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    We are now into the 15th weekly blog during the pandemic and confidence in the government is plummeting as the weeks roll on. The UK stands out as the sick man of Europe according to the Economist with the highest excess deaths per million population and with the OECD forecasting the UK as having the highest % decrease in GDP for 2020 compared to a year ago

    Channel 4 broadcast a speech by Prince Charles on Monday (June 22nd), saying how grateful the Nation was to the Windrush Generation who came to staff the NHS and other public services after WW2. Viewers have been horrified by the programmes on TV showing how badly they had been treated under the Hostile Environment policy of Theresa May, and how disproportionately they are currently suffering from Covid-19..

    In this week’s blog we will touch on familiar themes such as the slow rebirth of local test and trace/outbreak control plans, the failure of the world beating NHSX app on the Isle of Wight, the scandal of government contracts for PPE purchases and the revelation that there was indeed a Fenton report on BAME deaths that was withheld.

    BAME

    As protests about Black Lives Matter continue across the country and the world, our Ministers are on a learning curve about the historic slavery/civil rights context of ‘taking the knee’, and that Marcus Rashford is a famous black Man U footballer and English international. The PM and his Cabinet Ministers continually display how out of touch they are.

    Having looked at the Fenton Part 2 report “ ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’ most people will nod quietly at the eminently sensible recommendations he made which were based on a rapid review of the literature, his group engaging with 4,000 people across the country with direct experience of racism and suggestions about what is to be done. These stakeholders expressed deep dismay, anger, loss and fear in their communities about the emerging findings that BAME groups are being harder hit by COVID-19 than others. This exacerbates existing social, economic and health inequalities.

    Professor Fenton’s report recommends that there be improved ethnicity data collection, more participatory community research, improved access to services, culturally competent risk assessments, education and prevention campaigns. He calls for pandemic recovery plans that are designed to reduce health inequalities caused by the wider determinants of health to create long term sustainable change.  The SHA heartily supports these recommendations and, along with David Lammy MP, demand that the government implements findings from previous BAME related reviews that date as far back as the Stephen Lawrence inquiry in 1999.

    We know that inequalities reflect racism and structural factors in society outside health. The Runneymede Trust looked at Pensioners’ Income for the Financial Years 2017-18 and found that Black pensioner families receive almost £200 less a week than white British pensioner families. Black households were the least likely to receive personal pensions. They also found that Black African and Bangladeshi households have approximately 10p for every £1 of white British savings and assets. The figures show that for every £1 a white British family has, Black Caribbean households have about 20p and Black African and Bangladeshi households about 10p. Its not just COVID!

    Test and Trace

    Remember that the Government called a halt to the local test and contact tracing that was happening in early March, claiming that there was too much community transmission for it to have an impact and there were not sufficient local resources to manage the surge? The real reason it has emerged was that there was insufficient test capacity to sustain both NHS hospital testing and testing in care homes and the community. That fateful decision meant that local test and trace schemes were stood down, and did not follow the pandemic by analysing local surveillance and build-local systems. A few weeks ago, quite suddenly, the government recognised the role that such local test and trace schemes might have as the pandemic continued, and demanded that local Directors of Public Health prepare new Local Outbreak Control Plans by the end of June. Thankfully they appointed a CEO from Leeds Council to advise them and quite properly he has been working with the Local Government Association (LGA) and the Association of Directors of Public Health (ADsPH). At long last local plans are emerging and demands increasing for timely access to test results. Some government investment has been extracted from Deloittes and other consultants and safely invested in local government teams.

    As we have touched on before, the government has been too centralised in its approach and the national testing sites have been ‘out sourced’ to firms in the private sector, such as  SERCO, with Deloittes hovering, and also creaming off profit while mismanaging things. This means that there is undue delay in getting test results back to local teams and the initial contact tracing is being handled by inexperienced call handlers at a distance from the person involved. Remember that COVID-19 has shown us that it affects older people, people in care homes, people of BAME heritage and those from the most disadvantaged communities in the UK, disproportionately badly . I wonder what advice scientists might have given about the most effective way of reaching the most at risk people? Surely by now we know that, despite apps and complicated ventilators, health care is still a people business.  Skilled and empathetic care workers matter. Meanwhile GPs and primary care are bystanders to this world beating system and local public health teams are frustrated at step one of outbreak control, namely information about who has relevant symptoms and whether they have tested positive.

    The app!

    The app the app my kingdom for an app!’ It is alleged that people have heard the scream from the SoS who has a boyish interest and naïve faith in apps and other digital technologies. The ‘world beating’ app being developed in the exceptionally clever UK and tested on the Isle of Wight has bitten the dust. Stories are now emerging about the errors and misjudgements that there have been on the way. Developers of successful apps, such as that of Prof Tim Spector of Kings College London which now has 3.5m users, tells us that the NHSX treated his research teams as the enemy. They told him that far from collaborating, their world beating all singing and dancing app would make his redundant. In case we think this is just Tim Spector we hear that Ian Gass of Agitate tried to tell the NHSX in March that its app design, which tried to use Bluetooth signals was flawed. He describes this weird almost paranoid state, where the government says publicly that they’re asking for help, but then rejects it when it is offered.

    PPE contracts

    With the PPE supplies debacle we also heard the refrain that the government was inviting local UK companies to help produce PPE for the NHS and Social Care. Company boss after company boss reported trying and failing to make contact with government commissioners. It seems that it is only the insiders who get the contracts. Some previously small companies like PestFix are under scrutiny having won contracts with a value of £110m. This amount is nearly a third of the £342m public sector contracts signed for COVID-related PPE.

