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    Up to a third of UK social class differences in health was probably caused by work 50 years ago. Since then, many hazardous jobs have been exported but new types of unhealthy work have emerged.
    Work can be bad for health but so is unemployment. The most disadvantaged suffer unemployment in recessions and poor-quality work during economic growth. Work in a safe and supportive environment benefits health.
    Chronic illness and disability often prevent obtaining such work, or lead to its loss. People with impairments should be employed for their abilities. Punitive ‘welfare to work’ policies damage health, cause stress and diminish self-respect.
    Profit-driven economic activity can damage health through pollution, environmental harm, unhealthy products and unhealthy lifestyles.
    Comprehensive occupational health services provide biological monitoring, employment rehabilitation, workplace clinical services and health promotion. They support workplace health and safety systems, identifying hazards, assessing risk, preventing occupational disease and supportively managing disability and sickness. They should also work with trade union health and safety representatives in the workplace.
    About a third of the workforce had a comprehensive occupational health service in the 1980s, a third had a partial service and a third had no service. 
    Most of the workforce today have no direct access to occupational health services.
    Occupational health services in the UK have never been statutory, but mostly employer-provided services. There have been campaigns to incorporate occupational health into the NHS, but by 1980 this was seen as medicalising the issue.
    But with no statutory duty on employers, occupational health services declined and were commercialised. Public ownership is essential to ensure accountability to workers’ health rather than to corporate interests.
    DiU (MPU) has often provided medical support to trade unions. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Network. We also liaise with the H&S representatives of other unions and the TUC.



    Doctors in UNITE (the Medical Practitioners’ Union) believes there should be National Occupational Health Services (NOHS) for England and devolved nations, including the following criteria:

    NOHS  should cover all workers, paid or unpaid.
    NOHS  should address occupational, environmental and commercial determinants of health.
    NOHS  would provide biological monitoring, employment rehabilitation, and health promotion, and support safety management. We will discuss later whether it should also provide clinical services at the workplace.
    NOHS  should normally be publicly provided, although where a satisfactory comprehensive occupational health service already exists in a particular workplace, and has the confidence of the trade unions, it could be publicly licensed and its role extended.
    NOHS  should be accountable to Parliament through a Minister for Industrial Health shared between DHSC, DWP and DBEIS.
    They should also be accountable to devolved Assemblies
    The existing national organisations for health and safety, employment of sick and disabled people, or control of pollution should be redesignated as part of the statutory comprehensive health service and should review ways to work together and fill gaps. This does not imply any major reorganisation.
    Locally NOHS should be controlled by workers (preferably through their trade unions), the appropriate regulatory agency (be that HSE or the local authority), consumer representatives and local communities. In a previous policy statement some years ago, we advocated joint control by employers, expert regulators and trade unions/ communities/ consumers, as that fitted with the tripartite model of health and safety current at the time. However, that model has not proved robust so we now feel NOHS must be controlled by those it serves.
    Professional independence is central.
    The issue of funding will be raised. In a previous statement we said this needs to come from employers, but funding from general taxation would enhance independence so increases in corporate tax would be better. As health services have a Keynesian multiplier in excess of the figure at which they become self-funding, it may actually not be an issue. At a Keynesian multiplier of 2.5, £1 spent generates £2.50 of growth which generates £1 of tax. Keynesian multipliers for health, education, welfare, recreation and cultural services, care, and social protection are significantly in excess of that – about 4.32 for health – implying that spending reduces the Government deficit.
    In smaller and medium sized workplaces, NOHS would be provided on a group basis. For the smallest workplaces (such as a corner shop) it might be provided by the kind of neighbourhood public health system which we have advocated in our paper “Public Health and Primary Care”.
    In creating safe and healthy systems of work and in biological monitoring NOHS would feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supported a supportive management of disability and sickness. This system must extend to contractors and volunteers as well as employees.
    NOHS and the workplace health and safety system must address stress at work not by victim-blaming “stress management” terms but through the factors in the workplace environment which we described earlier such as autonomy, social networking, training and resourcing of responsibilities, pleasant environments and work/life balance.
    There has been much debate about whether occupational health should also provide clinical services at the workplace. This must not dominate and take occupational health staff away from other roles. Many services described as “partial” in 1980 consisted of a factory nurse providing mainly clinical care. This led to doubts about the appropriateness of a clinical role. However, the workplace is a convenient place to provide certain types of health care, including screening, blood pressure measurement, stress counselling and treatment of minor injuries or minor illnesses manifesting at work. There needs to be a system for providing the simple front-line healthcare that in many countries would be provided by a “barefoot doctor” or “community health worker”. This should be planned on a universal basis, so as not to exclude retired or unemployed people, but for those who spend time at a workplace, either as an employee, a contractor or a voluntary worker, clinical care at the workplace could sensibly be a part. In providing such clinical services at the workplace NOHS would be linked to the NHS.
    In employment rehabilitation, NOHS would be linked to a Work and Health Service which would take over the disability functions of the DWP, would be part of the NHS (New Zealand is an interesting model here) and would offer employment-focused rehabilitation. Such services were previously operated by EMAS, by Employment Rehabilitation Centres and by Remploy but were inadequately resourced and only operated for the most severely disabled people – at the time we described it as “an excellent icing on a mouldy cake”. Government then shifted the function into a “welfare to work” model which operated too late in the process, missing the opportunity to retain people in work. Both of these systems were separate from the NHS clinical care of the patient, in which work needs to be a central factor.
    In addressing the environmental and commercial determinants of health NOHS would be linked to the public health system
    NOHS would have access to all levels of management and of regulation.
    NOHS needs specialist support from the NHS, laboratory services, environmental services, HSE, public health and academic institutions.
    NOHS should be part of the statutory health service. The 1948-74 terminology in which the statutory health service was called “the NHS” should be restored. Even with current terminology there are services NOHS should provide for the NHS, especially front-line health advice, health promotion and employment rehabilitation. NHS bodies may act as local providers of NOHS in some areas.

    https://doctorsinunite.com/news/

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    ‘A Radical Practice in Liverpool: the rise, fall and rise of the Princes Park Health centre’ Katy Gardner and Susanna Graham-Jones.

    Published by Writing on the Wall. 2021. 268 pages. ISBN 13:9781910580561.

    This book covers 40 years in the life of Princes Park Health Centre (PPHC), a progressive practice serving a diverse and deprived inner city community in Liverpool 8. This area in South Liverpool hit the headlines in 1981 with the so called Toxteth riots which were the result of long term deprivation and racism and were sparked off by incidents of police ‘stop and search’. Such tensions still resonate today in our disadvantaged ethnically diverse inner city communities. The authors are two practice partners during the period up to 2005, both of whom played important medical leadership roles in the practice and further afield. Katy Gardner for example has been a regular contributor to the Morning Star, is a longstanding SHA member and remains active in Doctors in Unite.

    They have drawn on a wide range of other contributors to tell their stories and provide illustrations from patients, staff and people from the local community in Merseyside. Having been an inner city GP in the 1980s and visited Cyril Taylor as a GP trainee, I feel that this account captures the vision, advocacy and commitment required. The national policy and professional influence of PPHC’s work is reflected in the Foreword by Iona Heath, President of the Royal College of GPs between 2009-2012, who worked for 35 years in the Caversham Group practice in London NW5, a health centre also opened in the 1970s under the leadership of a Socialist Medical Association (SMA) member Hugh Faulkner.

