Category Archives: NHS

I trust that the latest episode of “Hancock’s Half Hour” made you laugh a lot.

The transcript of his speech, exactly as it was delivered on 20 July 2018, is available here, in case you missed it.

It was the same script, more or less, but delivered by a different newsreader.

As once said, it was the ‘same meat but different gravy’.

One of the lines delivered is this:

“Paramedics, doctors, nurses, community health staff, managers, IT workers and support staff all working together to provide the best care possible.”

Trish Greenhalgh immediately saw the problem with this.

 

 

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As Brenda once wisely said, “Oh no. Not again.”

Matt Hancock picked his five ‘fundamentals’ he wished to focus on: “NHS values”, “Long term plan”, “Workforce”, “Technology” and “Prevention”.

Intriguingly, there was nothing on the openly fraudulent activity of using the “NHS logo” to badge up private providers in the discussion of “NHS values”.

Integration wasn’t given its own heading, but was mentioned twice.

In relation to “prevention”, Hancock said:

“The integration of the NHS and social care and wider services in local government is vital to getting this right.”

The most parsimonious explanation for the drive towards integrated services, across health and social care, has been, apart from the clinical case to drive up ‘value’ and to focus on ‘clinical outcomes’ meaningful to the patient, has been to harmonise the NHS with other jurisdictions to attract inward investment in the drive towards post-Brexit globalisation.

This of course has a long ideological history. In the U.S., prevention was a critical feature of the development of their health system based on private insurance systems.

As explained in the New York Times,

“At least one of Kaiser’s dreams has foundered. Because H.M.O.’s dish out care for fixed prepayments, they argue that they will practice preventive medicine to keep people healthier. Dr. Garfield, in his desert days, after treating an epidemic of wounds in the feet of workmen caused by nails protruding from boards, used to go out and hammer the nails down himself.

Kaiser had touted the idea of the annual checkup for everyone, until a Kaiser study concluded that it was a waste of time. The plan still offers lifestyle programs, but it admits that it has no idea what good they do.”

There is a long history of England looking to other jurisdictions for inspiration.

Look at Prof Sir Chris Ham’s observation on the U.S. giant Kaiser Permanente:

“We agree with Black that improved bed management is not expensive and with Badrinath that other evidence supports our argument that the NHS can learn from Kaiser.”

Interestingly, likewise, “patient safety” did not have its own heading. It was shoo-horned into “technology”, however.

“Not only can the right use of technology save time and money, it can improve patient safety.”

Patient safety is addressed in an oblique reference to safe staffing, e.g.

“First it means receiving the best training and support – the right number of people with the right skills so you are able to provide the safest, highest quality care to patients.”

But there is no real explicit recognition of the recruitment and retention crisis across the board, especially in general practice. Many reasons have been given for the problems faced in primary care, including over-the-top regulation, but Hancock managed to reduce the discussion to one line.

“GPs need more assistance to tackle with their substantial workloads.”

There was quite a long and interesting mention of “technology”, however.

“Emphatically the way forward is not to curb the technology – it’s to keep improving it and – only if we need to – change the rules so we can harness new technology in a way that works for everyone: patient and practitioner.”

But this idea is particularly intriguing.

“We are working with Amazon so the NHS Choices health information that millions use each day can be tailored for voice activated devices.”

But how far will Hancock want to ‘changing the rules‘?

Is it possible that someone will want to see a voice-activated device to run ‘diagnostic algorithms’ akin to “Babylon”?

Such a public-private partnership could badly skew the market, but the Conservatives’ track record on competition is not real competition at all, but delivering highly rigged markets which returns massive shareholder dividend for a few oligopolistic players.

On Babylon, Hancock gives good product placement.

“The discussion around my use of a Babylon NHS GP, which works brilliantly for me, has been instructive.”

Was there anything on the catastrophic effect Brexit might have on the social care workforce?

No.

Was there anything on the colossal PFI debt?

No.

Was there anything admitting to privatisation?

No.

Was there anything on nurses’ pay?

No.

Was it ‘business as usual’?

Yes. Very much so.

@dr_shibley

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“This is about the standards you want to abide by as a country”

So uttered Theresa May in defending a ‘carve out’ in a mythical trade agreement with the U.S.

We do not know what these standards are. For all I know, the NHS could be about to launch innovations which are the equivalent of ‘chlorinated chicken’.

 

Donald Trump, POTUS, admitted this week that he didn’t give Theresa May ‘advice’ on negotiating with the European Union, but he did make a ‘suggestion’. It eventually turned out that Trump advised May to ‘sue the EU’ according to May in her interview on the Andrew Marr show. But it seems that the British Government is trying to claim that it will be freed up to make a free trade deal with the U.S. if it is not tied into the single market. It certainly will be freed up to make a free trade deal with the U.S.  if the European Union rejects the U.K.’s proposals. Theresa May might be forced to do a John Major, and say, “Back me or sack me!” Falling off the cliff edge into the abyss means that junior doctors would no longer be protected by the European Working Time Directive – which has long been argued, particularly by some surgeons, to be a barrier to training. Doctors too tired to function safely? Nah.

 

But whisper it softly – actually, things are quite bad now.