    We are pleased that Meg Hillier MP, Chair of the Public Accounts Committee is taking evidence on these contracts. MPs have said rightly that the pandemic crisis should not be an excuse for failing to achieve value for money.

    And finally

    We started this blog with a reference to a report in the right wing leaning Economist magazine. It is extraordinary that their leader in the June 20th-26th edition under the banner heading ‘Not Britain’s finest hour’ should say:

    The painful conclusion is that Britain has the wrong sort of government for a pandemic – and in Boris Johnson, the wrong sort of prime minister…

    ….beating the coronavirus calls for attention to detail, consistency and implementation…..

    The pandemic has many lessons for the government, which the inevitable public inquiry will surely clarify. Here is one for voters: when choosing a person or party to vote for, do not under-estimate the importance of ordinary, decent competence.”

    Hear hear.

    22.6.2020

    Posted by Jean Hardiman Smith on behalf of the Officers and Vice Chairs of the SHA.

    Comments Off on SHA COVID-19 Blog 15

    This paper was developed by a group of primary care clinicians for the Labour Shadow Health Team at their request. We hope it helps illuminate the next steps for primary care.

    WHAT ARE THE RISKS, OPPORTUNITIES AND CHALLENGES FACING  PRIMARY CARE PROVISION DURING AND AFTER ITS RETURN  TO A NORMAL STATE OF OPERATION?

     

    “We will be facing some tough challenges over at least the next year: managing more consultations (and clinical risk) remotely by phone or video; catching up with resurgent patient demand, catching up with the care of long-term conditions (whilst trying to protect groups of vulnerable people from a continuing threat of Covid); managing a backlog of people who need to be referred; and coping with any spikes in Covid. This comes on top of the usual (preceding) strains on limited resources and lengthening ‘winter pressures.’ I don’t think that we will be seen as ‘NHS heroes’ in a few months!”

     

    DIGITAL WORKING IS TRANSFORMING CARE

    Opportunities

    • Easier and more flexible for people and practices, so may aid GP recruitment
    • The complex and subtle nature of the consultation seems to be maintained
    • Communication across sectors can be dramatically improved. One GP described helping a patient with lymphoma – in 10mins he was able to include a Ca nurse and consultant in a conversation with the patient.
    • Telephone triage also successful
    • Bricks and mortar general practice may become less necessary
    • Combining online personalised advice with online access to records opens the way to improved self-care

    Challenges:

    • Digital can widen inequalities and disenfranchise. Experience suggests it is the elderly rather than the poor who struggle the most.
    • The best balance between remote and face-to-face is unclear. Video may be best for follow-ups.
    • Video is seldom preferred by people. The telephone or face to face are most popular.

    Actions:

    • Support the elderly to become more digitally able while ensuring that traditional approaches remain available
    • Support digital cross-sector working: GP/hospital/Social Care
    • Encourage digital mentoring to improve self-care for people with LTCs

     

    SHIFTING TO PROACTIVE WORK WITH COMMUNITIES

    Opportunities

    • The spontaneous rise in mutual community organisations has been remarkable, often outwith the traditional voluntary sector, improving safeguarding and perhaps saving lives.
    • Primary care has been able to embrace that.
    • It offers a model for the future
    • There have been many examples of successful cooperation with communities, but they have been dependent on local circumstances and local heroes.
    • The health gain comes when communities can take more control over the area and their lives
    • The NHS and local government need to create the conditions whereby communities can work collaboratively with the statutory sector sharing decisions with their communities. We need a systematic approach for mobilising civil society, working with NHS and LAs.
    • PCNs offer a good base for such cross-sector working

    Challenges:

    • Sharing decisions with communities is a difficult skill the NHS would have to learn, perhaps from LAs and housing associations.
    • Building on existing work and with councillors would be essential. No new unnecessary initiatives.

    Actions:

    • Jointly fund, via NHS and LA, community development workers in each PCN, working with social prescribers. They would support the statutory sector sharing decisions with their communities.
    • Primary Care to be encouraged to support community groups and community development by, for instance, enabling practice space to be used by communities.
    • Asset mapping with LA and PH colleagues would be one early step
    • Encourage and incentivise cross-sector working.

     

    PRIMARY CARE TO ACTIVELY WORK ON THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES

    These have been thrown into sharp relief through the pandemic.

    Opportunities

    • Essential to make any progress on health improvement
    • Community development can assist
    • Local work on poverty, race issues, migrant issues, housing
    • Cross-sector working is essential to do this.

    Challenges

    • The independent contractor status of general practice may hinder this process.
    • Cross-sector working is difficult
    • It is political work

    Actions

    • Promote training GPs with a Special Interest in Public Health, sitting astride the PCN and LA
    • Support areas to become Marmot towns.
    • PCNs to link formally with LAs
    • Boost the status and effectiveness of Well-Being Boards
    • Borough-level linking (not merging) of LAs and NHS.

     

    PRIMARY CARE AND LONG-TERM CONDITIONS INC COVID

    Opportunities

    • The importance of community service provision has been made plain by the pandemic
    • Extensive primary care services and rehab re likely to be required for people recovering from Covid

    Challenges

    • Managing more serious illnesses outside hospital may require differently trained primary care staff such as District Nurses

    Actions:

    • Use a range of approaches to contact those who have delayed seeking help for potentially life-threatening illnesses
    • Digital self-care with remote links to home monitoring such as BP, weight, Peak Flows
    • Secondary care doing remote consultations to reduce the backlog
    • Explore a range of differently skilled staff for primary care

     

    RELAXATION OF RULES HAS BEEN HELPFUL

    Opportunities  

    • There has been relaxation of some bureaucracy
    • Flexible approaches have enabled doctors to return to the workforce.
    • These changes have enabled GPs to devote more time to patient care.