    The book provides a wonderful insight into the demands, stresses and strains of idealistic multi professional health workers grappling with the ill health created by socio-economic conditions, problems experienced by homeless people, refugees and asylum seekers and those subject to sexism and racism in all its manifestations. Some of the innovative services offered to their patients were the extended primary care team including social workers, counsellors as well as the more usual teams of district nurses, health visitors and other visiting professionals. The practice projects responded to the local needs in the population such as the Family Health Project for homeless people, the Somali Mental Health project and needs of asylum seekers more generally. A holistic perspective on health and wellbeing, is illustrated by extensive community engagement, patient participation groups and special events such as the 1992 ‘Health thru Arts’ festival. It is a story about a pioneering group practice, embedded in the local community staffed by health and social care workers, volunteers and activists all committed to creating an inclusive health and social service responsive to local needs.

    The PPHC was the brainchild of Dr Cyril Taylor who had been a local GP in the area since 1950. He had served as a local Labour councillor, was Chair of the Liverpool Social Services Committee and President of the Socialist Health Association (SHA). He was politically active locally in Liverpool but also nationally being for example a member of the Royal Commission on the NHS. This Commission was established by the Labour Government in 1975 and reported in 1979 to the new Thatcher Tory Government! It is worth noting the risk of these government reports taking too long given our short electoral cycle. The Black Report on Health Inequalities also established by that Labour Government missed the boat too by being published in 1980.

    There are golden threads that run through the book and provide the political and moral compass to their work. Cyril Taylor would have been aware of the pioneering Peckham Health Centre developed in the 1920s/30s in SE London where a swimming pool, gym and childcare facilities represented their interest in prevention and family health. As an SMA member he would have known about the policy support for health centres and a salaried service. A more contemporary influence manifest in the book is of his comrade Julian Tudor Hart (JTH), another past President of the SHA. The PPHC was attempting to provide a local and practical response to the Inverse Care Law first published by JTH in the Lancet in 1971.

    There is reference in the book to the potential benefit of primary care and public health working more closely together. Another SHA Chair, Alex Scott-Samuel was involved in the early days as a local public health academic in Liverpool University as was John Ashton who worked in public health academia in Liverpool and subsequently within the NHS as a Public Health Director. However the book outlines the serious obstacles that were confronted in making the case for building the Health Centre, staffing it and the ‘powers that be’ resisting the desire of the GPs to be salaried employees.

    The SHA and its predecessor organisation the SMA has promoted policies from before the launch of the NHS in 1948 that GPs and other health professionals such as dentists should be salaried employees and working together from purpose built health centres. The group of ‘independent contractors’ include dentists, pharmacists and optometrists and these professionals were one part of the 1948 tripartite NHS – separated organisationally from the hospitals and local authority services such as environmental health, public health, midwifery and health visiting. The SMA since the inception of the NHS had argued for health centres and salaried GPs. A policy document on health centres published in 1975 identifies the need to build modern purpose built health centres so that they could provide a base for extended primary care teams some 27 years after the NHS was born and a decade after the 1966 GP Charter. Since then we have seen what has happened to this vision with the corporate takeovers of community pharmacy, the extensive privatisation of general dental practice and the corporate takeover of the optometry and audiology services. We are also seeing the historic GP corner shops, merged into group practices and then taken over by unaccountable businesses. The original vision of health centres accommodating multidisciplinary teams located in accessible sites for the population served is vanishing. The story of PPHC takes us through a period of change, highlights the obstacles in bringing the vision into action and the damaging changes in NHS management and policy.

    The authors document the hurdles that they confronted in developing new services and wanting to move away from the independent contractor status of GPs. The frequent NHS disorganisations proved to be deeply frustrating and demoralising and there is a real sense that idealistic health workers were getting stressed and burnt out by trying to serve their patients in great need on a 24/7 seven day per week basis. The PPHC participated in the short-lived Association of GPs in Urban Deprived Areas (AGUDA), which articulated the higher needs and demands for NHS staff in inner city areas and how the pay and conditions did not compensate for the extra work involved. Encouraging primary care based maternity services with home deliveries and end of life care requires a huge personal commitment the timing of events being outside one’s control. The story of author Katy Gardner falling asleep in the early hours of the morning in a patient’s home while waiting to support the home delivery illustrates the willingness, commitment and consequential tiredness. It is good therefore to note the contemporary success of the Deep End project led by Graham Watt, a former Tudor-Hart MRC Registrar, which while based in Glasgow and across Scotland is also seeding a global network. 50 years on from the publication of the Inverse Care Law the structural determinants of ill health remain and it is good that the aspiration for greater equity in primary care is still alive.

    An opportunity for the GPs to become salaried arose in 1998 as part of a Primary Care Act pilot and the PPHC GPs became employees of the North Mersey Community (Mental Health) Trust. From then on however multiple changes were introduced including the creation of PCGs, PCTs, Alternative Provider of Medical Services (APMS) contracts and in 2011 PPHC was put out to tender by Liverpool PCT and awarded to SSP Health Ltd, a GP owned business. This was a very unhappy period and staff had left (Katy herself in 2005) and a poor Care Quality Commission report in 2015 followed. Services remained unsatisfactory and the SSP contract was not renewed. The Liverpool CCG asked the Brownlow Health group to step in and they were more aware of the history of PPHC, with one of Brownlow’s GPs having been a trainee there. This has proved a success with a five year contract awarded to them in 2018. However there remain huge risks as we enter a second decade of Tory government with continuing under investment in primary care with challenges in the recruitment and retention of GPs. Organisationally there are risks of privatisation as the new Integrated Care Systems develop with little in the way of local democratic accountability and assurance about safeguarding NHS provision from national and international ‘for profit’ organisations.

    I recommend this book which provides a history of the PPHC from 1977-2017, explores the vision which drove the pioneer practitioners, includes a realistic description of the work involved and the value that a socialist and culturally radical practice delivered to the people they served. The golden thread is like an Olympic torch handed over from socialists in the pre NHS period and through each decade of its 70year history. Organisations like the SHA and Doctors in Unite need to keep the flame alight to safeguard what we have and enthuse the next generation of radical practitioners.

    Dr. Tony Jewell was President of the UK Association of Directors of Public Health and was the Chief Medical Officer in Wales. He has been a member of the Socialist Health Association for over 40 years.

    Comments Off on Review of ‘A Radical Practice in Liverpool: the rise, fall and rise of the Princes Park Health centre’ Katy Gardner and Susanna Graham-Jones.

    The focus of the first article in this series was on Centene’s current – and anticipated – role within NHS England’s Integrated Care Systems (ICSs) programme. While brief mention was made of the corporation’s background, this article will examine it more fully, notably as the market leader within US Medicaid Managed Care (MMC), the private sector administration of state services for the poor, pregnant women, elderly adults and people with disabilities. It also provides care for 1 in every 3 children. Given the increasingly evident parallels between ICSs and MMC, it is worth looking at what the English public can expect, notably as most investigations into the MMC market reveal a system plumbing new depths of corrupt and exploitative behaviour.

    LARGEST

    As discussed in the previous article, in 2015 Centene was invited by NHSE and Nottingham healthcare leaders to design its ICS. In order to offset privatization fears the corporation was presented to the public as a tech expert offering data analysis to help integrate services, but in internal documents this was expanded upon. According to Dr Stephen Shortt, the Nottingham ICS lead, it was a journey into unknown territory and “to give us the best chance of success we had to work with people who have real life experience of doing this on a scale and at a pace that hasn’t been achieved in England before”. Centene, as the “largest and best-in-class US Medicaid Managed Care company” was seen as the ideal partner.