 

The British Government has been uniquely bad in offering to the European Union a platform for which they could work together. Even in the unlikely event that the European Union wants to make a deal with the U.K., the British Government is proposing that goods not services would be harmonised. So in this unlikely event any innovations invented in the NHS would have to comply with E.U. rules, if that market was to be tapped into. But that might entail protections on data privacy and retention which multi-national corporates might not find desirable. The British Government might wish to cut costs, by farming out as much as possible to the “cloud”, which could mean that patient data fall under the Chinese jurisdiction.

 

So, far from ‘taking back control’, patient data could be stored internationally and could easily be subject to cyberattack. This could be a ‘Project Fear’, but it could likewise be a major problem with the current Government’s desire to make money out of the NHS. It is clear that previous Governments have considered patients a nuisance to running a service which is a sink for money, and would much rather make the NHS profitable or an ‘export’. Apps are one way of doing this.

 

If an app generates anxiety in a patient, there would be no come back apart from lodging an administrative complaint.

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Private equity investors could invest in research and development, and market software for prompt diagnosis here and abroad, for example to cut down GP ‘waits’ etc.  It would not actually be possible to ‘strike off’ a dodgy app under current legislation, if for example it suggested that a ‘textbook’ heart attack was in fact an innocuous bit of indigestion. But it’s often been the dream of some to put offshore diagnostic services, e.g. interpreting a x-ray, even perhaps interpreted by ‘artificial intelligence’ which we are repeatedly told is superior in performance to an experienced clinician. Diagnoses of dementia could be made simply by tracking how many times you went to your local bank, or did online banking, for example.

 

Successive governments had had little interest in valuing the workforce, knowing that many NHS staff are indeed so loyal they would want to stay in the NHS for their whole career. Private companies take advantage of this by badging their services fraudulently using the NHS logo. It will suit the new Secretary of State for health and social care to pretend it values very much the workforce, while trying to flog off property or apps to make a healthy budget sheet. For too long, the NHS has had a split identity of wanting to run the NHS as cheaply as possible (in the name of efficiency), while trying to avoid ‘quality’ from going through the floor, but still trying to make bits of it discrete and profitable for international markets for goods. It has no interest in selling off unprofitable services. And it doesn’t particularly mind if the quality can go through the floor, and hopefully nobody notices – for example, by annihilating services for mental health rehabilitation. The only hope that NHS England has for selling off services internationally is from reducing liabilities (e.g. litigation costs of patient safety) or debts (hard to do with PFI), and if it can somehow turn an integrated NHS and social care into “bite size chunks” (hence the rumpus about the future of accountable care organisations).

 

If it were up to “innovators” and “entrepreneurs”, there would be no altruism any more. Data are a source of money, and it doesn’t matter if NHS England shills blandly claim ‘patients own data’. Self-management is a convenient cover for cutting services, shifting accountability and blame, and a way for the private sector to flog more products with little evidence base to a gullible public. The genomes of each and every one of us could be pumped into a giant Big Data computer, so that ‘population segmentation’ goes down to the level of n = 1, to ascertain whether the population which is at ‘high risk’ for ‘avoidable admissions’ is YOU, based perhaps on your genomic code. The future is here – embrace it. British inventors could patent their A.I. algorithms, and sell them to the US or Chinese. And the U.S. and Chinese could sell us their computer screens and drugs. “Fuck business” for EU services, as Boris Johnson might say.

 

So Donald Trump might want to get his little tiny hands on the NHS after all – and Jeremy Hunt in the cockpit is ably qualified to lubricate the future.

 

@dr_shibley

 

 

 

 

 

 

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Doctors advise that you shouldn’t stop suddenly certain drugs such as antidepressants for fear of severe discontinuation symptoms. Privatisation is a drug on which Government has been dependent in the UK for nearly 40 years, and we need to grit our teeth and come off  the drug.

In an era long ago, far predating the trials and tribulations of Brexit, the Coalition government of 2010 wondering what to do decided that they would do a ‘shake up’ of the NHS.

Everything was perfect. Andrew Lansley called on his friends in McKinsey’s to take another bite of the cherry following their last monumental cock-up “re-disorganising” the NHS in 1974. Perhaps he had been boyed up by the drip-drip of the ‘Nicholson challenge’ which would impose an austerity agenda on NHS Trusts recently saddled with debt from the policies of PFI from John Major and an incoming New Labour government, ably aided and abetted by a neoliberal consensus from a dying New Labour government in 2010.

New Labour were elected as Conservatives, and governed as Conservatives. The problem is that the relic of the routemap to privatise the NHS wholesale still carried on regardless, that routemap being the famous ‘The Health of Nations‘ document from the Adam Smith Institute. Of course, the list of the supporters and corporate shills is endless, and many people have played their part over the years.

Anyone looking at the Health and Social Care Act (2012) would have needed a degree in international corporate law to understand it. I, for different reasons, worked towards such a degree. Whilst it is 500 pages of incomprehensible company law, it makes perfect sense as a charter to throw the NHS into the hands of private industry.  It locks in a mechanism for everything to be up for market tender and market forces, and for failing economic entities to die off like some sort of neoliberal eugenics ‘survival of the fittest’.