    Challenges

    • Some of this bureaucracy is useful. We don’t want wholesale deregulation: that has often been dangerous
    • It is difficult to know which parts need to be kept and which don’t.

    Actions

    • Explore with the profession which regulatory aspects need to be kept and which don’t.

     

    FUNDING, TRAINING AND STAFFING

    Challenges

    • Primary care, GPs, HVs and DNs remain substantially understaffed. This must change.
    • Different training requirements may be needed for a different future.
    • The RCN is calling for wage increases for nurses

    Actions:

    • A system to support on-going review and remodelling of workforce capacity is needed to ensure that the primary care workforce is responsive to emerging need which may increase over time.
    • Clarification of plans for student health visitors and others who have had their training disrupted during the pandemic

     

    STAFF SAFETY IN THE TIME OF COVID

    • Continued need for PPE to protect staff and patients
    • Mental health support for staff

     

    PRIMARY CARE BUILDINGS

    Challenges:

    • Many primary care buildings were inadequate before Covid
    • Many more now need redesign to cope with new patient flows and requirements for cleaning etc

    Actions:

    • Funding must be found where premises need improving
    • Consider links with housing associations

     

    BOOSTING DEMOCRACY IN THE NHS

    Challenges

    • The NHS has used the Coronavirus Act to push through significant changes to the infrastructure of ICSs. This is baking in the risks posed by them: privatisation, fragmentation and cuts.
    • Hosp reconfigurations are happening rapidly without consultation and no equality assessment

    Actions

    • Call out these dangerous changes and use them to explore new approaches to democracy. For instance:
      • PCNs run with a Board with a broad representation of opinion
      • Link PCNs and local government through local forums with budgets – a form of participatory budgeting
      • Community development would assist participatory democracy

     

    ADVANCED CARE PLANNING

    Opportunities

    • Advanced care planning will need to sensitively change for the better.
    • General practice is well- placed to have discussions that allow patients to express their wishes, which will reduce unnecessary and possibly undignified hospital admissions.

    Challenges

    • There seemed to be sporadic inappropriate behaviour from CCGs and practices issuing blanket DNR notices to care homes
    • The pandemic seemed to cast a harsh light on relationships between some practices and care homes

    Actions:

    • Patients suitable for advanced care planning conversations could be identified— perhaps informed by frailty scores — and discussed in multidisciplinary meetings as part of routine care.
    • The public need to be involved, and the sector need to emphasise that these discussions are about providing quality of care.

     

    SOURCES:

    https://www.rcn.org.uk/news-and-events/blogs/covid-19-out-of-this-crisis-we-must-build-a-better-future-for-nursing

     

    https://ihv.org.uk/our-work/publications-reports/health-visiting-during-covid-19-an-ihv-report/

     

    A brave new world: the new normal for general practice after the COVID-19 pandemic.

    https://bjgpopen.org/content/early/2020/06/01/bjgpopen20X101103

     

    https://www.rcgp.org.uk/policy/fit-for-the-future.aspx

     

    CONTRIBUTORS

    Dr Onkar Sahota

    Dr Duncan Parker

    Dr Joe McManners

    Dr Robbie Foy

    Dr Brian Fisher

     

    CONFLICTS OF INTEREST

    Dr Fisher:

    I am Clinical Director of a software company called Evergreen Life www.evergreen-life.co.uk . We are accredited by the NHS to enable people to access for free online their GP records, to book appointments and order repeat prescriptions. We try to help people stay as fit and well as possible.

    Comments Off on SHA Briefing – Primary Care
    Proposals to create a new super NHS laboratory in the northwest by closing local sites while 200 biomedical scientists are busy testing for Covid-19 will create delays in processing samples, Unite, Britain and Ireland’s largest union, warned today (Thursday 7 May).
    Unite said the plans by Lancashire and South Cumbria Central Laboratories Partnership to merge the labs at Blackburn, Blackpool, Lancaster and Preston into one super lab at a yet–to-be identified site would mean delays in testing samples which would have a detrimental impact on the estimated 500,000 people the super lab would serve.
    Unite, which has 100,000 members in the health service, accused NHS bosses of using the coronavirus emergency to push through this already rejected merger plan ‘under the radar’ when other similar collaborations, such as at Guy’s and St Thomas’ NHS Foundation Trust, have postponed all further plans until the Covid-19 crisis has passed.
    Unite said the plans were ‘a stab in the back’ for the biomedical scientists currently working at full stretch to process lab samples, including those for Covid-19, who have not got the time to examine the plan.
    Merger plans for a super lab at Lancaster, covering the areas of five NHS trusts, were rejected last year as it would make the service too remote from local GPs and hospitals, and increase processing times from the current 24-to-48 hours.
    In a letter to the partnership, Unite regional officer Keith Hutson said: “Unite finds it totally unacceptable that during the Covid 19 crisis you have seized upon this opportunity to force through merger plans and exclude the participation of Unite, the main representative of laboratory workers for this project.
    “Unite calls upon this project to cease until the Covid-19 crisis has ended.  I can say that apart from the despicable manner the trusts have chosen to progress this matter, be aware that when it is appropriate Unite, if necessary, will move to immediately ballot its members for industrial action.”
    Commenting Keith Hutson added: “NHS bosses are using the pandemic to reintroduce this flawed plan under the radar which will increase the times for processing samples. Our members who have given their all during this crisis feel the deliberate lack of consultation is a stab in the back.
    “We are going to involve the region’s MPs in this campaign, including The Speaker Sir Lindsay Hoyle, MP for Chorley, as, in the long-term, we fear that any super lab could be ripe for being sold off to a profit-hungry healthcare company.
    “If one thing has become clear during the last two months, it is that the British public respect and deeply value the NHS and its staff – and don’t want to see it being salami-sliced and privatised.”
    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

    3 Comments

    The following article was first published in the Camden New Journal on 06 December, 2018

    A private company being promoted
    by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from the NHS, argue
    Susanna Mitchell and Roy Trevelion

    The sneaking privatisation of our National Health Service now aggressively threatens our GPs. In Camden and across London, we all need to be aware of the long-term harms this development will cause GPs and primary care NHS services.