    The first part of this statement is indisputable. Indeed, the corporation’s growth has been remarkable and built almost entirely on managing public programmes, particularly Medicaid. While the Affordable Care Act (ACA) of 2010 greatly expanded the number of people eligible for receipt of these services, almost all were channelled to MMC-owned plans which claimed they could save money by removing service duplication and unnecessary use of hospital provision as well as an emphasis on prevention, IT and integration of services. Since the ACA Centene’s revenues have grown enormously from $5.2bn in 2011 to $111bn by the end of 2020 with the last figure itself representing a near 50% leap from the previous year, largely owing to the purchase of a leading competitor, WellCare. As Centene’s CEO, Michael Neidorff, himself the highest paid healthcare executive in the US with annual compensation of $26m, told Forbes magazine, “we have an insatiable appetite” for further mergers and acquisitions.

    BEST-IN-CLASS

    But how are such figures achieved? According to the LA Times, Medicaid “is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry”. However, the newspaper reported in November 2017 that MMC companies in California made $5.4bn in profits from 2014-16 and that in this period “a unit of Centene’s raked in $1.1bn profits”, prompting a health professor at the University of Southern California to say, “these profits are gigantic – wow”.

    A variety of interrelated mechanisms can be identified, including: (a) reducing the quality of care; (b) control of the regulatory environment, through for example, political lobbying, donations and the revolving door of state and corporate actors; (c) failure to comply with regulations; (d) reduced reimbursement rates to medical providers; (e) minimizing provider networks; (f) exclusionary contract language, and (g) reducing and/or denying care, particularly for the most expensive patients.

    In Centene’s case, the examples could fill a book.
    • In California, Medicaid companies made $5.4bn in profits from 2014-16. Notably 6 of the 12 worst performing health plans in the state were run by Centene, and 7 of its 10 regional health plans scored below average on quality. The company’s San Joaquin health plan ranked last at 31%; the highest performing Kaiser Permanente plan scored 92%.
    • In Kansas there have been multiple allegations of improperly denied claims, often with no explanation, as well as inconsistent and inaccurate payments to providers.
    • Patients who bought policies from Centene filed a federal lawsuit in Washington state claiming the company did not provide adequate access to doctors. It also said that many doctors will not accept patients covered by the corporation because of its refusal to pay legitimate claims. According to the lawsuit, Centene targets low-income customers who qualify for substantial government subsidies “while simultaneously providing coverage well below what is required by law and by its policies”.
    • In Mississippi and Ohio, the corporation gave large donations to the State governors. It is also now under investigation in both states for allegedly obscuring and overcharging Medicaid by millions of dollars in drug costs. The Ohio Attorney General said; “Corporate greed has led Centene and its wholly owned subsidiaries to fleece taxpayers out of millions”.
    • Also in Ohio, Centene was the subject of four increasingly larger individual noncompliance sanctions — each between $1 million to $4 million — for failure to meet minimum performance standards for four consecutive years beginning in 2013.
    • The company paid Kentucky $7.5 million to settle a breach of contract lawsuit alleging it wrongfully terminated its Medicaid agreement and which cost the state $28 million to $40 million. It also agreed to pay $4.5 million to settle a lawsuit alleging it had failed to pay nurses overtime in multiple states, including Illinois, Ohio and Missouri.
    • Iowa health officials withheld $44 million from Centene under the state’s privatized Medicaid programme, pointing to unresolved issues with payments to health providers as the corporation had not paid more than 100,000 claims that providers had submitted. The state’s action “was the first time Iowa’s Health Department has withheld payment to a Medicaid insurer”.
    • In Illinois, Centene’s subsidiary, IlliniCare, “slashed payments for medical equipment by as much as 50% in 2019, a move that critics said was making it difficult for people to obtain life-sustaining devices”.

    ‘PAIN & PROFIT’

    The most comprehensive, and the most damning, investigation into MMC was however carried out by reporters from the Dallas Morning News in Texas and published in a series of 8 articles beginning in June 2018 and entitled ‘Pain & Profit’.

    As could be expected, the conservative state had embraced the shift to private management, and by 2018 over 90% of the Medicaid population were enrolled in private plans offered by 5 major healthcare companies, including Cigna, UnitedHealth, and the largest, Superior Health Plan, owned by Centene. According to the News, the deal was that the companies “would save taxpayers millions while delivering better healthcare in exchange for a small profit”. However, the articles proved so unsettling that within days of publication the state’s Health Commission convened an emergency meeting – they normally meet once a year – to deliberate on the findings.

    These identified a revolving door of legislators and company personnel acting in concert to award contracts, rewrite medical assessment rules, frustrate appeals, reduce fines, and cover up often dangerously low levels of care. Of perhaps even more concern for the authorities was the fact that the companies were reducing or denying care to those most in need of expensive medication, medical equipment, and hours of nursing provision. Cutting such services offered the greatest opportunity for profit, and indeed the articles found that it was the sickest patients, especially medically fragile children, which brought in the most profit on a per patient basis to the companies, netting them more than $145 million in 2017.

    While other companies were mentioned in the series, Centene featured most prominently, both as the largest Medicaid insurer in the state but also owing to the scale of its malpractice. The articles also offered clear descriptions of the effect privatizing Medicaid had on individual patients and in both the following examples the patients came under Centene’s care.

    The first was of twin 1-year old foster children with severe disabilities and requiring round the clock care, particularly as one needed 2 to 7 tracheal suctions per hour. Centene said this level of care wasn’t medically necessary and changed the authorization for 2 nurses on a 24-hour shift to one nurse for both babies for only 12 hours. During a break in care one child pulled out his trach and was left brain damaged.

    Such reductions in the level of care can save the company as much as $500 per day, and the News reported a paediatric specialist who treats medically fragile children as saying, “I believe this particular managed care organization is putting children’s lives in danger to make a profit”.

    The second concerned a 38-year old quadriplegic who had been promised enough help to live at home. However, Centene would not provide the hydraulic lift necessary for movement to the shower and the bathroom, so she remained in bed, nor would it provide the special mattress to protect her skin from life-threatening bed sores. Then, the company reduced her care giver hours from 12 to 7: “alone for 17 hours a day, unable to move, in pain, the patient began to plan her suicide”. Centene was collecting “thousands of dollars a month to provide everything she needed to live at home, but she didn’t receive the equipment”.

    The articles subsequently won at least two national prizes for public service journalism. The Bingham Prize judges said they “were struck by the injustice of the offenses and the time taken to identify victims who otherwise would have remained hidden, voiceless and sacrificed for profit”, and one judge added; “I’m not ashamed to say I wept in anger and despair as I read about the challenges families and individuals faced to get the care they needed to live or, quite literally, to breathe”.

    CONCLUSION

    It is worth spelling out. This is the corporation whose UK CEO has just become Boris Johnson’s health supremo and has designed at least two and perhaps several more of England’s regional-scale ICSs. It aims to incorporate itself as a for-profit, Managed Care insurer at the heart of these ICSs, administering public funds, negotiating with providers, and deciding which services will be available to patients. If it can save money by cutting or refusing care it will keep a sizeable amount of that money, and in order to do so it will cut as much care as it can. And if Texas, Iowa, Kentucky, or any of the other US states are anything to go by, it will be ruthless – irrespective of the client base.

    As Greg Dropkin points out, a contract notice following Centene’s design of the Nottingham ICS makes it clear that NHSE and local leaders knew that Clinical Commissioning Groups’ shelf life was limited and that there was a built-in place for an insurance middleman . As the notice says: “The implementation of the ICS will involve a variation to the contract and may involve the transfer of the contract to another Provider or the Care Integrator in the place of the CCG”. The word ‘may’ is disingenuous. A corporation of Centene’s size and ambition is not going to be content with a design role and it is no coincidence that CCGs are being disbanded as ICSs approach legal status.