This is one of the biggest tragedies of how the NHS has been treated in the last few years. There’s been a massive opportunity cost – the effort and money spent in promoting private companies such as Virgin, arguably, might have been better spent by producing financial resilience to NHS Trusts. NHS Trusts have not been ‘unsustainable’ – they have been simply underfunded.

The physician workforce is relatively under-doctored, and doctors are overstretched. The service has been deliberately run down, to make it attractive for private investors. That is why it is essential to stop journalists from repeatedly telling us private industry is more ‘efficient’.

The history is relevant, so that we do not go down this road again. Lansley simply wanted to sell off ultimately the NHS like the utility companies. The privatisation of the utility companies has generated huge profit for shareholders, has nothing for ‘taking back control’ (indeed has encouraged ownership of essential companies by foreign investors) and not seen better ‘quality’ (as would have been predicted, as they were all selling uniform products which do not vary.)

But the ‘lesson learned’ from the Thatcher era was that these big Leviathans had not been sufficiently fragmented prior to the privatisation. The neoliberal consensus which had emerged and still continues in government, from 2010, was to outsource as much of it as possible with a view to making the NHS so fragmented it can only be sold off.

All of this carries on, and the artist previously known as ‘accountable care organisations’ is simply a New Labour-induced mechanism, perpetuated by the current Government, albeit with a different name, to make the NHS into ‘sellable chunks’.

And this is entirely possible with devolution to atomise the NHS into groups of care providers, but a new direction for the NHS must be to ensure that the dependency on the drug that is privatisation has to stop. We now it has been a disaster for social care, with ’round the year talk’ of providers going bust.

The NHS does need ‘management’, but it very much now operates on the basis of ‘management based medicine’ rather than ‘medicine-based management’.

The problem is primarily of ‘money before health’. Privatisation is a drug which they all would have withdrawal symptoms if discontinued.

And this is seen in all sorts of ways.

Jeremy Hunt abolishing various targets, from A&E waits to cancer waiting times, is a perfect way to let the service come close to collapse, without none of it being discussed effectively. Jeremy Hunt is lucky to have such a pathetic media who can shill on his behalf.

The NHS continues to need its quick fixes of privatisation – getting any old income (revenue) from flogging off the nation’s silver, as the late Harold Macmillan, Tory Prime Minister, called ‘privatisation’.

It has just transpired, in the latest stunt, that the NHS is privately marketing a 100-year-old hospital building that provides affordable housing for 52 nurses and other key workers to property developers to create a One Hyde Park-style complex of luxury flats overlooking Hampstead Heath. A password-restricted website set up by the Royal Free London NHS foundation trust describes the 1.6 acre site as “the last major development site in Hampstead with an unrivalled position between the heath and Hampstead Village”.

A cross-party body to shape the future of the NHS would lock in the neoliberal consensus for good, ultimately sealing the fate of the NHS to the coffin. Astroturfers of course thrive, even with some NHS campaigners being head-hunted by US free-trade gurus.

Astroturfers need zombie policies, like hypothecated tax. The TV licence is a current example of hypothecation, as the revenue raised is earmarked for the BBC. Gordon Brown’s decision in 1999 to allocate additional revenue raised from real increases in tobacco duties to health expenditure is an example of weak hypothecation.

But it is plainly obvious that health spending should be determined by ‘need’ or ‘demand’ for a service, rather than how much a tax raises. Strong hypothecation ties spending to a single tax revenue, and would thus make health expenditure dependent on macroeconomic performance.  And we know that the current economic performance, a nation no longer of shopkeepers but couriers and drivers on zero-hour contracts, cannot sufficient monies to get us through paying for Brexit even let alone the NHS.

Spending on health would be exposed to macroeconomic shocks that have nothing to do with the health of the population. Furthermore, tax revenues would fluctuate over the economic cycle, which risks insufficient funding for health services during economic downturns, and wasteful spending during booms.

And the corporate sleaziness continues .It has just been revealed, somehow, that a £330 million deal between NHS England and Capita to outsource administration and transform services, in part due to a legacy IT system NHS England considered unsustainable, had the potential to seriously harm patients. The National Audit Office heavily criticised the seven-year deal struck in 2015 with Capita, a professional services firm, to undertake the duties of a newly formed unit named Primary Care Support England – all while cutting costs by 35%.

Politicians got onto this can-be-fatal privatisation drug, and they do need to wean us off it asap. But Rome wasn’t built in a day?

John McDonnell, shadow chancellor, said last week that the collapse of Carillion had highlighted the catastrophic failure and inadequacy  of the UK’s regulatory regime, as well as shortcomings in the audit market. Mr McDonnell said Labour had commissioned an independent review. The review will be led by Prem Sikka, a professor of accounting at the University of Sheffield and an outspoken critic of the big four audit firms: PwC, Deloitte, KPMG and EY.

We need to face facts. Private companies have absolutely no interest in the health of the nation, otherwise it would care about contributing to the training budget of clinicians in the NHS where ultimately most if not virtually all private clinicians in the UK have been trained. They only care about lining their own pockets.

It’s all a question of £ first – under the cloak of the logo of the NHS.

