining GPs also looms large. Both the GPC and RCGP in Wales still insist that “.. (i)t is a fact that the independent contractor model is best for the patients of Wales and is the most cost-effective option for those who hold the purse strings in both Welsh Government and Health Boards. “ But with 20% of GPs already salaried and with almost twice as many more working as locums and sessional doctors there must an urgent need to review the way they work for and with the NHS.

The Welsh Government acknowledges that the contractor partnerships will continue to be the cornerstone of general practice in Wales. But it also accepts that this model it is no longer a preferred option for many new doctors. They are not attracted to the business ethos, financial risks, administrative demands, inflexibility and investment costs which go with being an independent contractor. So while the concerns of independent contractors must be addressed there is also a need for a more diverse range of career options for future general practitioners.

There are some interesting innovations taking place seeks to address this need. The Primary Care Support Unit in the Cwm Taf Health Board has been in existence since 2002. Social enterprise models for care delivery have been adopted in Bridgend and south Powys. But overall they are still too few to achieve the critical mass that is needed to achieve transformational change.

Somewhat strangely the “GP establishment” seems to fear that health boards and the Welsh Government are rubbing their hands in glee at the prospect of becoming direct providers of primary care services. The reality is almost totally the opposite. There are now over 30 directly managed GP practices in Wales but in virtually every case local health boards have found themselves reluctantly obliged to get involved. This lack of enthusiasm for a public service general practice option must be urgently addressed.

The Strategic Programme for Primary Care confirms the Welsh Government’s commitment to delivering primary care services through 64 primary care or clinical networks based on populations of 50-100,000. These networks are tasked with bringing primary and social care services together along with the third sector to cater for the needs of their populations. There is a widespread support for this model both politically and across the professions. The Welsh Government has channelled much of its recent primary care investment through the networks to stimulate local innovation and service improvement. Their success to date is a bit mixed and in some cases they have an uneasy relationship with their local health boards.

Innovation in primary care is also being actively promoted though the £4m Pacesetter / Pathfinder programme which began in 2015 with 24 distinct projects. The objective was to either develop new ways of working or to promote the wider dissemination of new ways of working. The programme received support from Public Health Wales and it is hoped that health boards would mainstream the practice of the successful projects. As these projects come towards the end of their initial phase this is recognised as being critically important. But it has also been appreciated that those areas where services are under the greatest stress are least likely to engage with the exercise.

The Welsh Government has prioritised tacking health inequalities and asserts “..the fundamental Bevan principle that it is clinical need which matters when it comes to deciding treatment by NHS Wales.” In his annual report 2015-16 the Welsh Chief Medical Officer, Dr Frank Atherton, recognised this in stating “ … we make the case that one-size-fits-all health and care services in the traditional sense may not always be the best approach, as they can maintain, and sometimes increase, health inequalities. Instead we argue for an approach which is proportionate to the level of disadvantage which is often referred to as proportionate universalism.” But Welsh Government policy  is at its weakest it comes to outlining how this is to be achieved.

Public Health Wales (PHW) has done a lot of work in identifying health inequalities across Wales and profiling populations to clinical network level. It shows that the difference in prevalence of good health between people living in the least and most deprived areas is already apparent at age 0-15. This gap then grows as age increases, peaking in males at age 65-74 (79% in least deprived vs 52% in most deprived) and in females at age 55-64 (84% vs 56%). And it is in these disadvantaged areas where we also find the greatest prevalence of patients with complex multi-morbidity.

This work by PHW provides an excellent stepping stone for planning the promotion of health and well-being and the delivery of primary care services. But there is little evidence that this is happening on any scale. The Strategic Programme for Primary Care provides a lot of important one-size-fits-all advice for primary care but it only makes the most cursory of references as to how the new, transformed Welsh NHS will address health inequalities on the front line where 90% of health service contacts take place. This is its fundamental weakness.

Welsh health and social care policy strongly argues for a new approach that will put a focus on prevention, which promotes a social model of health and well-being, seeks to address the social determinants of poor health and which will tackle the stubborn continuation of health inequalities. In many policy areas concrete proposals have been put forward to address this agenda. But there in health and social care the details still need to be outlined and put in place.