    In 10 years, Centene’s revenues have grown from $5bn to over $110bn primarily by exploiting the most vulnerable groups in US society. It is now at the heart of the UK government and aims to redesign the English NHS. The threat of a takeover of a number of GP surgeries – while important – is very much of secondary concern.

    References

    1. It is worth mentioning that 83% of poor children and 48% of people with disabilities are dependent on Medicaid for healthcare services.
    2. Nottingham West CCG, ‘Combined meeting of Nottingham West CCG Clinical Development Committee (CDC) and Practice Commissioning Group (PCG)’, 7 December 2017. https://www.nottinghamwestccg.nhs.uk/media/2243/governing-body-papers-combined-25-january-2018compressed.pdf
    3. Under the Affordable Care Act, Medicaid coverage was expanded to all individuals under age 65 with incomes up to 138% of the federal poverty level, subject to the States’ elections. The numbers covered grew from $380bn in 2009, to over $600bn in 2020, and is now the nation’s
      largest public health programme. The scale of private outsourcing, according to many commentators, approaches Pentagon levels.
    4. https://www.macroaxis.com/financial-statements/CNC/Revenues
    5. In 2010 this figure was $6.1m.
    6. https://www.forbes.com/sites/brucejapsen/2020/02/05/centenes-insatiable-appetite-for-deals-remains-after-wellcare-buy/?sh=47d6829f6731
    7. Nearly one in five Americans, 74 million people, are on Medicaid. For states, it is the biggest source of federal funding and the second-largest budget item, behind education. In total, children comprise roughly half of Medicaid recipients. 35.7 million children were
      enrolled in either Medicaid or CHIP at the beginning of 2018. This means that one-third of American children are on Medicaid, and half of all births in the country are paid for by the program.
    8. https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
    9. Often called ‘rationing by inconvenience’ it means placing administrative barriers in the way of healthcare services: “that of slowing and controlling the use of services and payment for services by impeding, inconveniencing, and confusing providers and consumers alike”.
      See, for example: https://pnhp.org/2010/08/06/rationing-by-inconvenience/
    10. https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
    11. https://www.inthepublicinterest.org/wp-content/uploads/ITPI_PrivatizingVAMedicaid_March2018.pdf
    12. https://www.nytimes.com/2018/01/11/health/centene-health-insurance-lawsuit.html
    13. https://www.djournal.com/news/state-news/mississippi-started-investigating-its-largest-medicaid-contractor-2-years-ago/article_bc5ab565-b03e-5053-9805-e799975d82e8.html
    14. https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
    15. Ibid.
    16. https://eu.desmoinesregister.com/story/news/health/2020/01/03/health-medicaid-department-human-services-withholds-money-insurance-provider-iowa-total-care/2807411001/
    17. https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
    18. The Dallas Morning News articles are unavailable in Europe. However, a very useful summary is offered by: https://claudepeppercenter.fsu.edu/side-posts/dallas-morning-news-pain-and-profit-briefing-by-the-claude-pepper-center/
    19. See comments section in: https://www.sochealth.co.uk/2021/05/10/centene-the-real-agenda/
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    The news that Sir Simon Stevens was standing down from his post as NHS England Chief Executive in July prompted some remarkable tributes from the Health Service Journal (HSJ), even by own standards. The editorial said that Stevens had managed to save the health service on no less than three occasions and has been the most important figure in NHS history since Aneurin Bevan. It also said that Stevens was “the greatest strategic health policy thinker of his generation”, and in this point at least the journal is accurate.

    STRATEGIC THINKING
    Back in May 2004 the Guardian’s John Carvel asked with regard to Stevens: “Why does a bright young man who has probably had more influence on NHS policy over the past seven years than anyone else in Britain decide to quit the public service to work for a $28bn US healthcare corporation intent on aggressive expansion into a new NHS market”? Indeed, Carvel thought that “If he had gone back into NHS management, he could have been running the whole shooting match after two or three more moves”.

    At the time Steven’s move did appear odd as UnitedHealth’s – his new employer and the largest health insurer in the world – anticipated role within the NHS was thought to be marginal at best. It only ran two GP practices in Derbyshire and a case management programme for elderly people. But by 2007 Stevens’ former colleagues had given the green light to 14 companies, including United and other US insurers, to bid for potentially much bigger contracts from primary care trusts providing data analysis and research, giving PCTs a clearer idea of how to manage patients with chronic condition.

    However, as the Guardian pointed out, “their role may be bigger than that. Companies may also be invited in to act as middlemen, negotiating with hospitals on the trusts’ behalf to reduce costs, ushering in the prospect that some patients may find their care plan managed not by a doctor but by an American insurance company”.

    While this programme – the FESC – proved a little premature, it offers much of the key to Stevens’ strategy. Transnational capital was in the early stages of creating a global market in healthcare and adopting standardized organizational formats from which the greatest profit could be extracted. As this process was US-led, it was inevitable that its dominant and most profitable format, that of Managed Care, would be adopted as the guiding template, and Stevens’ move to Minneapolis was in part to familiarize himself more fully with the working of this system and with its leading participants.

    It was also, as became evident, to locate himself as a major player within this wider market creation, and to bring English healthcare into its framework.

    US ‘REFORM’
    The focus of Stevens’ early work in the US was Managed Care’s applicability within public programmes, and in 2007 he became chief executive of Ovations, United’s division providing insurance packages for older patients, and which accounted for over 1/3 of its revenue. It also included Medicare Advantage, the private sector management of the state-funded programme for the over-sixties; a programme which had been heavily criticised for excessive administration costs, its evolution into a multibillion-dollar subsidy for private companies, as well as the insurer’s monopoly within certain states.

    Indeed, the scale of profiteering within Medicare Advantage, and within the US system in general, produced considerable clamour for reform. In 2007, Stevens told the Guardian, “For all its problems, there is often an ability in the States to innovate faster and really test new models of care. This is an exciting time in health reform in the US – there’s a real sense that there will be meaningful change here in the next few years”.

    But this was nonsense. Any sense of global market creation would be fatally undermined if Managed Care was to be replaced by single payer – a national system that would eradicate the need for insurers – on its home ground, and every effort was made to make sure this didn’t happen. Indeed, United, and Stevens himself, played significant roles not only in destroying single payer but ensuring that the position of the giant insurers was strengthened; in large achieved by taking greater control of Medicare, Medicaid and the new market exchanges, to the extent that within a few years these programmes had become the main artery of profits.

    GLOBAL CONCERNS
    With the home territory secured, United, and Stevens, began to apply themselves more fully to global market formation.

    In 2009 Stevens was also charged with managing United’s international operations, growth and M&A in 123 countries, including North America, Europe, and the Middle East. One of his first tasks was helping set up, in 2011, a high-level trade lobby group, the Alliance for Healthcare Competitiveness (AHC), which wanted “the Office of the US Trade Representative, acting through the World Trade Organisation, to force other nations to open up their national health systems to US for-profit insurers, hospitals, professionals, medical device makers, pharmaceutical firms, IT companies and other investor-owned firms”.

    However, it makes little sense to open up national systems unless these conform to standardized templates. A year later, Stevens was helping to pursue this aim, by acting as Project Steward within the World Economic Forum’s (WEF) year-long project on Sustainable Health Systems. Co-organized with the leading US consultancy, McKinsey, workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London were, according to the WEF, “remarkable in their consistency of vision”, advocating new care models with delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”.

    In ‘Health Incorporated’, undoubtedly the WEF’s scenario of choice, the boundaries of the health industry would be redefined. “Corporations provide new products and services as markets liberalize, governments cut back on public services and a new sense of conditional solidarity emerges”. Further, “Health schemes and insurance markets boom as people seek to cover their health costs. Governments, meanwhile, focus on regulating large integrated health providers in a complex expanding global marketplace”.