Disgustingly, a GP practice taken over by Virgin Care has just been placed in special measures after going from an official rating of ‘outstanding” to “inadequate” in less than two years despite increased funding. The Sutherland Lodge practice in Chelmsford, Essex, was taken over by the private provider in July 2016 after the previous partners handed back their contracts following £400,000 funding cuts to their contract with NHS England.

The arguments against the atomisation of the NHS and social care are not simply economic – e.g. the increased cost of bureaucracy, commissioning or litigation. Experience from devolution in Manchester has now shown that a major barrier to integration of health and social care policies has been ineffective inter-agency working, for example in sharing safeguarding concerns, or in communicating about which providers can provide in a timely way home care packages.

One thing leads to another. It is no surprise, given the parlous state of social care infrastructure, then, that delayed transfers of care have gone through the roof, so that even if you can get into hospital you can’t check out. In a way, it is even worse than Hotel California, where you could at least check out?

All of this dependence on privatisation has been carefully sold to the public, avoiding any public panic by avoiding any talk of ‘Tell Sid’. It’s been ideologically-driven, but has nearly killed the NHS off for good. Unless we stop the atomisation of the NHS, death by a zillion cuts, making what’s left of it into sellable bite-size chunks, we will have no universal, comprehensive, free at the point of need NHS.

The problem has been for 40 years “money before health”.

But look on the bright side – we can sell off what’s left of it in a trade deal to Donald Trump.

That last sentence was sarcastic, by the way.

 

@dr_shibley

 

 

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The antecedents of the NHS are to be found in Tredegar and in the Beveridge report, which preceded it. Disease was one of Beveridge’s five great evils. Infectious diseases such as polio, diphtheria and tuberculosis caused people to die in their early and mid-50s on average. The need for a sufficient and healthy labour force to rebuild the economy necessitated combating those diseases, which also caused a high rate of infant mortality. The need for a better, longer-living workforce drove much of what Beveridge looked at.

There was in fact a good deal of state funding provision before 1948 to cope with the devastation of disease, but what Bevan did, against tremendous opposition within the service and politically, was to centralise the system, nationalise hospital provision, create standards across the country and, crucially, give people the assurance that they would always be seen and treated, based on their need, not their ability to pay.

The health service was built on a tripartite structure of hospital, GP and community services. In return for good terms and conditions, clinical freedom and autonomy in the system, the doctors finally agreed and the NHS was born. It was a wonderful achievement, but it was also a wonderful compromise. Over the past 70 years, the tensions in that compromise—the local versus the national, the role of clinical autonomy, priorities and the quality of the service—have regularly surfaced. There are always crises—astonishingly, every year there is a winter.

We now treat 1 million people every 36 hours, and employ nearly 2 million people. We are very grateful for everything they do, and we celebrate them today on this 70th year. However, the challenges are different today, and the service should therefore be different in the next 70 years. This anniversary is an opportunity to celebrate the achievement, revisit the compromise and set a course that is as resilient for the next 70 years. The diseases that are with us today—cancer, and cardiovascular, respiratory and liver disease—are very different. Depending on a person’s social class, dietary risks, tobacco and obesity are the biggest contributors to early death and disability. Alcohol and drug misuse, and lack of physical activity, are also key. We are finally starting to appreciate the impact of mental health and social isolation on physical health.

Life expectancy has increased, but the prevalence of people living with one or more limiting long-term illnesses has changed the picture of healthcare demand, and that requires the system to change. In Bristol, women live an average of 64 years in good health, but a further 19 years in poor health. For men, the figures are 63 and 15 years, but that average masks a huge range in social class. Several areas of my Bristol South constituency are in the bottom 5% in England for male life expectancy. In 2010 the Marmot review told us that such health inequalities cost us approximately £36 billion to £40 billion in lost taxes and costs in welfare and to the NHS—that is a huge amount of money. We must prevent and manage life-limiting diseases and address the silent misery of families who support and cope with people living with them.

Accountability is a major issue for the service in the next 70 years. We need to start treating patients and the public as assets to the health service, not as nuisances. We need somehow to introduce democratic accountability into decision making. The complex fragmentation of the health service makes it wholly unclear where responsibility, and hence accountability, lies. From the bottom up, hundreds of bodies are involved. The 200-odd clinical commissioning groups are members’ clubs with no element of either direct or representative democracy, and they are plagued with conflicts of interest. At the top, there is not just the Department and Ministers, but a raft of arm’s length bodies, which Members of Parliament find it impossible to navigate. I worked in the system for a CCG, and I still find it really difficult—it is an absolute mess.

One reason for the mess is the disaster of the Health and Social Care Act 2012, but the NHS has been poor on accountability since the early centralisation. It has always been fragmented in a way that makes accountability harder, and it has always seen itself as separate from the rest of the local system, which has democratic accountability. That is a problem. It has always been riven by powerful vested interests that distort the general accountability. That is a key part of Bevan’s compromise, and I think we need to revisit it.

Presented with a well-made case that is supported by, dare I say it, experts or informed leaders, the public will make difficult decisions. I know local politics can make things difficult when tough issues such as service changes are necessary, but excluding people does not make that any easier. Making a hard case to local people and their MPs is challenging work, but if that does not happen decisions gain no legitimacy. We can keep the “N” in the NHS, but we need to give local people far more control to make it more resilient for the next 70 years.