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Security staff at Southampton General Hospital being attacked in the A&E department is key to an industrial dispute over pay and sickness pay.

Unite, Britain and Ireland’s largest union, said its 21 security staff members were being attacked on a regular basis by members of the public either under the influence of drink or drugs, or with mental health problems.

Unite is currently holding a ballot for strike action or industrial action short of a strike of its members, employed by Mitie Security Ltd, at Southampton General Hospital over pay and conditions. The ballot closes on Wednesday 15 March.

Unite said that Mitie Security was refusing to provide adequate personal protection equipment (PPE), such as stab vests and  safety restraints, even though knife-related incidents are increasing.

Unite lead officer for health in the south east Scott Kemp said: “With cuts to the police force and mental health services, there is a tendency for those suffering from various conditions to be dropped off at the hospital and left to the security guards. 

“The statistics are not easily available as to the number of our members who have been injured. There has been a lack of proper investigation into the incidents over a considerable period.

“The guards report incidents that have occurred on every shift, but the bosses at the University Hospital Southampton NHS Foundation Trust and Mitie Security will only investigate when someone is injured.

“Our members are very concerned over incidents occurring right across the Tremona Road site when there has been little or no support from the police who are under pressure because of government cuts.

“Our argument is that we should not have to wait for someone to get injured before a full investigation is instigated.

“That is why the sick pay arrangements are really important. At present, if the security staff are injured at work, and if the resulting investigation finds in their favour, they get two weeks’ full pay and then two weeks’ half-pay. After that, it is the statutory minimum.

“We have members getting beaten up and then having to return to work after two weeks, when they are clearly not fit to, as to drop down to half-pay would mean missing mortgage or rent  payments and significant financial hardship.

“What we want is enhanced sickness payments for those off work due to being injured protecting patients and hospital staff; proper and transparent investigations into all attacks; and our members having the necessary personal protection equipment.

“Our members are seeking six months’ full-pay, followed by six months’ half-pay for all sickness absences. We don’t think those are unreasonable requests, given the level of violence in today’s society generally.”

Unite said that the demand for an increase in pay from the current £8.64 an hour reflected the stress of the job. The security staff are seeking £10.50 for security officers and £12.16 for supervisors, with additional payments of 50p per hour on night rates; £1 an hour on Saturday and double time on Sunday.

Scott Kemp added: “Our members are at the forefront of providing security and a safe environment for staff, patients and visitors – that’s why Mitie’s management needs to get around the table and negotiate constructively.

“There is now a good window of opportunity for such talks before the ballot for strike action closes on 15 March.”

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The Pharmaceutical Journal reports that the Good Law Project threaten DHSC with legal challenge over “failure to consult properly”

From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

The Good Law Project has warned the Department of Health and Social Care that it will start judicial review proceedings if serious shortage protocol powers are not revoked on the grounds that the consultation was “insufficient and unlawful”.

A non-profit group has threatened the government with legal action unless it revokes new powers designed to allow pharmacists to switch patients’ medicines if there is a shortage.

The Good Law Project has said it will start judicial review proceedings over newly implemented “serious shortage protocol” powers if the Department of Health and Social Care (DHSC) fails to remove the amendments in legislation by 25 February 2019.

Amendments to the Human Medicines Regulation 2012, which came into force on 9 February 2019, mean the government can now issue protocols asking pharmacists to respond to a medicines shortage in one of four ways: to dispense a reduced quantity, a therapeutic equivalent, a generic equivalent or an alternative dosage form of the drug.

Under the protocol, the pharmacist would not have to consult the patient’s GP before making the switch.

The Good Law Project is now seeking to launch a judicial review of the amendments, partially on the grounds that the government’s initial consultation – which lasted one week on 5–12 December 2018 – was “insufficient and unlawful”.

In a legal document sent on 19 February 2019 from the group’s lawyers to the DHSC to inform them of their intent to start the review proceedings, the Good Law Project said it was “unclear exactly who the Secretary of State consulted with and how/on what basis”.