    The final part of the jigsaw was applying these structures within the English NHS, and Stevens’ policy formation over the following years – the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 regional-scale Integrated Care Systems – must be seen entirely within this context. With, for example, UnitedHealth “sitting within the ICS in Somerset and acting as the engine room” of transformation, and with Centene playing the same role in Nottingham, such relationships will be pursued in as many ICSs as possible. The bulk of the English policy community is firmly behind this and as yet the process only requires legal ratification.

    CONCLUSION
    This is Stevens’ legacy: that of helping to create a global regime of accumulation, and situating English healthcare within that. In this, and here we must agree with the HSJ, he has proved remarkably successful. Rather than viewing Stevens as unique, however, he should instead be seen as an exemplar of a widespread phenomenon, as throughout his tenure with NHSE, for example, he continued to work with the World Economic Forum on its Executive Board of the Value in Healthcare Coalition, alongside CEO’s from Humana, Kaiser Permanente, Takeda, and several others, to further the aims of transnational capitalism. But in terms of developing and promoting the central tenets of the NHS – those of universality, equity, and indeed ‘freedom from fear’ – he is as far removed from Aneurin Bevan as you can get.

    References

  • https://www.hsj.co.uk/policy-and-regulation/stevens-has-been-the-most-important-figure-in-nhs-history-since-bevan/7029999.article
  • https://www.theguardian.com/society/2004/may/26/nhs2000.health
  • https://www.theguardian.com/politics/2007/nov/11/uk.publicservices
  • The Framework for Procuring External Support for Commissioning. This was set up by Mark Britnell, then the Department of Health’s director general of commissioning and system management, and now short-listed to be Stevens’ successor as NHSE CEO. The policy community clearly
    expects some form of continuity.
  • See for example: https://pnhp.org/news/the-health-insurers-have-already-won/
  • Hellander, I. ‘Health firms’ proposal: Use trade rules to force other nations to import our failed “health ecosystem”’. Physicians For a National Health Program, 4 October 2011.
  • http://www3.weforum.org/docs/WEF_SustainableHealthSystems_Report_2013.pdf
  • http://www3.weforum.org/docs/WEF_Value_in_Healthcare_report_2018.pdf
  • Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.

    2 Comments
    1. 1. Legislating for Integrated Care Systems: Provider Selection Regime Consultations
      Legislating for Integrated Care Systems: five recommendations to Government and Parliament
      includes the Response to Public Consultation on ICS (See Pages 8-22)

    The consultation findings are attached above (at 2) and it is disturbing to read some of the NHSE/ NHSI conclusions.

    Firstly, the report appears to blur the distinction between what is regarded as an engagement seeking views and a consultation which it was described as on line. It begins by declaring that 5,171 responses from people identifying as members of the public or patients who were concerned with “privatisation” of the NHS in some way, They identified these comments as part of a “national campaign” group ( later named as KONP) which involved speculation about the creation of ICSs! Therefore, they considered them as a single response. So, over 5,000 responses who may or may not have been members/ supporters of KONP, were reduced to one response and treated differently. 5,000 plus responses have been reduced to being described as “speculation” whilst the ” clear opinions” of some of the other 1700 respondents are accepted as having individual validity and are quoted in some detail.

    The distinction being drawn between speculation and a clear opinion is disingenuous, How does someone give an opinion unless you do speculate about what the implications or effects may be of any proposal for change? Furthermore, when the white paper does not actually contain much detail because the government and NHSE say they wish to increase flexibility and move away from prescription, what else can you do but speculate on possible outcomes!

    Not surprisingly, the majority of comments included from groups such as The Kings Fund, NHS Confederation; NHS Clinical Commissioners etc support the NHSE views with a few perfunctory caveats included for the sake of showing some ” balance”. This then feeds into the claim that 79% of respondents agreed or strongly agreed with the proposals ( See Page 3, 1.3; Provider Selection Regime consultation on proposals).

    Of course, this blatantly skewed approach to “consultation” is no surprise, as the Local Foundation Trusts/ CCGs used similar tactics during the consultations over Phase 1 of the Path to Excellence and The Urgent Care Review in Sunderland. It continues a growing trend by the NHS and others of discounting the strength of support for particular campaigns by characterising them as being “protest” groups with no real understanding of the issues. Unfortunately, this seems to be a further indicator of the direction of travel these proposals make in regard to governance of ICSs with moves to marginalise local scrutiny and representation and return control of the NHS to government.

    The NHS says it proposes that ICS bodies should be statutory public bodies but their legislative recommendations to government provide only that they should have a Chair and a CEO with representation from trusts, GPs and a local authority which could literally mean one representative for all local authorities in the ICS footprint ( there are 12 unitary local authorities in the North East and Cumbria ICS). Other unspecified bodies can also be appointed which could include private sector healthcare providers, management consultants or population health experts. But, of course, that’s speculation!

    Developments are now moving on at pace and the NHS has launched another consultation: NHS Provider Selection regime: Consultation on proposals which is due to close on 7th April 2021. This invites responses on developing a bespoke NHS regime to replace the current procurement requirements. You will recall that the White Paper includes the NHSE strategy for bypassing procurement which the MSM heralded as the end of privatisation.

    The first question on this engagement/ consultation is:

    “Should it be possible for decision-making bodies (eg the clinical commissioning group (CCG), or, subject to legislation, statutory ICS) to decide to continue with an existing provider … without having to go through a competitive procurement process?”

    This has obvious advantages in terms of less bureaucracy and administration but if the existing provider is a private health care provider then it does not reduce the privatisation already inherent and makes it more likely that future larger contracts will also go to private companies, particularly if the ICP is able to award one overriding contract. The government and NHS are making great play that this will enable greater flexibility and control locally but without appropriate safeguards being in place it is clear that the way is open for long term commercial contracts of 10-15 years which are already being suggested.

    Please will you look at all this and advise about the next steps.

    Is the Government’s way of dealing with over 5,000 responses legitimate?

    Posted by Jean Smith on behalf of an SHA and KONP member.

    Comments Off on Government response to Public Consultation on ICSs

    Something major happened in the NHS in February. No, not the new White Paper on rearranging the furniture; something else. This was the announcement, or lack of announcement, that a large number of GP Practices have been taken over by a US Health Insurance giant – Centene. AT Medics, a London based GP group, which runs 37 practices, has essentially been bought out by Centene. This means overnight hundreds of thousands of patients woke up with a new GP provider, without their consent. The acquisition makes Centene the largest provider of General Practice in England with 69 practices.

    The way this has happened follows a pattern seen in recent years. No consultation or public scrutiny; use of legal loopholes; and the use of the revolving door of ex-NHS leaders who know the system as gamekeepers turned poachers. It is possible by a sleight of hand similar to the methods of the cuckoo. The incoming company adds or replaces directors of the ‘host’ organisation, which technically still exists so keeps its NHS contracts, just as a cuckoo displaces the host’s chicks out of the original nest.

    The significance is twofold.

    Firstly, deep and comprehensive commercial involvement in our NHS is troubling. In this case the US health insurer is not only now the largest provider of GP services in the country, it also is providing contracts to NHS England and Integrated Care Systems to advise how they run the NHS – nationally and locally. This gives great insight into the decision makers and influence over how the money is spent. Combined with Centene having a major stake in private hospitals, it is not hard to join the dots- involvement in the design of systems, financing of services and the provision of services gives companies a great degree of involvement in our NHS.