It looks like we are going that way. We have heard about the experience in Scotland, and this is also a devolved matter in Wales. Very interesting things are happening in Manchester, but we need a much better debate about what local looks like. We must recognise that the key issues for now are the money and the workforce. Technology gives us huge opportunities, including on some of the workforce issues.

I want to finish by talking about leadership. I joined the health service as a manager in the late 1980s, and I am very proud of the role that managers play in the services. General management, which was introduced in the 1980s, has few friends, partly because it was associated with the Thatcher era of reforms, and partly because it threatens clinical autonomy and freedom, which were fundamental to Bevan’s compromise. We should use this anniversary to celebrate managers and leadership in the NHS. We need good clinical and non-clinical managers to make the changes we want to see, deliver the efficiencies we need and keep making the system safer. I hope that they can also help leaders make the NHS more open and accountable. We need that for the next 70 years.

From the  Westminster Hall debate  16th May 2018

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3 challenges to the NHS on its 70th birthday.

NHS embodies a set of key principles and values which are increasingly under attack. In an age of austerity, with widening social and economic inequality, and increasing intergenerational division, I argue that these principles are more relevant and necessary than ever. In this talk for a meeting of the East Dartmoor Labour Party, I look at threats to three of the underpinning principles of the NHS, and considers how we might respond . . .

  1. NHS celebrates its 70th birthday on 4 July. Timely to look at the challenges it faces, why it is important to be aware of these, and consider how we might respond.

  2. Founded after the WW2 as a key component of Beveridge’s war on the 5 giants (idleness, squalor, want, ignorance, and disease) the HS continues to occupy a unique place in the British psyche. It embodied and continues to embody a set of principles and values: universality, collective citizenship, fairness, social and redistributive justice. It was established as a publicly funded; publicly provided, universal service, free at the point of use.

5 giants

  1. NHS was part of a social vision which connects health, housing, education, and employment – we know empirically how health is influenced by each of these – so in that sense challenges to the NHS now are in my view part of a broader neoliberal assault on the entirety of that vision.

  2. Throughout the 50s, 60s, and 70s that vision broadly held good. That is not too say that we should be too misty-eyed about these times: financial problems still occurred, waiting lists were too long, and the delivery of services on a universal basis was problematic.

  3. It was in the late 80s and 90s that the underpinning principles began to be challenged. The 1990 Act separated for the first-time provision of services from planning (purchasing) and the assessment of need. Under the banner of modernisation later reforms introduced more fully the language and behaviour of the market. The consequences were:

  • Entry of new providers into healthcare
  • Redefinition of patients as consumers who wanted to express choice
  • The business of contracting was invented, a performance management industry (star ratings, performance targets) created
  • Regulatory agencies established
  • Repetitive, disruptive cycles of organisational change begun (FTs,PCT,CCGs)
  • All under the control of New Public Management.
  1. This policy direction culminated in the Health and Social Care Act (2012). Directly this absolved the Secretary of State (SoS) of accountability for the NHS, allowed the passage into law of a set of secondary legislation which opened the door for private health insurance schemes, top-up payment schemes, co-payments, and by the introduction of the “any qualified provider” test, heightened the possibility of private sector involvement through the application of competition law to the commissioning of care.

  2. HSCA was translated into a vision for the NHS through the Five Year Forward View, which further changed the NHS by creating 44 Sustainability and Transformation Plan geographical footprints for future service design – which in turn are the basis for new care models such as Accountable Care Systems, Accountable Care Organisations, and Integrated Care Organisations.

  3. If this is the policy background – let us turn to the key challenges now. My argument is that the current direction of policy is a clear and present danger to the NHS and the principles behind its establishment: and 3 principles in particular: publicly-provided service; universality; publicly-funded.

  4. Firstly, public-provision. Consider the growing insertion of private providers within the NHS, and philosophy of marketisation. NHS funding on the private sector has grown from £2.1bn in 2006 to £9bn in 2016. From the early experiments to the most recent examples, a considerable body of evidence has accumulated about private provision which, in summary, shows:

  • A market system has created huge transaction costs for the NHS (estimated to cost £4.5bn)
  • The inability of regulators to assure patient safety within a profit-motivated private sector (Ian Patterson as the example)
  • The significant diversion of funds away from patient care, for example the PFI scheme (Barts Trust pays £127m, pa, until 2049 for its PFI scheme; Central Manchester pays 10% of its annual clinical revenue to the PFI scheme)
  • That patients want high quality local services, not artificial choice
  • Loss of trust as providers game the targets and avoid accountability
  • And that, as with banks in 2008, whilst profit is privatised for shareholders, the risk when providers fail (Carillion) or withdrawn (Circle) is borne entirely by the state.