It added: “The failure to consult properly with organisations representing specific patient interests was unlawful.”

Ekklesia reports:

Jolyon Maugham QC, Director of the Good Law Project, said: “Both doctors and patients have proper concerns about their safety in the event of medicine shortages. We want the Government to withdraw the prospect of SSPs [Serious Shortage Protocols] until it has complied with its legal duties and consulted properly on their use. If the Government does not take this step, the Good Law Project will launch judicial review proceedings in the High Court.”

Professor Tamara Hervey, Specialist Adviser to Parliament’s Health and Social Care Committee, said: “In the event of a no-deal Brexit, there would be likely to be shortages of medicines. The absence of a legal framework for imports and exports drastically affects supply chains. Stockpiling plans cannot cope for more than a few weeks. This is a serious issue for people needing a regular supply of a particular type, strength and quality of medicine.”

Jane Hanna, Chief Executive of SUDEP Action, who is supporting the judicial review said “Patients, doctors and pharmacists are used to prescriptions and the processes surrounding them. For people with long-term conditions, like epilepsy, what is on the prescription may represent months and years of trying out the best medication schedule. Changes made to this delicate balance can for some, undo this in an instant. For epilepsy this could lead to less seizure control, impacting on quality of life (ie: losing a driving licence, affecting home and work) and significantly for some this can prove fatal.  At present if a supply of medication is made in error, lessons can be learnt because of the clarity of who signed and who supplied the prescription.

Deborah Gold, Chief Executive of NAT (National AIDS Trust) said: “We are deeply concerned that these changes were made without proper consultation. Prescribing HIV medication is a complex process which must take account of a multitude of factors. The only person qualified to safely alter the medication prescribed to a person living with HIV is that person’s HIV consultant.”

• The Pre Action Protocol Letter can be seen here

 

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Responding to the Health Secretary’s pledge to overhaul mental health and wellbeing services for NHS staff following the launch of a Health Education England review, BMA mental health policy lead, Dr Andrew Molodynski, said:

“Staff are fundamental to the delivery of patient care in the NHS and without a healthy workforce our health service can barely function, let alone thrive.

“Given the current pressures that the NHS workforce is under, the Secretary of State for Health and Social Care’s commitment to improving mental health and wellbeing support for staff is both timely and necessary.

“We know that doctors’ mental health and wellbeing has been adversely affected by the increasing demands of their work and this is true also for medical students who are dealing with stress, fatigue and exposure to traumatic clinical situations, very often without adequate support on hand.

“The BMA recently for greater provision of mental health support for NHS staff as their report¹ found that only about half of doctors were aware of any services that help them with physical and mental health problems at their workplace – while one in five respondents said that no support services are provided.

“While these measures will go a long way to providing much-needed support for NHS workers who are struggling with their mental health and overall wellbeing, more must be done to address the wider pressures on the system, such as underfunding, workforce shortages and rising patient demand, so we can reduce the number needing to seek help in the first place.”

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The Health & Care Professions Council (HCPC) delivered a snub today (Thursday 14 February) by pushing ahead with an ‘extortionate’ registration fee hike, despite receiving a 38,000-signature petition protesting at the 18 per cent increase.
Unite, Britain and Ireland’s largest union, led the protests at the increase from £90 to £106 a year – on Monday (11 February) the union handed in the petition to HCPC chief executive Marc Seale calling for the rise to be scrapped.

Unite lead professional officer for regulation Jane Beach said: “Today the views of the 38,000 mainly health professionals who signed the petition have been ignored which is very disappointing, given the cogent arguments we put forward that NHS pay has stagnated in real terms while the cost of living has raced ahead.

“The HCPC has given a massive snub to our members’ legitimate concerns about any fee hike.

“We consulted widely with our members who have to register with the HCPC in order that they can work professionally – and they gave the proposed increase a resounding thumbs down. Now they have been given a financial kick in the teeth by the HCPC.”
Unite argued that the increase from October 2019 would be another financial blow to hard-pressed NHS staff, such as biomedical scientists, paramedics and speech and language therapists, who have seen the fees increase by 40 per cent since 2014.