    Last year, a global multinational corporation called Babylon Healthcare – owned by a former Goldman Sachs investment banker and Circle Health CEO – established a “digital- first” business called “GP at Hand”.

    Disastrously for the NHS, Babylon Healthcare Services Ltd can be traced back to a holding company in Jersey, the offshore tax haven.

    GP at Hand is contactable through a mobile app which uses standard calculations as a symptom checker. Unfortunately NHS England have not provided our existing practices with this software.

    Instead any patient registering with this commercial enterprise will be deregistered from their normal GPs. And, although the GPs employed by the company can also be accessed by video or phone, this process delivers no continuity of care or whole-patient assessment.

    Continuity of care is a cornerstone of general practices. However, Matt Hancock, the health secretary says, “If we need to change the rules to work with the new technology then change the rules we must.”

    In addition GP at Hand’s own promotion material actively discourages older people from registering. Explicitly these are those who are frail or living with dementia, or in need of end-of-life care. Pregnant women and those it describes as having complex social physical and psychological needs are also discouraged from signing up.

    In other words it is “cherry-picking” young and healthy patients who will be more profitable to its shareholders. Its use of standard practice via information technology, and the easy access it offers, is particularly attractive to the young.

    Of the 31,519 new patients who have signed up with GP at Hand over the past 12 months, 87 per cent are aged between 20 and 39 years, while patients over 65 now make up just 1 per cent of the population registered with the service.

    All this poses serious problems both for patients and general practices. In the first place, our present primary care system consists of GP practices committed to whole-person and integrated care for everyone in their local communities. Healthcare services are organised around geographic areas to enable better co-ordination with hospitals and social services.

    In contrast to this, GP at Hand fractures this fair and impartial community-based model, registering patients who live or work anywhere within 35 to 40 minutes of one of the clinics. In addition, should any of their patients require more complex care, they will no longer have their own GP to turn to.

    Secondly, by picking the most profitable patients, GP at Hand drains money away from ordinary GP surgeries. Normal GPs are funded according to the number of people on their patient list and this funding is combined into a single budget to provide the services they offer. This means that funding from the roughly 80 per cent of patients who remain reasonably well helps to pay for the 20 per cent who are elderly, who are chronically sick, or have multiple illnesses.

    But if the “capitation fee” of the young and healthy is scooped up by a for-profit company like GP at Hand, it will critically undermine the funding available to surgeries. This will leave practices to deal with the sick, the frail and the old on a much reduced budget.

    Shockingly this commercial entity is funded by NHS England. It can be commissioned through our clinical commissioning groups (CCGs).

    It’s expanding fast, and already has over 35,000 patients. Currently the corporation operates out of five clinical locations in London including one in King’s Cross. Plans for rolling it out nationwide are under discussion. It is also advertised widely, with the health secretary Matt Hancock recently announcing that he has registered with the company.

    Future developments in information technology and artificial intelligence that can be useful to our public health systems should be funded directly towards our existing GP surgeries.

    It should not be used as a vehicle for profit-making by private corporations at the expense of our NHS.
    We need to make the dangers of adopting this business model clear to the widest possible public. We must encourage those who care about our publicly-funded NHS to boycott Babylon’s GP at Hand.

    We need to bring public pressure to bear and end this attack on a valued and trusted institution that serves us all.

    The NHS has always been for the benefit of everybody. It must be kept that way.

    • Susanna Mitchell and Roy Trevelion are members of the Holborn & St Pancras Labour Party and of the Socialist Health Association.

    2 Comments

    Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

    The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

    HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

     

    A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

    This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

    NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

     

    We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

    As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

    Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

    And here is Health Campaigns Together on the subject at this link.

    As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

    When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

    As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

    Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

    Comments Off on Consultation survey for the NHS England Integrated Care Provider Contracts – all answers are here

    National Health Service (Co-Funding and Co-Payment) Bill

    2017-19

    Type of Bill:

             Private Members’ Bill (Presentation Bill)

    Sponsor:

             Mr Christopher Chope

    Progress of a Bill

    House of Commons

    First reading, Second reading, Committee stage, Report stage, Third reading

    House of Lords

    First reading, Second reading, Committee stage, Report stage, Third reading

    Consideration of the Amendments

    Royal Assent

    This Bill is expected to have its second reading debate on Friday 26 October 2018.

    This Bill was presented to Parliament on Tuesday 5 September 2017. This is known as the first reading and there was no debate on the Bill at this stage.

    Details of the Bill

    National Health Service (Co-Funding and Co-Payment) Bill (HC Bill 37)

    A

    BILL

    TO

    Make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes.

    Be it enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the authority of the same, as follows:—

    1.    Amendment of section 1 of the National Health Service Act 2006

      (1)      The National Health Service Act 2006 is amended as follows.