Despite all this evidence, the national policy response has been to ignore it, and to pursue ever more enthusiastically an irrational, ideologically-driven, zombie policy of privatisation. Thus, we now see new, novel forms of privatisation. In general practice, PUSH Doctor, Doctor at Hand, Babylon and Simply Health are growing
threats to primary care.  In community health, Virgin is now a major provider, with over 400 contracts, including here in Devon where it is bidding to extend its control over childrens’ services. And in the acute sector, separate firms are being established to employ hospital staff, whilst land sales are key to hospital financial recovery plans. In summary, the implementation of market reforms has transformed the NHS from a single healthcare system to a complex conglomeration of public and private providers under the umbrella of the NHS brand.

  1. The second challenge is to the universality of service provision. – the notion that services are broadly the same in Buckfastleigh as in Birmingham. STPs have been explicitly established to solve national problems on a local basis. Direct responsibility has been given to them to make local choices – choices which have primacy over national ones. Looking again at the evidence we see that STPs and CCGs are accentuating local variation through 6 processes, Deflection, Delay, Denial, Selection, Deterrence, and Dilution.

GP referral management schemes delay, defer and deflect patients from secondary care; the explicit exclusion of certain groups (smokers, the obese) denies care; blaming patients for presenting inappropriately deters the future expression of need; the tightening of referral criteria (hip replacements; IVF, continuing care) selects patients, and increasing funding variation in community nursing dilutes quality.

Through these processes geographic variation is being magnified, and the principle of universality undermined. Rather than making transparent the boundaries of care and seeking national agreement on acceptable variation. STPs are developing and implementing their own criteria and policies, the effects of which compound variation and institutionalise the postcode lottery of care.

  1. The third challenge is funding. At this point speakers generally reveal a graph showing historical NHS expenditure trends, and the debate is framed by international comparisons (relevant or not), anecdotes about efficiency and waste, and discussion about the meaning of the figures and timescales. There is inevitably reference to “infinite” demand.

I’d like to approach it differently. We are constantly told by the rhetoric of austerity that money is tight, that demand is rising (those old people keep living longer and longer), and that difficult choices have to be made.

I want to challenge that. For me, that narrative is about the government trying to locate this funding crisis within the minds of taxpayers and to get them to accept their interpretation of the problem and, also, to be part of the solution by agreeing to new funding alternatives, such as top-up payments, co-payments, by accepting restrictions on access to care for immigrants, or the obese, or by agreeing to use more private healthcare. Moreover, the funding crisis in the NHS is constructed as a purely financial one, predicated upon convincing people that the austere response is the only possible one. Underpinned by notions of staff ineffectiveness and inefficiency, this creates a narrative strong enough to compromise the principle of treatment being free at the point of use.

An alternative narrative is that we are (according to Liam Fox no less) the 5 th largest economy in the world: that 78% of people consistently rate health spending as a priority, and 67% would pay more tax for the NHS. Current health spending has increased (4.1% of GDP in 1978 to 7.2% in 2016; but going down to 6.8% in 2019) but even the promises made by Tony Blair to equal European average spending, have been, in this context, modest. Am I alone in thinking we can and should do better?

The challenge is to resist the dominant narrative that it is a service that can’t be afforded, that the only solutions lie in private care and insurance; that demand rises inexorably, or that a cross-party Royal Commission, or a hypothecated tax, is needed to sort this all out. It can be afforded – it is a question of political will.

  1. I’ve identified 3 challenges to the principles of the NHS: to universality; to its public provision; and to its national funding. It is often questioned whether the principles, established in 1948, of social justice, collective citizenship, and an active, assertive role for the state are still relevant today. For me, in an age of austerity, with widening economic and social inequality, and increasing inter-generational division, these principles seem more relevant and necessary than ever.

  2. How can we respond individually and collectively to the challenges?

A) NHS Reinstatement Bill is being debated in Parliament on 11 July, sponsored by Eleanor Smith. The Bill re-establishes statutory health bodies with responsibility for health and underlines accountability to local people. It reinstates the national accountability of the SoS. Further, it abolishes marketisation, commercial contracting, and
centralises PFI debts. This bill should be widely supported.

B) Local action is key to disseminating the message about what is happening within our health service. There are active campaign groups across the country including the Keep our NHS Public  and the NHS 999 campaigns, and local NHS SOS campaigns here in Devon.

C) Real stories, patient experience stories are valuable material on the doorstep when campaigning about the NHS. Its is important to challenge the myth that “there is no money for the NHS,” or that it cannot be afforded, and real examples of the damage that has been done to the NHS, by talking about patient care stories can help
here.

D) Finally, those who understand best the changes that have occurred with the NHS are often those who work within it. Talking to local practice and community staff, going to see hospital staff, is an effective way of learning about what is happening, and building allies and future supporters.

 

 

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

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

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

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

The main changes to this edition include:

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

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

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

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

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

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

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

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

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

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

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

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

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

COMMENT

These comprehensive Standards are very welcome.

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

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

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

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

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

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

Reference

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

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The interim report on the Parliamentary Review on the Welsh Health and Social Care Service was published in July 2017 just before the National Assembly’s summer recess. Its main message was that both services needed to innovate and modernise at a much faster rate if they are to continue to provide quality care over the next five to ten years.

This is a well rehearsed and often repeated message. However, unlike previously, instead of encouraging “a thousand flowers to bloom”, the Review urges more limited and strategic approaches with a particular emphasis on the needs of the older population. These limited innovations should be properly and thoroughly evaluated before a wider general application across the two services….in summary a call to “innovate, evaluate and disseminate”.