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DELIVERED AT JULIAN HART’S FUNERAL — JUNE 16th 2018

 

Julian and I were chatting once about heaven and hell, as you do. He didn’t believe in either, but supposing he was wrong, he thought he might be allowed into heaven, not as a believer, you understand, but for good behaviour.

Julian always wanted to be a doctor in a mining village, partly because his father had been a colliery doctor in Llanelli; partly it was the romance of mining practice as popularised in AJ Cronin ‘s novel The Citadel; but mainly it was the sort of community to which he wanted to belong.

And belong he did. As Gerald Davies, one of his patients, said in a BBC documentary , Julian wasn’t aloof like the other doctors, the headmaster and the colliery manager. He lived in the village and shared the common experience.

He wrote about it for medical students, “No one is a stranger; they are not only patients but fellow citizens. From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.”

Julian loved his patients – not romantically, of course. The opposite of love in this context is indifference and Julian was never indifferent. He hated when bad things happened to his patients, especially when they could have been prevented. In his last 28 years at Glyncorrwg, there wasn’t a single death in women from cervical cancer.

In his book A New Kind of Doctor, he described a man, invalided out of the steel industry after a leg fracture, aged 42. With no further use for his big muscular body, he had become obese, had high blood pressure and cholesterol, got gout and was drinking too much. 25 years later, Julian described how, after 310 consultations and 41 hours of work, initially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes. He described this as the real stuff of primary medical care.

At a seminar in Glasgow, we asked Julian what happened next. The man had died, of something else, a late-onset cancer I think, but when Julian told us this, there was a tear in his eye. His patient had become his friend.

This was Dr ‘art, without an “H”, as known to his Glyncorrwg patients. None of this explains why Dr Julian Tudor Hart became the most famous general practitioner in the history of the NHS.

In 1961 with large numbers of very sick people, huge visiting lists and a nearby colliery that was still working, the Glyncorrwg practice was extremely busy. His initial base was a wooden hut. It took five years to reach a stable position.

He was the first doctor in the world to measure the blood pressures of all his patients. Famously, Charlie Dixon was the last man to take part, had the highest blood pressure in the village but was still alive 25 years later. Julian became an international authority on blood pressure control in general practice and wrote a book about it which went to three editions and was translated into several languages, with a companion book for patients.

What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years he showed that premature mortality was almost 30% lower than in a neighbouring village – the only evidence we have of what a general practitioner could achieve in a lifetime of practice.

It’s said that behind every great man there is an astonished woman. Behind Julian, was a great woman. When Deborah Perkin was planning her BBC documentary, the Good Doctor, (which we keep showing to medical students and young doctors), I said to her, there is something you have to understand. There’s two of them. Mary was his partner and anchor every step of the way.

Glyncorrwg was the first general practice in the UK to receive research funding from the Medical Research Council. Mary and Julian had both worked with Archie Cochrane and his team at the MRC Epidemiology Unit in Cardiff where they learned a democratic type of research in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. And so, in Glyncorrwg, there was the Shit Study, the Pee Study, the Salt Studies and the Rat Poison Study, all with astonishing high response rates.

Julian counted as a scientist anyone who measured or audited what they did and was honest with the results. Brecht’s The Life of Galileo was his favourite play and he often quoted Brecht’s line, “The figures compel us.” Julian didn’t pursue scientific knowledge for its own sake. His research always had the direct purpose of helping to improve people’s lives.

He had a talent for the telling phrase. His Inverse Care Law stated that the availability of good medical care tends to vary inversely with the need for it in the population served, or more simply, People without shoes are clearly the ones who need shoes the most.

When Sir Keith Joseph, a Conservative Secretary for Social Services, announced that
“Increased dental charges would give a financial incentive to patients to look after their teeth,” Julian commented, “The government has not yet raised the tax on coffins to reduce mortality, but Sir Keith is assured of a place in the history of preventive medicine.”