      (2)     In section 1 (Secretary of State’s duty to promote comprehensive health  service), in subsection (4)—

               (a)   the words “the making and recovery of charges is expressly provided for by or under any enactment, whenever passed” become paragraph
                      (a), and

                     (b)   after paragraph (a), insert or

                     (b)   the charges form part of an agreement in England for co-funding or co-payment.

    2.  Other amendments of the National Health Service          Act 2006

      (1)       The National Health Service Act 2006 is amended as follows.

      (2)      After section 12E (Secretary of State’s duty as respects variation in provision of  health services), insert—

                                           ““Co-Funding and Co-Payment

      12F                Co-Funding and Co-Payment: England

      (1)            For the purposes of this Act, co-funding of NHS care shall be permissible in England when NHS-commissioned care is proposed to be partly funded—

                         (a)         by a patient, or

                         (b)      on behalf of a patient

      (2)           Co-payments permitted by virtue of this Act shall, in England, include payments made through co-funding as provided for in subsection (1)

     3             Extent, commencement and short title

      (1)          This Act extends to England and Wales.

      (2)          This Act shall come into force at the end of the period of two months after the day on which it receives Royal Assent.

      (3)          This Act may be cited as the National Health Service (Co-Funding and Co-Payment) 2018.

    2 Comments

     Court of Appeal grants NHS campaign group permission to appeal against NHS England’s new Integrated Care Provider contract

    Some very good news – which also means NHS England is consulting on an ACO contract that may be unlawful.

    They knew full well that was a possibility, despite their protestations in the consultation document that both Judicial Reviews had ruled in their favour.

    (They have rebranded the ACO contract the Integrated Care Provider contract and their consultation runs until 26 Oct.)

    We shall be putting out more info shortly about this.

     

    The Court of Appeal has issued an order granting campaign group 999 Call for the NHS permission to appeal the ruling against their Judicial Review of the proposed payment mechanism in NHS England’s Accountable Care Organisation contract.

    The Accountable Care Organisation Contract (now rebranded by NHS England as the Integrated Care Provider contract) proposes that healthcare providers are not paid per treatment, but by a ‘Whole Population Annual Payment’, which is a set amount for the provision of named services during a defined period. This, 999 Call for the NHS argues, unlawfully shifts the risk of there being an underestimate of patient numbers from the commissioner to the provider, and endangers service standards.

    In April, the High Court ruled against the campaign group’s legal challenge to NHS England’s Accountable Care Organisation contract – but the group and their solicitors at Leigh Day and barristers at Landmark Chambers found the ruling so flawed that they immediately applied for permission to appeal.

    Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the Accountable Care Organisation contract – now renamed the Integrated Provider Organisation contract.

    The consultation document asserts that the payment mechanism in the ACO/ICP contract is lawful, because:

    “The High Court has now decided the two judicial reviews in NHS England’s favour.”

    Steve Carne, speaking for 999 Call for the NHS, said

    “It beggars belief that NHS England is consulting on a contract that may not even be lawful.

    And a lot of public funds is being spent on developing the ACO model – including on the public consultation.

    We are very pleased that 3 judges from the Court of Appeal will have time to consider the issues properly.

    We shall shortly issue our stage 5 Crowd Justice appeal for £18k to cover the costs of the Appeal.

    We are so grateful to all the campaigners and members of the public who have made it possible for us to challenge the lawfulness of NHS England’s attempt to shoehorn the NHS into an imitation of the USA’s Medicare/Medicaid system.

    We will not see our NHS reduced to limited state-funded health care for people who can’t afford private health insurance.”

    Jo Land, one of the original Darlo Mums when 999 Call for the NHS led the People’s March for the NHS from Jarrow to London, added,

    “All along we have been warning about the shrinkage of the NHS into a service that betrays the core principle of #NHS4All – a health service that provides the full range of appropriate health care to everyone with a clinical need for it, free at the point of use.

    Since we first started work two years ago on bringing this judicial review, there have been more and more examples of restrictions and denials of NHS care, and the consequent growth of a two tier system – private for those who can afford it, and an increasingly limited NHS for the rest of us.”

    Jenny Shepherd said

    “NHS England’s rebranded Accountable Care Organisation contract consultation is a specious attempt to meet the requirement to consult on a significant change to NHS and social care services.

    We don’t support the marketisation of the NHS that created the purchaser/provider split and requires contracts for the purchase and provision of services.

    Integration of NHS and social care services, in order to provide a more straightforward process for patients with multiple ailments, is not aided by a system that essentially continues NHS fragmentation.

    This new proposed contract is a complex lead provider contract that creates confusion over the respective roles of commissioner and provider. It requires multiple subcontracts that are likely to need constant wasteful renegotiation and change over the duration of the lead provider contract. This is just another form of fragmentation, waste and dysfunctionality.

    The way to integrate the NHS and social care is through legislation to abolish the purchaser/provider split and contracting; put social care on the same footing as the NHS as a fully publicly funded and provided service that is free at the point of use; and remove the market and non-NHS bodies from the NHS.

    Such legislation already exists in the shape of the NHS Reinstatement Bill.”

    The campaign team say they are determined in renewing the fight to stop and reverse Accountable Care. Whether rebranded as Integrated Care or not, they see evidence that it is the same attempt to shoehorn the NHS into a limited role in a two tier healthcare system that feeds the interests of profiteering private companies.

    Steven Carne emphasised,

    “It is vital that we defend the core NHS principle of providing the full range of appropriate treatments to everyone with a clinical need for them.”

    999 Call for the NHS hope the 2 day appeal in London will happen before the end of the year. The Appeal will consider all seven grounds laid out in the campaign group’s application – with capped costs.