But while this central message is clear the report itself throws up a range of issues which do not sit easily within the confines of this central recommendation.

The initial Welsh Government response welcomed the Review but highlighted this ambiguity when it  summarised the conclusions as

“Frontline staff, the public, and other public and voluntary organisations will be asked to work together to develop new models of care, to help hospital, primary care, community health and social care providers to work more effectively together. The models will be developed to work in different settings such as urban and rural, and take account of Welsh language needs. The Parliamentary Review interim report recognises that new models will need to be underpinned by action in a number of areas and makes further recommendations including the need for a step change in the way the health and social care systems adapts to the changing needs of the population the people of Wales, staff, service users and carers to have greater influence on new models of care with clearer, shared roles and responsibilities new skills and career paths for the health and social care workforce with a focus on continuous improvement better use of technology and infrastructure to support quality and efficiency streamlined governance, finance and accountability arrangements aligned for health and social care.”

This is in effect is calling for a total, rather than limited, system and culture transformation across the combined health and care service. The final report plans to provide a range of specific recommendations which will both inform and provide benchmarks for what the new service will look like. However the sheer scale of the change agenda will test the Review Panel’s ability to deliver its own objectives.

In undertaking such a broad ranging review, the interim report covers and comments on many areas which are central to the future sustainability of services but often they are just noted or merely mentioned in passing. While it might be argued that some of these findings are beyond the formal remit of the review they could provide an importance context in evaluating the prospects for success of the final detailed recommendations.

It reports that NHS spending in Wales will need an annual increase of 3.2% to 2030/31 with adult social care requiring 4.1% to maintain pace. In an era of continuing austerity this level of financial growth is a forlorn hope and consequently increasing service effectiveness and efficiency “is essential for future sustainability”. However the interim report does not quantify the possible impact of its recommendations on achieving the reduction in funding pressures which a sustainable service needs. This is a major gap which, hopefully, will be addressed in the final report.

But even if there were sufficient resources there are crucial bottlenecks and imbalances across the system. Staff recruitment and retention at all levels is vital but there is a growing problem with conditions of pay and conditions. The chaotic Brexit negotiations is only aggravating the uncertainty. In addition infrastructural investment needs to have a clear vision and sense of purpose. IT will be particularly important in providing the communication network though which new integrated, partnership working will take place.

The need to have a unified health and social care vision is reiterated on many occasions. It is acknowledged that looking at the barriers between a “means-tested” care system and “free at the point of use” health care system is beyond the remit of the review but there are areas where meaningful progress can be made. In responding to the report, the Welsh Health Cabinet Secretary pointed out that pooled budgets, facilitated by the Social Services and Well-being Act (Wales) 2014, will be rolled-out across more service areas from April 2017.

The imbalance between primary care and the rest of the health service is also highlighted. While innovation has taken place it still remains the case that despite a relatively older GP workforce, the number of GPs in Wales have effectively been static over the last half decade. This is in contrast to the hospital sector where consultant numbers continue to increase. This lack of growth inevitably means that community based health services are not achieving the type of outcomes which will make a difference to patients’ experience and well-being as well as the optimal smooth running of the overall system.

Addressing and reducing health inequalities in Wales was also part of the Parliamentary Review remit. It acknowledges the importance of the social determinants of health and the importance of other parts of public policy such as welfare benefits, housing and early years. However it is remarkably light in scrutinising the continuation of “the Inverse Care Law” in health and social care. This omission is glaring and addressing it must be a major priority for the Review in its final phase of work.

The review spends a lot of time considering how to make things happen and looks at the role of the Welsh Government in facilitating change without outlining specifics. A separate recent report on health and care services stressed the need for the Welsh Government to give a stronger lead. This is a bit challenge for them.

On the one hand Welsh Government is keen to promote more locally sensitive and delivered services. But clearly this approach has only had limited success in delivering the the scale of change that is required. In practice “localism” can be a barrier to much needed change when “parochialism” tends to dominate the debate and decision making. And with many of crucial “facilitators” of change in the hands of the Welsh Government, this will be a critical area for the final report’s recommendations.

The overall success of this Parliamentary Review will be judged on how useful its final report will be. In producing the final report the Review Panel is aware that other similar work has failed to make a comprehensive transition from the page to the clinical setting. It states its determination to make recommendations which will be meaningful, focused on outcomes, manageable and implementable over a reasonable timescale. Based on the interim review this will be a very tall order faced with continuing austerity in our public finances.

https://beta.gov.wales/review-health-and-social-care?lang=en

http://www.assembly.wales/en/bus-home/pages/rop.aspx?meetingid=4304&language=en&assembly=5&c=Record%20of%20Proceedings&startDt=10/07/2017&endDt=21/10/2017#C489167

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Conference notes:

  • The NHS Accountable Care System contracts announced on 7 August impose a basis for 44+ local health services to replace England’s NHS, bypassing Parliamentary debate and legislative process.
  • On 9 August, the House of Commons Library revealed a doubling of the number of NHS sites proposed for sale. 117 of these currently provide clinical services.