Julian’s friend and fellow GP, John Coope from Bollington in Lancashire, admired Julian’s nose for what mattered in the published literature. In his book The Political Economy of Health, that magpie tendency was on display, the footnotes comprising one third of the book and worth reading on their own. A Google search could never assemble such a mix. Goodness knows what readers made of it in the Chinese translation.

He lectured all over the world – in the US, Australia, Kazakhstan, Italy and Spain in particular. Julian could deliver formal lectures but for brilliance and exhilarating an audience he was at his best in impromptu, unscripted exchange.

When principles were at stake, Julian could argue until the cows came home. In his younger years he took no prisoners. A famous medical professor reflected that he had been called many things, but never a snail.

Dr Miriam Stoppard arrived in the village to interview Julian for her TV programme, determined to cast him in the role of a doctor who made life or death decisions concerning his patient’s access to renal dialysis and transplant. They battled for a whole afternoon, Stoppard trying to get Julian to say things on camera that fitted her script. He defied her, ending every sentence by mentioning how much dialysis and transplant surgery the cost of a single Trident missile could buy. She went away defeated and empty-handed.

I was surprised once at Paddington station to see him with a copy of the London Times. He was no fan of the Murdoch press. On boarding the 125 for South Wales, he laid out the newspaper as a tablecloth and over it spread a messy, aromatic Indian carry-out meal. If businessmen in their smart suits wanted to sit next to us, they were very welcome.

Standing for election to the Council of the Royal College of General Practitioners, Julian topped the poll. What he offered GPs was a credible image of themselves as important members of the medical profession – alongside specialists, not beneath them.

Julian was humble in himself but ambitious for his ideas. He accepted with ambivalence the honours and sentimental treatment that came with age but he never lost his edge, and if we are to celebrate his life it should be by holding to the principles he held dear.

The work of a general practitioner is immeasurably enhanced by working in, with and for a local community, for long enough to make a difference.

Everyone is important, the last person as important as the first, and the work isn’t done until everyone is on board.

Julian was the “worried doctor”, anticipating patients’ problems, not waiting for them to happen, and then avoiding them by joint endeavour.

Drawing on his reading of Marx, he saw health care as a form of production, producing not profits but social value, shared knowledge, confidence, the ability to live better with conditions, achieved not by the doctor alone but by doctors and patients working together. Patients were partners, not customers or consumers.

The NHS should never be a business to make money but a social institution based on mutuality and trust – the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In re-building society, co-operation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.

My daughter Nuala met Julian many times. Losing him as a person, she said, was like the Mackintosh Building at Glasgow School of Art, burning down. We lost someone dear, a big part of our lives, an institution, a one man “School of ‘Art”, full of life, light and creativity.

Julian’s gift to us today is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the present challenge of how we follow and give practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us do.

 

Professor Graham Watt
MD FRCGP FRSE FMedSci CBE
Emeritus Professor
General Practice and Primary Care
University of Glasgow

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‘Back to the Thirties’ by Charles Webster (previously Director, Wellcome Unit for the History of Medicine, University of Oxford).  

First published in September 1984 in the public health journal Radical Community Medicine, this essay reflects many of the issues the NHS and public health face today, from the PR management of statistics and altering of history to the refusal of government to acknowledge the need to spend to alleviate poverty. We are grateful to Alex Scott-Samuel, editor and publisher of the journal, for his kind permission to re-print this essay.  

A multiplicity of ways are being used to undermine public confidence in the National Health Service. Among other things history is being rewritten to cast doubt on the record of the Welfare State. It is now common to find the Welfare State portrayed as a destructive force ‘expanding at an explosive rate’ or as the ‘time bomb ticking under us all’ (Daily Mail 24.1.84). By contrast, in appealing for the revival of Victorian values, it is implied that welfare was handled better under the voluntary system. Social scientists and historians have obligingly come forward to suggest that stories of adverse social effects of the slump have been magnified. The inter-war period is portrayed as a phase of expansion, of new industry and of general increase in living standards. By contrast, the welfare state is described as a ‘cult of superstition’, a myth to be destroyed by the economic realists. We are thus from many different quarters temptingly invited to turn the clock back to the Thirties.