    Details on the first instance judgment can be found here, and the judgment itself here.
    David Lock QC and Leon Glenister represent 999 Call for the NHS, instructed by Rowan Smith and Anna Dews at Leigh Day.

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    In 2009 the internal market was abolished in the Welsh NHS. Seven unified Health Boards (and three trusts – Ambulance, Public Health and Velindre cancer services) took over the responsibility of the former 22 Local Health Boards and most of functions of the seven Trusts to both plan and deliver health care for the population resident in their geographical areas.

    In the initial phase following the internal market abolition the acute hospital sector seemed to have “captured” the planning process. But as things have matured the Welsh Government has sought to re-balance matters with the introduction of Integrated Medium Term Plans (IMTP).

    All NHS organisations are now expected to operate to three yearly IMTPs as part of their planning cycle. The latest framework covers the period 2018-2021 with yearly iterations providing firm plans for the initial year, indicative plans for Year 2 and outline plans for Year 3. At the heart of the process is the creation of a collaborative approach which will be sufficiently robust not only to withstand the continuing pressures of austerity but to deliver real improvement for patients, service users, carers and wider public health.

    The planning framework ( http://gov.wales/docs/dhss/publications/171013nhswales-planning-frameworken.PDF ) and the IMTPs continue to be informed by the principles of “Prudential Healthcare” ( http://www.prudenthealthcare.org.uk/ ) and an emerging distinctive Welsh legislative backdrop including the Mental Health Measure (2010), Social Services and Well-being Act (2014), The Well-being of Future Generations Act (2015),  Nurse Staffing Levels Act (2016) and Public Health Act (2017).

    The planning and delivery process needs to achieve the “Triple Aim” of improving outcomes, improving the user experience and achieving best value to money supplemented by the Parliamentary Review’s ( http://gov.wales/docs/dhss/publications/180116reviewen.pdf ) recommendation of enriching the well-being, capability and engagement of the health and social care workforce.

    There are five priority delivery priorities outlined which represent a real effort to re-balance the Welsh NHS away from its initial over-focus on acute secondary care covering such areas as:-
    Prevention
    Tackling health inequalities
    Primary & community care
    Timely access to care
    Mental health.

    Each of these priorities are important in their own right. The prevention and tackling inequalities agendas acknowledge the social determinants of health but they also re-emphasise the importance of addressing “the inverse care law” which is about how the health service responds to the unequal health experience of people. Access to care is recognised as being both clinically important and a key quality measure of the patient’s experience. And as well as timely access to services the quality agenda requires that patients receive safe, effective, personal and efficient care in an equitable way.

    Health boards and trust IMTPs must be the product of collective working that extends from the clinical experience of patients and NHS staff to engaging with a wider range of bodies outside the NHS family. Particular attention must be paid to the plans being developed by the primary care clusters ( http://www.primarycareone.wales.nhs.uk/primary-care-clusters ) as well input from traditional sources such as Public Health Wales. In addition participation in regional and local service boards, as well as bilateral discussions, must be used to co-ordinate planning and delivery with other public bodies such as local government, social care, education and housing.

    The governance within the Health Boards and the wider NHS must improve if the planning process is to effectively identify and respond to local need. To date the record is not great. Health boards are not always adept at either identifying service failures or responding effectively to them. The Welsh Government has a clear pathway of escalating intervention when health organisations are struggling but even then improving performance has proven elusive ( http://gov.wales/topics/health/nhswales/escalation/?lang=en ).

    The final report of the Parliamentary Review recommended that the Welsh Government itself needed to more pro-active in promoting innovation, evaluation and implementation of best practice across NHS Wales. The planning framework preceded the publication of the final report and its silence on the Welsh Government’s role in being a catalyst for service transformation is therefore missing. This needs to be rectified.

    The abolition of the NHS internal market was widely welcomed in Wales. This in itself it does not provide automatic answers to all of the problems the NHS faces. But it allows for new ways of addressing them based on the principles of partnership, collaboration and public service values which are more clearly reflected in the latest planning framework guidance.

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    STPs are loose coalitions of agencies without statutory powers, so they cannot implement change, only encourage it. With little money left in the Transformation Fund, they have to “work around” their local NHS and social care organisations. At the launch of the King’s Fund report ‘Delivering sustainability and transformation plans: from ambitious proposals to credible plans’ (on 21st February) we heard that “with the right leadership” STPs could stabilise the NHS, that STPs mean that “politicians must be brave” (and not impede changes in the NHS in their constituencies), that NHSE and NHSI need to work as one (because they don’t), and that “there is no Plan B”.

    STPs

    Much of what was said at the launch was familiar. Plans to shift care into the community and integrate health and social care have surfaced several times in the last decades, leaving little trace. There is little new in the STPs, except perhaps the higher profile of local government.  The NHS is famous for its lack of memory, a point made gently by Chris Ham of the Kings Fund at the end of the launch event. The language used was standard NHS speak – “challenges”, “conversations”, “journeys”, “taking plans forward”, “meaningful engagement” – and the speaker who described how the STPs were “moving fast” surprised those who thought progress was painfully slow.

    It was not clear from the discussion that there really are many parts of the NHS or social care where practitioners are straining at the leash to change, are constrained by present structures and rules, and are ready to innovate given permission and leadership. Perhaps the Vanguard sites are such places.

