Category Archives: NHS

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

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


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

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

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

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

 

Jeremy Corbyn’s Labour speech in Northampton is clear:

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

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

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

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


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

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Labour will halt Tory deaths rise and save the NHS

 

Sunday 22 September, 7.00pm (for 7.15)- 9.30pm

Friends Meeting House, Ship Street, Brighton, BN1 1AF

Speakers

Professor Danny Dorling, University of Oxford;
Jonathan Ashworth MP, Shadow Secretary of State for Health;
Sussex Defend Our NHS

Chair Dr Alex Scott-Samuel, Socialist Health Association

Programme

Professor Danny Dorling – What Labour must do to halt the Tory rise in baby and early adult deaths in England and Wales

Jonathan Ashworth MP – How Labour will revive the NHS and our health

Sussex Defend Our NHS – Our fight for a healthy Sussex

 

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Join us on September the 12th at the Quaker Meeting House, Sheffield, at 6pm.

PM Boris Johnson, on the steps of Downing Street: “My job is to protect you, or your parents or grandparents, from the fear of having to sell your home to pay for the costs of care and so I am announcing now on the steps of Downing Street that we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.” July 24th 2019

 

Social Care: Fixing the broken system – The Marmot Review 10 years on.  Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals. The Marmot Report.

We invite our Yorkshire community to join this vital conversation on ensuring that, finally, a Prime Minister’s words become action. For too long successive governments have promised action and failed:

  • Labour admitted yesterday that it had failed to transform the life chances of Britain’s poorest children, despite a succession of initiatives costing billions of pounds. (The Times, February 25, 2005)
  • The Government has cut funding for childcare despite a Conservative manifesto pledge to double the number of free hours parents get, says the NAO (Independent, March 2,  2016)
  • Theresa May pledges to seek long-term solution to social care squeeze … through a properly funded social care system”. Then, in 2017. May’s opinion poll lead ahead of a June 8 election halved in two recent polls since she set out proposals to reduce financial support for elderly voters. Theresa May’s social care package fails “to tackle the biggest problem” facing elderly people, Sir Andrew Dilnot has said.(Independent, May 18, 2017)

 

Format

Dr Simon Duffy, Founder of the Centre for Welfare Reform: The “what and how to” challenge to Boris Johnson based on Simon’s policy proposal for the Reclaim Social Care campaign.

A panel of experts, council members and users, will join him, with full participation from the audience.

We will agree a list of demands to present to the Prime Minister that must be included in his plan. Easy sound-bite pledges and promises of money mean nothing if there is no improvement plan.

The goal of the Great Yorkshire Conversation is to get the right government action and the right funding to put right the system that has been broken by Austerity and sticking plaster policies.

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The Socialist Health Association (SHA) notes the public health green paper – Advancing our health: prevention in the 2020s, which was published on the 22nd July by the Cabinet Office.

 

We believe that this is a missed opportunity, which ignores much of the evidence on what works best to improve people’s health and wellbeing. Doing something at the level of communities, such as changing an ‘obesogenic’ environment, is more effective and much better value for money, than doing something one by one for individuals..  The paper also largely ignores the impact of poverty and the gross and worsening inequalities in health. At a time when the Government wishes to unite the country, this again betrays its inability to put first the health and wellbeing of all communities.

We support the recognition that health is an asset and a composite health index should be used at Cabinet and across government departments in their planning and investment decisions. We also strongly support the goal of a smoke free country by 2030 but believe that this will need strong regulation and taxation policies. We also support the removal of barriers put in place of water fluoridation, which is an effective way of promoting oral health in children and thus their dentition for life. Finally we support the strengthening of food and drink regulations in respect of salt, sugar and fat content but look to committing to specific measures such as the sugar tax for milky drinks and beverages.

40 years after the Black report on ‘Health Inequalities’ (1980), there is still too little commitment to address poverty. Poverty exacerbated by years of austerity, has resulted in reducing life expectancy and increasing infant mortality. There is no shortage of expert evidence and advice such as the Marmot reports which point to investment in the first 1000 days of life, early years education, the need to have a living wage and a society which enables ageing well. We need to see a strategic commitment by government to abolish child poverty, support parents in the early years and ensure that people have access to jobs that provide a living wage for families.

The Green Paper disappoints too in drawing back from a purposeful commitment to regulate and use taxation to shape the powerful commercial determinants of our health, such as the food and drink market.  We do not see the evidence for change unless linked with regulation (salt), taxation (sugar) and pricing (alcohol unit price). Similarly the rapid growth in gambling driven by advertising on television and social media and enabled by the digital world will require urgent legislation to prevent the growth in harm caused by addiction and consequential debt.

The SHA has recently published our own ‘Prevention and Public Health policy’ endorsed by the Central Council (available at www.sochealth.co.uk), which unlike the government’s Green Paper gives priority to the Climate Emergency and Planetary Health as well as prioritising addressing the social determinants of health.

The Green Paper makes individuals responsible for their own health in a way which will exacerbate the health outcome gap between the rich and poor. There is strong evidence for achieving better health outcomes through implementing interventions on the social, economic and environmental determinants of health and wellbeing. The emphasis on genomics, big data and artificial intelligence (AI) is misplaced in population level prevention policies, although we agree that these areas are exciting and need further research and evaluation

More recent evidence over the past 20 years of the Climate Emergency – the 21st century public health challenge – also needs to be a high priority for prevention and public health.

SHA 26th July 2019.

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

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

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

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

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

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

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

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

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

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

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

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

Anna Athow

annaathow@btinternet.com

9.6.19

references;

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

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

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

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

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

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

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

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

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

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

Deborah Harrington

Who We Are

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

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

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

 

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

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

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

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

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

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

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

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

To take three examples, first comparing cost:

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

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

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

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

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

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

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

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

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

 

 

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All the Tory contenders to be prime minister should categorially rule out the NHS being part of any future US/UK trade deal, Unite, Britain and Ireland’s largest union, said today (Wednesday 5 June).
Unite, which has 100,000 members in the health service, said the new prime minister ‘should not offer up the NHS as a sacrificial lamb to US president Donald Trump’.
Unite national officer for health Colenzo Jarrett-Thorpe said: “The Tory prime ministerial contenders need to put the national interest – in this case, the safeguarding the NHS from US privateers – before the personal ambition of getting their hands on the keys to 10 Downing Street.” 
Concern about what a US/UK trade deal could mean for the NHS has heightened this week following remarks by Donald Trump and his ambassador in London, Woody Johnson about the NHS being included in a future US trade deal
Colenzo Jarrett-Thorpe added: “The NHS is the UK’s greatest achievement – but for Trump and his ilk, who despise the very idea of universal healthcare free at the point of delivery, all they can see is the money to be made from the sick, frail and vulnerable. 
“This was made obvious by the US ambassador’s very frank comments about his country’s intentions towards the NHS in any future US/UK trade deal, a point that was again made by Trump himself. The president’s comments today are not reassuring in any way. Unless the government categorically says that the NHS is not for sale, then patients and staff will face increasing uncertainty and worry.
“The Tory leadership hopefuls need to state categorially to the British public that the NHS is not up for sale to profit hungry US private healthcare companies as part of a future trade deal.
‘Leading Tories and their cheerleaders in the media may think that the US offers a blueprint for how a post-Brexit Britain should be – however, it should not be forgotten that millions of Americans don’t have any health insurance which does not inspire confidence.
“We strongly believe that the NHS should not be offered up as a free trade sacrificial lamb to the mercurial whims of Donald Trump – our sick, frail and vulnerable deserve so much better.”

 

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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.

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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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