But history is not so obliging a servant of the establishment. To any critical observer it is clear that the NHS was not created out of a gratuitous desire to extend state intervention. Quite the reverse: the NHS was the unavoidable consequence of World War 2.  At the outset of hostilities it was realised that effective defence necessitated complete recasting of the medical services. Once this Emergency Medical Service was in operation it was realised that it would be impossible to revert to the previous system by dismantling what was in effect a prototype NHS. The force of this argument was appreciated by all political parties and by all sections of the medical profession. To this extent the NHS was supported by an almost universal consensus and that consensus has remained intact until the recent commencement of crude attacks upon the Welfare State.

The need to form the Emergency Medical Service and then the NHS thus arose from the unsatisfactory state of the health services in interwar Britain. Because the dismal record of these services is now tending to be overlooked it is useful to recall just how inadequate was the state of healthcare before World War 2.

Paradoxically, one of the striking indications of the inadequacy of Britain’s health record comes from the excessive tone of optimism adopted in official reports, especially the influential Annual Reports of Medical Officers of Health at the local level. These reports tell a story of continuous improvement on almost all fronts. Collectively they convey an impression that problems of ill-health were being contained to such an extent that they had reached an almost irreducible minimum by the Thirties. These records bear comparison with Stalinist excess in statistical falsification and in retrospect it is clear how epidemiological data was used as a political weapon to justify low rates of unemployment relief and as a buttress to the policies of retrenchment of the National government.

Inevitably the above complacency produced a severe backlash. For instance, the MOH for Stockton-on-Tees G C M M’Gonigle and his sanitary inspector published Poverty and Public Health (1936) giving an almost diametrically opposite impression of health in the depressed towns from that contained in official reports. The impact of M’Gonigle’s work was reinforced by the inclusion of a preface written by the great biochemist, Frederick Gowland Hopkins, who was at the time President of the Royal Society. Gradually the rosy edifice of official health statistics crumbled away and it became apparent that minor improvements in indices relating to life expectancy and infant mortality was insufficient to disguise the nation’s inadequate health record.

Among the major grounds for concern were:

  1. By 1939 England and Wales had slipped to ninth position in the League of Nations’ Table of Infant Mortality. Scotland by then was 17th. This was merely one indication that Britain was falling behind its Dominions and other major western nations in its health record.
  2. Striking regional, class and occupational disparities were evident across the broad front of mortality and morbidity statistics. Scotland and Northern Ireland were comparable with the worst regions of England and Wales, which tended to be South Wales and the North West.
  3. The pattern within any region was complex with regard to its distribution of blackspots. For instance, taking the industrial towns of the North West in 1930, the best wards had an Infant Mortality Rate of below 40 whereas in the worst wards the IMR was above 150. Similarly, in better areas the Maternal Mortality Rate was about 2 whereas in ‘problem areas’ it was commonly above 10.
  4. As Titmuss was the first to demonstrate in 1938, there was every sign that differentials between the social classes were persisting, despite the claim that welfare benefits had largely solved the problem. Using methods recently revived for the purposes of the Black Report, Titmuss demonstrated that there was commonly a 500% differential between social classes I and IV. The differential among infants increased rapidly after the first month of life.
  5. Maternal mortality had increased dramatically during the interwar period to reach a peak in 1934. Levels of maternal disablement were so great that formal investigation into this problem was blocked by the Ministry of Health. However, officials confidentially admitted that estimates of some 50,000 cases of maternal disablement occurring annually were likely to be correct.
  6. Among the major causes of maternal mortality and morbidity, it became increasingly clear that a) the low health status of the mother and b) incompetent medical intervention, were of primary importance. Thus, in South Wales, Lady Rhys Williams claimed to achieve a reduction in maternal mortality from 6.39 to 1.64 solely by means of supplementary feeding of mothers. In a representative study by a leading gynaecologist, Aleck Bourne, it was estimated that of 1,917 cases of death, more than half might have been saved if ‘the full resources of knowledge both of prevention and treatment could have been utilised’.
  7. On the basis of the first elaborate nutritional surveys to be undertaken in Britain, Sir John Boyd Orr drew the alarming conclusion that a substantial section of the population was malnourished. Evidence from a variety of sources suggested that up to one half of the child population was malnourished to some degree. On the basis of budgetary surveys it was clear that malnutrition was likely to be endemic among the families of the 1.5 – 3 million unemployed, as well as among a large population of low wage earners, numbering at least 2 million according to Kuczynski.
  8. The large section of the population living in overcrowded or insanitary accommodation was exposed to much higher rates of infectious disease, tuberculosis, bronchial diseases, infestation etc. Once again, levels of overcrowding and slum dwelling were so high that the Ministry of Health adopted standards disguising the seriousness of the problem. Even according to the unrealistic standards adopted by the Ministry, industrial towns commonly showed 20% overcrowding, whilst in Clydesdale this estimate reached 45%.
  9. The above conditions contributed to high levels of debility among working class schoolchildren, which was to some extent reflected in height/weight measurements but even more in levels of rickets, bronchial conditions, rheumatic heart disease, infestation, etc. Prior to World war 2 4,000 child lives were unnecessarily lost each year owing to non-implementation of diphtheria immunisation.