    The impression I left with is that transforming social care and health services that are struggling to survive is a David versus Goliath battle, in which STP advocates are hoping for a lucky shot. The Kings Fund launch did say that in a way, suggesting that STP footprints should prioritise two or three changes, in effect abandoning transformation as an objective. The NHS Confederation has since urged ‘patience’ in developing STPs, not the current unrealistic timetable. This may be an opening for Labour to gain some traction within the NHS, and avoid being marginalised into “Slash, Trash and Privatise” rejectionism. We need to look at provision over the whole health and social care system and sort out a governance framework for a single health and social care service. STPs are an attempt to bring together relevant players at a higher organisational level than Joint Planning Boards, so could offer the overview and design the governance. If the STPs were led by local government, with a topped-up Transformation Fund and a ten year remit to bring about change, we might just make haste slowly.

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    Wales is the only part of the UK where “deemed consent” to organ donation applies. The means that any deceased who is over 18 years, is mentally competent and who had lived in Wales for  12 months is deemed to have given consent to organ donation unless they have formally registered their objection.

    About a decade ago, the UK had a low organ donation rates (13 / million population) compared to countries such countries as Spain, USA and France. As well it had a much lower rate of next of kin refusal. In Wales around three people per month died while waiting for an organ donation with about 300 people on a transplantation list.

    The issue was considered by the National Assembly for Wales Health and Well-being Committee in 2008. Though its report did not recommend  “presumed consent”, the Welsh Government felt there was sufficient public support for the proposal and indicated its intention to legislate on the matter. A commitment to do so was included in the Welsh Labour, Plaid Cymru and Liberal Democrat’s manifestos for the 2011 National Assembly election.

    The Bill was introduced into the National Assembly in December 2012. Over the next year an extensive debate and consultation took place. There was broad support for its purposes though concern was expressed, by Christian and Islamic faith groups in particular, that “deemed consent” was not real consent and that it undermined the altruistic virtue of the gift of donation.

    A key feature of the legislation was its “soft opt-out” option whereby close relatives are involved in the donation decision with particular attention being paid to any evidence that the deceased may not have wished to have their organs donated.

    In the run up to the beginning of the legislation in December 2015 there was an major campaign to both explain the new legislation and to raise awareness on the wider organ donation need in Wales. The legislation will require the Welsh Government to maintain a programme of promoting public awareness and to report on progress.

    At the end of the first year of the legislation the Welsh Government reported “… the latest figures show that 39 organs from patients whose consent was deemed have been transplanted into people who are in need of replacement organs.

    In the two years prior to the introduction of the new system of deemed consent, .. (we) made significant efforts to inform the public of the exact nature of the upcoming changes in respect of transplantation activities. During this period the number of organs transplanted increased each year, from 120 between the 1 December 2013 and 31 October 2014, to 160 between 1 December 2015 and 2016.

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    Last week the Governing Body of Bristol Clinical Commissioning Group agreed a plan to remove from its constitution the clause which prevents it from giving contracts to companies which practice tax avoidance.

    We understand that it is likely that other CCGs with similar constitutional clauses will also move to remove them.

    Bristol Protect our NHS was founded just over three years ago in response to a 38 Degrees campaign to amend the model constitutions of CCGs then in the process of being created. The inclusion of a clause preventing contracts going to tax-avoiders, and other clauses, was our first success. We know that groups in other parts of the country were also successful.

    So this looks like the start of an initiative to counter those successes and make life more comfortable for the tax-avoiders.

    This is astonishing timing given the almost daily reports about the immorality of tax-avoidance in the national media and the public distaste for it.

    The paper agreed at yesterday’s Bristol CCG Governing Body is here:
    https://www.bristolccg.nhs.uk/media/medialibrary/2016/01/govbody__26jan2016_item23.pdf

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    Speech delivered in the House of Commons – 28/01/2016

    Many Hon. Members have raised the seriousness of the financial challenge facing our health and care system. They are right to do so. Many Hon. Members have also been right to say that we need a big, honest national debate about what excellent care services look like and how we might pay for them.

    I’ve been the Shadow Secretary of State for Health now for just over 4 months. In that time, it has become blindingly obvious to me – if it wasn’t at the outset – that the NHS and care system in our country is on the verge of collapse. Huge hospital deficits, care home providers on the brink of failure, older people in hospital because they can’t get the support they need at home, more critically ill people than ever before waiting too long for ambulances and large chunks of the workforce so demoralised that they want to up sticks and head for the Southern hemisphere.

    For many people who use the NHS, this picture may sound unfamiliar. For the majority, it still provides excellent care – and it is important to recognise that and to thank the thousands of dedicated staff who ensure that happens. But for many others, the system fails them and the risk is that it starts to fail more and more people as time goes on.

    When I was asked to do this job, I knew that the NHS and care system was under pressure. I knew that demographic change and the march of technology – both in and of themselves, good things – were placing demands on a system designed for a different century. As a constituency MP, I had visited isolated older people, many feeling like prisoners in their own homes, surviving with the help of a meagre care package or the support of family and friends if they were lucky. As a councillor before that, I had seen the soaring demand for adult social care and the woefully inadequate budget to deal with it. Demand which is growing because of our ageing population – but also because of advances in medicine which enable babies who may not previously have survived at all, to not only survive into childhood but adulthood too.

    On a personal level, I knew that in my own family, my grandmother had spent the last few years of her life in and out of hospital on an almost weekly basis – driven as much by crises of loneliness as by a deterioration of her COPD.

    And I knew that my other nan was forced to sell her own home to pay for her own care when she developed vascular dementia, meaning that all but £23,000 of her £140,000 estate disappeared.