    Secondly these developments are a logical conclusion to major changes for some years in the way family doctors services are organised and delivered. As a GP I have huge concerns and patients will do as well. Why does it matter?

    When invited in Parliament by his shadow, Jonathan Ashworth, to condemn the takeover, Secretary of State Matt Hancock declined, replying: ‘What matters for patients is the quality of patient care… what matters to people is the quality of care. That is what we should look out for’.

     Is he correct? Is the quality of care all that matters? Or do the people providing it, and their ethos, motivation, interests and agenda matter? Is it possible to disentangle ‘quality’, an abstract notion, from the specific people providing a service and their very non-abstract interests?

    One of the reasons I became a GP, and probably the major reason I have stayed in my practice working full time for nearly 15 years, is the deep-rooted feeling that I have of being part of something more than just a clinical service. Myself and my GP colleagues, similar to many across the country, both lead the service and work in it. Every day we see our patients and work in our communities, we know the people and the community. There is no escaping direct and sometimes blunt feedback. Our teams are small, if there is a problem, we are around to fix it. If something needs to change, we don’t need to enter into a large corporate machine for it to happen. We get the spanner out and make the adjustment.

    Can we really say the same for a company that has its eye on more than just providing a ‘good quality’ GP service for the 69 different sites it has control of? There are those who compare health care to supermarkets, or banks. The argument is that efficiency and scale are what is needed; the people who provide it can change and the patient-doctor relationship isn’t a problem, as long as the measurements prove ‘quality’. This may work for a simple transactional arrangement, such as buying some groceries or cashing a cheque, but healthcare – and especially holistic primary healthcare is a more complicated than that. It does matter who cares. It is all about the people, their motivations and their relationship with their patients and community. This is not to say that UK General Practice can’t be improved, but let’s at least keep the baby if we are changing some of the bathwater.

    If anything, General Practice feels more like farming than retail. When done well, looking after the health of the community well takes time, and deep commitment. When done badly it can result in destruction of the environment and soulless communities. Will this new huge, commercial type of model of healthcare care about this?

    I doubt it.

    https://www.theguardian.com/society/2021/feb/26/nhs-gp-practice-operator-with-500000-patients-passes-into-hands-of-us-health-insurer

    https://hansard.parliament.uk/commons/2021-02-23/debates/7CDE78FD-D275-41D3-B02E-D7690F054DB1/TopicalQuestions

     

    US Centene expands in the UK with increased stake in Circle Health

    3 Comments

    Posted by Jean Smith on behalf of Labour Trans Equality

    05.3.21

    First some background. NHS England Commissions GIDS (The Gender Identity Development Service) at the Tavistock & Portman NHS Foundation Trust. GIDS accepts referrals of young people with the features of gender dysphoria up to the age of 18 in England and Wales. The service at Tavistock & Portman in London has a regional centre in Leeds and satellite clinics in Exeter, Bristol and Birmingham.

    As a result of representations, to the Care Quality Commission (CQC) including by the Children’s Commissioner, the CQC undertook a focused inspection of GIDS in October and November 2020.  This resulted in a rating of Inadequate for the service..

    The CQC report presents a sobering picture of a service under considerable pressure. It finds that at the time of the Inspection the service was working with 2093 young people with a further 4677 young people on the waiting list resulting in a waiting time of at least 2 years for access to the service.

    While these figures would be cause for concern for any NHS service it is what lies behind them in terms of safeguarding and the risk to these young people which is most important and worrying. It is worth quoting directly from the CQC report….

    “Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment”.

    This is currently the reality for thousands of young people and the background to the current debate about the desirability of providing access to “hormone blockers” to young people below the age of 16 and cross sex hormones for young people from the age of 16. A debate heightened by divergent views about the legitimacy and safety of such therapies which has crystallised leading up to the recent Bell v Tavistock Court Case and its outcome now subject to Appeal. The case hinged on the role of parental consent in the treatment of trans children and young people Its impact has been significant for access to treatment and will remain so pending a conclusive outcome to the Appeal. (See commentary on the case by Robin Moira White & Nicola Newbigin of Old Square Chambers)

    This debate about treatment at GIDS frankly rather misses the point. In reality the number of young people currently being prescribed “hormone blockers” and cross sex hormones  at GIDS is less than a hundred. The NHS England treatment protocol for prescription of hormone blockers and cross sex hormones is very strict and following the outcome of the court case has become more so.  Meanwhile as the CQC report makes crystal clear thousands of young people are at varying degrees of risk because they are unable to access the diagnostic and clinical support which they desperately need from GIDS because of the size of the waiting list and the capacity of GIDS to assist them.

    It follows surely that if we are truly concerned about the care and wellbeing of a significant cohort of young people many of whom are at risk  this is what we must be focusing on.

    So what is to be done ? Simply we must focus on the reality rather than be influenced by myth and misinformation about the use of these treatments. Fortunately two key initiatives are now underway. Prior to the CQC Inspection NHS EI had already commissioned Professor Hilary Cass formerly President of the Royal College of Paediatric and Child Health to conduct a review. (The terms of Reference can be viewed on the NHSEI web site)

    Also and in response to the CQC’s findings, NHS EI is currently preparing proposals for establishing local support structures for young people seeking access to GIDS details of which will be revealed shortly. Implementation of these proposals will require support and engagement from people working with young people locally and especially in primary care.

    Meanwhile SHA members can play an important role in ensuring that the discussion about the care and support of these young people focuses on the realities facing thousands of them, their families and their carers and what must be done.  When NHS EI comes forward with its proposals for addressing this problem we must hope and expect that it will receive a positive response from primary care and local mental health services.

    References

    CQC Report

    Tavistock & Portman NHS Foundation Trust Gender Identity Service Inspection Report 20.01.21

    The Cass Review

    “Review of GID Services for Children & Adolescents”

    Click to access GIDS_independent_review_ToR.pdf

    Legal Commentary

    “What about Parental Consent in the Treatment of Trans Children and Young People”

    Nicola Newbigin & Tobin Moira White

    Click to access What-about-parental-consent-1.pdf

     

    Comments on this article can be sent to Labour Trans Equality at

    admin@labourtransequality.org.uk

    Website

    http://labourtransequality.org.uk/

    Comments Off on “Safeguarding Young Trans People; The Real Issues!”
    An industrial action ballot is one of the options that Unite the union will be considering as it steps up its campaign for a fair and decent pay rise for NHS staff.
    Unite, Britain and Ireland’s largest union, will be liaising with other health unions as to the next steps in the pay justice campaign, as the row continues over the government’s evidence to the NHS Pay Review Body (PRB) which recommends a one per cent rise for 2021-22. The PRB is due to report in May.
    Unite national officer for health Colenzo Jarrett-Thorpe said: “Following yesterday’s ‘slap in the face’’ announcement that the government wants to peg NHS pay at one per cent for 2021-22, Unite will be considering all its options, including the holding of an industrial action ballot, as our pay campaign mounts in the coming weeks.
    “We will be fully consulting our members on the next steps, given that inflation could be two per cent by the end of 2021, so what prime minister Boris Johnson is recommending is another pay cut in real terms.
    “The prime minister has a short memory as it was only last spring that he was praising to the skies those NHS staff who had saved his life
    “This proposal shows an unyielding contempt by ministers for those who have done so much to care for tens of thousands of Covid-19 patients in the last year. It should not be forgotten that more than 620 health and social care staff have lost their lives to coronavirus.
    “We will also be consulting the other health unions and professional bodies to coordinate and strengthen our approach to the pay campaign – mobilising public opinion will be key.
    “The public is rightly outraged by a government that can spend £37bn on the flawed private sector-led ‘test and trace’ programme, but can’t find the cash for a decent pay rise for those on the NHS frontline.
    “Some estimates reckon that a one per cent pay rise will be the equivalent of £3.50-a-week for the average NHS worker, which is shabby compared to how ‘friends’ of the Tory establishment have profited so greatly from the ‘fast track’ PPE contracts.
    “It leaves a sour taste in the mouth and insults the British public’s sense of fair play. We believe that public opinion will be key in shaming the government into changing its recommendations to the NHS Pay Review Body.
    “What the government is proposing will do nothing for NHS staff morale and will have a deterrent effect on filling the estimated 80,000 -100,000 vacancies in the health service, of which about 40,000 are unfilled nurse posts – the very people that care for Covid-19 patients every hour of every day.
    “Chancellor Rishi Sunak will suffer severe reputational damage if he fails to deliver the money necessary to fund a decent pay rise after a decade of austerity that has seen the pay packets of many NHS staff shrink by 19 per cent in real terms since the Tories came to power in 2010.
     “Unite, which has 100,000 members in the health service, will continue to make the case strongly that NHS staff deserve an immediate pay rise of £3,000-a-year or 15 per cent, whichever is greater.
    “Even this figure won’t start to make up for the 19 per cent decrease in pay in real terms that many NHS workers have lost since the Tories came to power in 2010.”
    Unite senior communications officer Shaun Noble
    Comments Off on Unite considers industrial action after government’s ‘indecent proposal’ of one per cent pay rise for NHS staff