The above catalogue of mortality and debility is by no means exhaustive. Shocked by official complacency concerning these facts, experts such as Titmuss were stung into expressions of deep indignation. ‘The high maternal mortality, the excessive mortality among infants, children and young people, the severe incidence of nutritional defects and tuberculosis among young people, and of deaths from heart disease in the Thirties, the premature ageing and the defect-shortened lives and all the amassed evidential statistics from many and varied sources (shows) that we are losing one quarter of our population every generation, and faced with the fact that that at least 500,000 excess deaths have occurred in the North and Wales during the last ten years can only point…to the presence of intense poverty on a scale so considerable and so widespread…’

Many of the above problems had their roots in poverty, unemployment, low income and environmental degradation. Incompetence of the health service was superimposed on these threats to life. The inefficiency and inadequacy of the interwar health services resulted from the haphazard way in which the structure had developed. By 1939 the British healthcare system had achieved labyrinthine complexity,  but it was still deficient in many respects.

The reputation of this system rested on the much acclaimed ’glory’ of the voluntary hospitals. To be more precise, the genuine reputation derived from the teaching hospitals, whereas the great majority of the 1000 voluntary hospitals were inconveniently small, overcrowded, impoverished and obsolete. The system of honorary medical appointments was breaking down, while the nursing staff were tiring of exploitation. By the outbreak of war the charitable basis of funding had collapsed and the system as a whole was bankrupt.  Although new sources of income had been developed, these were insufficient to keep up with rising costs. By 1940 10 of the 28 teaching hospitals were in deficit. In London, voluntary contributions, which were the traditional source of income, were accounting for only 30% of the voluntary hospital income. Payments from patients were now accounting for a further 30% of that income. In other words the principle of free treatment had been sacrificed. Patients were thus faced with a choice between contributory schemes and means-tested payments.

Of the remaining element in voluntary hospital income, a substantial amount was derived from fees for services paid by local authorities. The war further precipitated reliance on public funds. Consequently by 1945 the voluntary system was voluntary in name only.

The inadequacy of the voluntary hospital system prompted local authorities in many areas to extend into the acute hospital sector. By 1939 the voluntary system and the local authorities were contributing equally to the 140,000 acute beds. Because the local authorities were already providing chronic, mental and mental deficiency hospital care, they now became the dominant partner in the hospital field. By 1939 certain local authorities were providing virtually comprehensive hospital services, which were better coordinated and more adequately financed than the voluntary system. But local authority hospitals were themselves variable in quality, often marred by the taint of the poor law and providing a low grade of service. Only gradually were staff being recruited capable of matching the quality of the honorary medical staff of the teaching hospitals.