Like their US templates, Accountable Care Systems will provide limited services on restricted budgets, replacing NHS hospitals with deskilled community units.  This will worsen health indicators like the long term increase in life expectancy, stalled since 2010. The ACSs and asset sell-off result directly from the 5 Year Forward View currently being implemented via ‘Sustainability and Transformation Partnerships’.  The 5 Year Forward View precisely reflects healthcare multinationals’ global policy aims.

Conference reaffirms its manifesto commitment to restore our NHS by reversing its privatisation and halting Sustainability and Transformation Partnerships. We therefore call on the Party to oppose and reverse funding cuts (ideally meeting Western European levels) but also 5 Year Forward View policy:

  • creating Accountable Care Systems;
  • replacing 7500 GP surgeries with 1500 “superhubs”;
  • downskilling clinical staff.
  • reclassifying NHS services as means-tested “social care”;
  • cementing the private sector role as Accountable Care System “partners” and as combined health/social care service providers.

Conference recognises that reversing this process demands more than amending the 2012 Health & Social Care Act and calls for our next manifesto to include existing Party policy to restore our fully-funded, comprehensive, universal, publicly-provided and owned NHS without user charges, as per the NHS Bill (2016-17)

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In my role as a Shadow Health Minister, while it did not grab many headlines; it was extremely disappointing that a House of Lords amendment, which would have seen more patients able to access life-saving innovative medicines without delay was voted down by the Conservatives. I spoke in support of the proposed changes to the Government’s Health Service Medical Supplies (Costs) Bill, which I have been leading on for Labour.

Through both their failure to back this amendment and their recent changes to NICE, which could further delay access to new medicines, the Government is presiding over a system which leaves increasing numbers of patients in the heart-breaking situation of being unable to obtain innovative treatments which could save or extend their lives. It is also worth pointing out that this directly breaks the Conservative party’s 2015 manifesto promise to speed up the introduction of cost-effective medicines into the NHS.

Last week, even more promises were broken, as the new NHS England Plan, “Next Steps on the NHS Five Year Forward View” confirms that the NHS does not expect to meet the A&E target, to see 95% of patients within 4 hours, which Jeremy Hunt described as being “critical for patient safety,” for at least the next year. It also sets out plans for another round of rationing of treatments and the abandoning of the 18 week waiting target for surgery.

Of course all of this leads up back to where I began with the fact that only an adequate financial settlement can deliver the health and social care service that we all want to see.

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On November 1st 2016 the Welsh Government’s Cabinet Secretary (Minister) for Health, Well-being and Sport, Vaughan Gething, announced the establishment of a Parliamentary Review which will look at the key challenges facing the health and social care services in Wales.

He said  “ … (it) will review the best available evidence to identify key issues facing our health and social care services and draw out the challenges that these will present over coming years. For example, there are challenges with NHS finances within a reducing Welsh Government budget, workforce planning, recruitment and retention, and meeting the rising demands of healthcare and rising public expectations. The review will examine options for the way forward and will then make recommendations about what the health and care service of the future could look like.”

The review was initiated as part of the “Moving Wales Forward” agreement between Welsh Labour and Plaid Cymru underpinned by wider cross party consultation and discussion.

The current Welsh health strategy, “Together for Health “ is due for revision and the Cabinet Secretary hopes that the Parliamentary Review will be completed in time to inform its replacement. This seems sensible and should give the Review a sharp operational focus.

However such a relatively short time window may not provide sufficient opportunity for the Review to engage in the innovative thinking needed to come up with the radical proposals that an under-resourced health and social care service is likely to need just to sustain itself and survive.

The Review will be led by the former Chief Medical Officer for Wales, Dr Ruth Hussey, supported by an an independent panel drawn for a wide range  of experienced backgrounds predominantly from outside Wales. It will be supported by a stakeholder reference group made up of representatives of professional bodies and social service organisations within Wales. Faced with such an strong resource, which has attracted cross party political support, the Welsh Government might wish to consider asking the Review for a relatively early report to help with the revision of its overall strategy and then requesting it to give additional thought as to what Welsh health and social care is likely to need for the medium and longer term.

 

http://gov.wales/topics/health/nhswales/review/?lang=en

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The festive period may be a time of celebration and cheer for most of us, yet medical staff across the country are gearing up for their busiest time of the year. Services across the NHS are set to face a strain not just in terms of workload, but everything from the amount of hospital beds taken up to the demand placed on the primary care services.

Whilst the health service is looking to recruit more and more recruits into GP and nurse jobs, demand on the system is the biggest issue along with a lack of trained professionals. Approximately 89% of hospital beds were occupied over winter last year, delaying treatment by more than 18 weeks for a tenth of all patients. £80 million was lost this way and that’s before the impact on primary care.

On the frontlines, nearly 10% of visitors to A&E were found to have waited more than 4 hours to see a staff member. With the level of severe conditions such as major physical injury, respiratory issues and dementia being on the up, resources have to be spent elsewhere and not on issues that can likely be treated at home. Prevention is better than treatment though so remember to think before picking up the phone this Winter.


Winter Pressures on the NHS – An infographic by the team at Primary Care People
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