    The following is a major speech from Shadow Health Minister Justin Madders.  In Parliamentary terms it is extremely critical of the government.  Even though the prime minister may have lowered the tone of debate, this is polite, measured, and at  the end, does threaten the PM with his P45.  I work with Justin a lot, and have developed considerable respect for his honesty and integrity over the years.

    Jean Hardiman Smith

     

    As we know, we are now a year into this pandemic. It has been a year unlike any we have experienced before, and it certainly was not the one we would have hoped for. The virus has turned the world as we know it upside down. We have seen the very best of many: our frontline health and social care workers who have selflessly looked after us, our key workers who have kept our vital services running and our country going, and our communities who have come together to support one another, especially those in need. But it has also been the very worst of times for many: families kept apart for months, individuals and businesses left with no support and, of course, the grim milestone of more than 120,000 deaths from coronavirus, which was reached this weekend. We know that each life lost is a tragedy that leaves behind devastated family and friends, and that death toll does need explaining. I will return to that issue later, but I would like to start on a more positive note.

    As the Minister referred to in his opening remarks, more than 17.5 million people in the UK have received their first dose of the covid-19 vaccine. I echo his congratulations to everyone who has been involved in that roll-out. From the scientists to the NHS to the volunteers, it has been nothing short of brilliant, and it is something for us all to celebrate. While we are on the subject, we should also extend our congratulations to Mark Drakeford and the Welsh Government for becoming the first country in the UK to get through the first four priority groups.

    I am sure that all of us have breathed a sigh of relief or even shed a tear when a parent or vulnerable family member or friend has received their first vaccine dose. Yesterday’s news that all adults in the UK will have been offered their first dose by the end of July is very positive indeed, but can more be done? When Simon Stevens says that the NHS could deliver double the number of vaccines it currently is, we will all be asking, why is that not happening? With research showing that some minority groups are well behind the general population in terms of take-up, another question that I am sure Members will want to raise about the roll-out is: what can the Government do to vaccinate more people in hard-to-reach communities?

    I am sure that many Members will have been moved by the story of Jo Whiley and her sister, Frances. She has talked about the anxiety shared by many families across the country. We know that people with learning disabilities are much more likely to die from coronavirus than the general population, with the death rate in England up to six times higher during the first wave of the pandemic, but currently only people with severe learning disabilities have been prioritised for the vaccine. I am sure the Minister is aware that over the weekend, at least one clinical commissioning group announced that it will be offering the vaccine to all patients on the learning disability register as part of priority group 6. I would be grateful if the Minister updated us on whether there are any plans to consider that issue again.

    I have one last question regarding the vaccine. We have asked a number of times for the Government to publish figures on how many health and social care staff have been vaccinated. The Secretary of State said last week that a third of social care staff had still not been vaccinated, so I hope that when the Minister responds to the debate, she will be able to update us on those figures and on what more we can do to improve take-up in that group. It is vital that we look after the people who look after us in social care and the NHS. Our NHS rightly deserves huge congratulations on its impressive and speedy vaccine roll-out, but despite its incredible efforts, it will still take many months before the vaccine offers us widespread protection. With the emergence of new variants, increasing pressures on our health service and continuing high rates of transmission, it is vital that Ministers do everything possible to ensure that frontline health and care workers, who are more exposed to the virus, are fully protected.

    Healthcare staff deaths are now estimated to be approaching 1,000. That is tragic. We know that our frontline workers face higher risk. During the surge in cases last month, the British Medical Association reported that more than 46,000 hospital staff were off sick with covid-19 or self-isolating. A survey conducted by the Nursing Times during the last two weeks of January found that 94% of nurses who work shifts reported that they were short-staffed due to similar absences. We support calls from the BMA and the Royal College of Nursing to urgently review PPE guidance and increase stockpiles of high-grade PPE such as FFP3 masks for all frontline NHS employees. I hope the Minister can update us on what plans the Government have to ensure that health and social care staff are fully protected.

    Finally, we need a plan for staff to address what comes next. Just as the nation needs a recovery plan, the NHS workforce needs one too. We must not forget that we entered this crisis with a record 100,000 vacancies in the NHS. What I hear from staff, who have now been working flat out for a year, is that they desperately need a break, and they need a tangible demonstration that their efforts are truly valued. The NHS rightly has a special place in the hearts of the people of this country, but without the staff, the NHS ceases to exist. That is why we need to recognise that we cannot keep dipping into that well of good will, and that at some point, NHS workers need cherishing as much as the institution itself.

    I cannot mention PPE without briefly addressing last week’s High Court ruling that the Government had acted unlawfully by failing to publish details of covid-related contracts. Why has the Secretary of State not come to Parliament to explain himself? Is breaking the law such a common occurrence in Government nowadays that it does not warrant an explanation from those responsible? The Government’s approach to procurement during the pandemic has been marred by a toxic mix of misspending and cronyism. We all understand that the Department was and is dealing with many pressing issues, but transparency is important, and accountability matters. Of course, we need to remember why there was such a rush to get PPE in the first place—it was because the Government had ignored the warnings and allowed stockpiles to run down. The pandemic has been used too often as an excuse for standards to slip, but it really should not need saying that transparency goes hand in hand with good government.

    Another area where we need greater transparency is the Government’s general response to the pandemic to date. With the highest number of deaths in Europe, those in power now need to answer why that has been the case, because such a grim death toll was not inevitable. If it is the right time to undergo an expensive and disruptive reorganisation of the NHS, it is also the right time to have the inquiry into covid that the Prime Minister promised more than six months ago. The families of the deceased deserve answers, and we all need to know that lessons have been learned and that the same mistakes will not be made again. If we look at what has happened so far, we can see that there has been a tragic failure to learn the right lessons. That is why what we have heard from the Prime Minister today matters, because we are not out of the woods yet. Infection rates, though they are reducing, remain high; there are more people in hospital now than there were at the start of the second lockdown; and there are still more than 1,000 people being admitted to hospital every single day. So, what we do next, when we do it and how we do it remains critical.