Hospitals were merely one part of the expanding constellation of local authority services. Perhaps the most important addition in the ‘30s was the midwifery service. Although in theory local authorities were providing a virtually comprehensive system of clinics for mothers, infants and children, provision of these services was usually not mandatory, while their performance was not as good as the bureaucrats supposed from superficial statistics. There was thus enormous variation in quantity and quality of provision of such services as maternity units, specialist treatment, dental services, nursery schools, or supplementary nutrition for mothers and children. By 1939 25% of deliveries were occurring in hospital; in some districts more than half the deliveries were taking place in maternity units, while in others this facility was vitually absent. Although the school meals service had existed for 30 years by 1939 it was only providing free meals for 2% of the school population. By 1939 only a few towns had immunised more than half of their children against diphtheria, while the level in London was only 6%. Such statistics suggest that for the majority of the population local authority services represented no more than a token effort. Also, by its nature the clinic system tended to sacrifice the important principle of continuity of care, and it related to the single disease rather than to the health of the individual taken as a whole. The latter was supposed to be taken care of by the general practitioner and for this reason the local authorities were forbidden to undertake domiciliary care.

The most highly developed part of the general practitioner service was provided under National Health Insurance, but this ‘panel’ scheme suffered from crippling disadvantages. First, the income limit was £250 until 1942, when it was raised to £420. Consequently a large class of wage earners was excluded from the panel without being sufficiently well-off to afford private medical fees. Secondly the service was limited to GP care and did not extend to specialist treatment. Thirdly, the range of services offered depended on the Approved Society contracted with. On the whole the less needy secured the best additional benefits such as false teeth and glasses. Fourthly, there was a clear sense that NHI was a second class compared with the service secured by fee-paying patients from the same GP. Finally, the greatest defect was the divisiveness resulting from exclusions of dependents from the scheme. Workers deeply resented their wives and children being deprived of the service for which they were paying, even if the service itself was inadequate. This provides just one example of the way in which non-working women were allowed to fall through the net of health services.

Family incomes were of course inadequate to make up for this shortfall in health care provision, with the result that working class wives tended to deprive themselves not only of medical treatment but also of the basic necessities of civilised existence. Janet Campbell rightly detected the intolerable apathy in which working class women habitually sank: ‘They need encouragement to feel a wholesome impatience with remedial discomforts and trials, and some stimulating influence to counteract the inevitable apathy which so naturally settles upon them, as well as practical assistance to rid themselves of some of the almost intolerable weight of unpaid domestic labour which presses so hardly, and which is spoiling not only their own lives but the contribution to national health and efficiency which they might make as happy wives and mothers’.

The above represents the reality of family life for the majority of women before World War II. These realities are worlds apart from the rose-tinted image of Victorian family life which our present political masters believe persisted until its virtues were suppressed by the welfare state. Totally inadequate health services made their contribution to the misery of working class life, and doctrinaire glorification of the voluntary system did more than its share to prevent the modernisation of health care. By the late thirties the weaknesses of all components of the health services were becoming publicised. It was no longer possible for bureaucrats and medical politicians to disguise the bankruptcy of the system. Critics were making their mark and health was emerging as a major political issue. As Bourne noted: ‘there is an almost rebellious feeling abroad that the health conditions of the people are bad because of avoidable causes rather than uncontrollable circumstances or lack of knowledge. Not only are the results of the working of our medical services disheartening as indicated by our existing health standards, but many progressive minds amongst us feel that these poor results can be traced to a fundamental lack of organisation of the profession in the cooperation with central and local public bodies. It is possible to see beyond this, that not only must the machinery of the health services be reorganised, but that the very economic basis of the lives of the people must be changed so that widespread poverty, which is at the root of so much disease, may be abolished rather than masked by what should be the unnecessary sops of social services.’

It was correctly perceived that the only viable way forward rested in the policies that were to create the welfare state and the National Health Service. The vested interests opposed those policies and they prevented their full implementation. These same forces have now regrouped and are determined to set the clock back to the Thirties. They must be defeated!

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