    The Opposition have been clear all along about the importance of following the science. We know where not following the science takes us: it leads to the worst death rate and the deepest recession in Europe. It leads to the farce of the Prime Minister refusing to cancel Christmas plans, only to U-turn three days later, and it leads to the shambles of children returning to school for one day, only to find it closed the next. We know that the virus thrives on delay and dither. As we approach a year of life under restrictions, any ambiguity over when, where, why and how the restrictions will be eased in the coming weeks and months is just as big a threat as the virus itself.

    Before I conclude, I just want to say a bit about test and trace. We did not hear anything new from the Prime Minister on that today, but it nevertheless remains a vital part of the pandemic response. We need to remind ourselves that the number of new cases is still above 10,000 each day, and that every day thousands more people are required to self-isolate. For this lockdown truly to be the last, we need to continue to cut transmission chains and the spread of the virus, so this continuing blind spot when it comes to supporting people to self-isolate is as baffling as it is wrong.

    When we first came out of lockdown, the scientific advice repeatedly stated that the easing of restrictions would work only if there was a fully functioning test and trace system in place. That was true last year and it is still true today. We still do not have all test results back within 24 hours, as the Prime Minister promised would happen last June, but perhaps most important are the continued low compliance rates with self-isolation. The Government have known for many months that the lack of financial support to those self-isolating has resulted in extremely low adherence rates. Surveys between March and August last year found that only 11% of people in the UK notified as having been in recent close contact with a confirmed case did not leave their home. That figure has improved a little recently, but it is still well below where it needs to be.

    Around a quarter of employers will only pay statutory sick pay for such an absence. The Secretary of State has previously said that he could not survive on statutory sick pay, so we should not be surprised when others cannot do so either. We also know that seven in 10 applicants are not receiving self-isolation payments from councils, with one in four councils rejecting 90% of applications. They are rejecting them not because there is no need but because the rules have been so tightly drawn that seven out of eight people do not qualify for a payment under Government rules. When Dido Harding herself says that people are not self-isolating because they find it very difficult, a huge question needs to be answered about why the Government have still not acted to rectify this.

    Last month, the Government announced more cash for councils for self-isolation payments, but that was to last until the end of March, and actually the amount handed out was the equivalent to one day’s-worth of people testing positive. That is clearly not enough, and what about after March? We need confirmation of how much support will continue to enable people to self-isolate after that date. Following reports in The Independent late last week that some people working for the NHS through private contractors, such as cleaners, porters and kitchen staff, were being denied full sick pay for covid-related absences because of the removal of supply relief, we need a commitment that this will be investigated urgently and that the direction of travel will be reversed so that everyone in the NHS is properly supported. The Government should be setting an example here, not leading a race to the bottom. On wider financial support, where is the road map for businesses that will still be operating under restrictions for many months to come? We know that the Budget is next week, but they need clarity and support now.

    In conclusion, what the Prime Minister announced today has to be the last time the word “lockdown” passes his lips. There must be no more false dawns and no more boom and bust. With this road map, relaxations should now be clear and notified to the affected parties in advance, but also approved by this place in advance. There should be no more muddle between guidance and laws; no more regulations published minutes before they become law; no more businesses having to throw away thousands of pounds-worth of stock because decisions are reversed at a moment’s notice; no more of the stop-go cycle; and no more hopeless optimism followed by a hasty retreat. This time really has to be the last time. The vaccine has given us hope. It has given us a route out of this. With a year’s experience of the virus and with multiple vaccines on the way, there can be no excuse for failure this time. The Prime Minister has said that he wants the road map to be a one-way ticket. I hope he is right. We all want him to be right, but if he gets it wrong, he should expect nothing less than a one-way ticket to the jobcentre.

     

    3 Comments

    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

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    Author: B Fisher on behalf of Keep Our NHS Public

    The SHA asks you to support this great project if you can. Please spread the Crowdfunder with friends, families and in your networks – we need to know why so many deaths – why so many families, the NHS and social care were let down so very badly.

    The target for funds will sustain our campaigning efforts.

    Please share the crowdfunder for the KONP People’s Covid Inquiry:

    https://www.crowdfunder.co.uk/peoples-covid-inquiry.

    People’s Covid Inquiry site for info and evidence:

    https://www.peoplescovidinquiry.com/

    https://www.crowdfunder.co.uk/peoples-covid-inquiry

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    The pharmacists’ defence association and trade union, PDA, is to urge the NHS to develop its strategy for the delivery of the second vaccination in good time and to give the role of the second vaccination of the Astra Zeneca vaccine to the national community pharmacy network as part of a collaborative and integrated NHS process.

    The decision to delay the second dose of the Covid-19 vaccination to twelve weeks so that the current efforts can concentrate on giving as many people as possible a first dose of the vaccine has already resulted in more than 6 million first vaccinations being successfully delivered in one of the UK’s designated vaccinating hospitals, primary care GP hubs or in one of the large regional centres.

    However, this means that in just over two months time, a large and ever-increasing cohort of the population will be due to receive its second vaccination and this will create logistical challenges to the current vaccination programme and risks slowing down the rollout of the critical first doses.

    PDA to launch “A thousand little ships” policy

    Individual pharmacies will never be able to deliver the high-volume vaccination operations seen in the large regional centres or the primary care hubs. However, like the large number of privately owned little ships that supported the larger Royal Navy carriers to save the lives of more than 330,000 allied soldiers from the Dunkirk beaches, they have the capacity to deliver smaller numbers that add up to a significant amount.

    With the potential of vaccinations across more than 13,500 locations in the UK, this mathematical capacity, even if providing an average of only 25 vaccinations per day, per pharmacy, would be able to deliver more than 2 million vaccinations each week. This would represent a very substantial component of the overall national vaccination programme.

    Working in a collaborative way and integrated within the wider NHS vaccination delivery pathway, pharmacists located in all community pharmacies delivering the second dose of the Astra Zeneca vaccine would protect the NHS by maintaining the capacity of the purpose-built, high volume hubs.

    This would enable the hubs to continue at pace with the successful first vaccination programme, as well as enabling them to deliver the second more operationally complex Pfizer Biontech vaccines.

    According to PDA Chairman, Mark Koziol:

    “The system needs to be dynamic and the number of vaccinations delivered in each pharmacy will depend on demand and location. Some pharmacies may be able to deliver more than 80 a day, while others may only be required to deliver 8 vaccinations on two afternoons a week. This would depend on how many patients booked appointments at the pharmacy of their choice. Appointments could be organised to ensure that no vaccine was ever wasted or left unaccounted for and in a way that enables the local community pharmacy to organise the right staffing levels for their vaccine clinics.”

    The PDA envisages that the community pharmacy vaccination programme could easily be built upon the existing Covid-19 vaccination service where the NHS local vaccination centres or primary care organisations would continue to be in control of the vials. The local centres would ensure that only the requisite number of vials were distributed to participating pharmacies on the specific days they were needed based on the number of appointments booked via the NHS vaccination booking system. This distribution and governance system would operate much in the same way that it currently does with the local care and residential homes.

    Mark continued:

    “The current GP vaccination hubs are successful because they rely on dedicated vaccinators. This means that the existing GP practice patients continue to enjoy access to their wider GP service. In our proposal, just as in the GP practice setting, the public would expect the wider community pharmacy service to continue and be delivered safely with full-time access to the community pharmacist to discuss their wider healthcare issues on an opportunistic basis. For this reason and also because the movement of the vials requires the vaccination service to be carefully structured and managed to avoid waste of vaccine, the vaccinations would have to be delivered in planned clinic sessions by a second dedicated pharmacist who comes in specifically to support the vaccination programme.” 

    The PDA’s “A thousand little ships” policy will be presented to governments in all four UK countries over the next few days.

    You can download the England version here:  PDA-Little-Ships-Initiative-ENGLAND-FINAL

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