    All of these things I knew before I became the Shadow Secretary of State but it was only when I visited hospital after hospital, up and down the country, that my eyes were really opened. The image of frail, elderly people, perched alone on beds in emergency admissions units or in rehabilitation wards is THE abiding picture which stays with me following my first 4 months in this job. It made me feel uncomfortable. As a childless 40 year old woman, would that be me in 40 years’ time? Was it the best place to be? Was it the best we as a country could do? The image may have been uncomfortable, but the numbers say it all: 1 in 4 hospital beds occupied by people with dementia, half of all people admitted to hospital aged over 65, 300,000 people aged over 90 arriving at A&E by ambulance every year.

    When we get older – and it will come to all of us, hopefully – hospital will sometimes be necessary but it shouldn’t become the norm. I know that we have to address this problem. The system needs to be redesigned so it gets the right sort of support to people at the right time and in the right place to prevent problems from escalating. But we have to be honest and say that there is a price tag attached to this.

    Yes, there are still savings that can be made, ways to make the system more efficient and less wasteful but there are simple underlying pressure that can’t be wished away. Every day that goes by there are more and more, older people living with more and more complex, often multiple, conditions. Some say family members need to step up to care for elderly relatives. Others say that’s unrealistic. Every day that goes by, new drugs and treatments become available at not insignificant cost. It may be tempting to brush these uncomfortable truths under the carpet but we can’t and we would be failing generations to come were we to.

    So, that brings us to the proposal we are discussing today to establish an independent, nonpartisan commission to establish what a long term financial settlement for the NHS and social care might look like. I understand the superficial attraction of this idea. I’ve been stopped on the street and in the gym by people I’ve never met before saying “why can’t the politics be put to one side when it comes to the NHS?” I understand that sentiment. Politicians aren’t the most popular bunch of people out there and too often we are seen to be advancing our own party’s interests and not those of the public. But for me, I think the question of how we fund elderly care going forward is THE most deeply political question our country faces over the next decade.

    It’s political because it’s about who pays and who benefits.

    Whilst the NHS is a universal, taxpayer funded system, free at the point of use, social care provision is a mixed bag – those with money, pay for it themselves, those without rely upon councils to provide what support they can. It’s been a make do and mend approach to social care in recent times but our changing population means that it no longer an option.

    I spoke about my Nan earlier. A woman of limited means who experienced catastrophic care costs because she developed dementia. My family is not a rich family. We are not a poor family either. We are like many families up and down the country. When I was growing up my dad decided to take us on a two week holiday to Spain each year, instead of paying into a pension. He’s never bought a brand new car in his life but he never let his children go without either. The costs of care which fell upon my Nan and my family, fell randomly.

    Is it right that a woman of limited means who dies of dementia at 85 passes nothing meaningful onto her family when a wealthy man who dies of a heart attack at the age of 60 does? What about those who plan their financial futures having invested in expensive tax advice to avoid the costs of care? It is my view that these are deeply political questions.

    In order to adequately fund the NHS and care system in the future, the truth is that a political party needs to be elected to Government having stood on a manifesto that sets out honestly and clearly how we pay for elderly care and how we manage in a fair and transparent way the rising costs of new treatments, new drugs and new technology.

    No matter how well researched, well intentioned, well-reasoned the recommendations from an independent commission, someone at some point will have to take a tough decision.

    When I think about the cross-party work that has been done on this in the past, I think I can also be forgiven for being cautious. Take the discussions that took place between by predecessor, the Rt Hon Friend the Member for Leigh and the then Conservative and Liberal Democrat Opposition prior to the 2010 election. Just weeks out from the election, the Conservatives pulled the plug on those talks and accusations of “death taxes” were suddenly being hurled – so much for a grown up debate to answer the difficult questions. Take also the attempt at cross-party agreement in the last parliament which led to some of the Dilnot proposals on capping the costs of care. These proposals were in the Conservative Party’s manifesto, but were swiftly kicked into the long-grass just weeks after the election. I’m not sure that attempts to take the politics out of inherently political decisions have worked.

    Even if we take something which should be straightforward – a new runway for example – an independent commission hasn’t exactly led to consensus on how to proceed – just more delay. As the well-respected Nuffield Trust has said: “Experience shows that independent commissions into difficult issues can have little impact if their recommendations do not line up with political, local or financial circumstances.”

    How we pay for elderly care is one of the most difficult decisions facing our generation. The truth is it will require political leadership. A political party needs to own the solutions and be determined to make the case for them. I am not ashamed to say that I want the Labour Party to lead this debate. I want us to build on some of the excellent work that has already been done in this area, in particular that of Kate Barker and The King’s Fund. And I want us to spend time talking to people up and down the country about the kind of health and care service they want to see and to have a frank and honest discussion about what some of the different options to pay for that service might be.

    I must also be honest though and say that I think it was a profoundly political decision in the last parliament to cut the amount of money available to councils to pay for adult social care. I say gently to the Hon Member for North Norfolk that he stood at that dispatch box opposite and defended the cuts that his Government were making to social care – he dismissed many of warnings that my hon friend the Member for Leicester West was making when she was the Shadow Care Minister about delayed discharges, about cuts to home care, and reductions in other vital services like meals on wheels and home adaptations. So I don’t think it is either realistic or right to pretend we don’t have fundamental differences on this issue.

    Any attempt at finding consensus must begin with an acknowledgement of the damage done to social care over the last five years.

    The public are crying out for some honesty in this debate. They understand the pressures created by rising demand and new technologies and they want to be treated like adults. To suggest that this can be all neatly sewn up by an independent commission with the politics taken out of it sounds attractive but I worry it just won’t deliver. For the millions of people who depend on our NHS and social care system, we can’t afford to have yet another Parliament where we fail to grasp the nettle. I know this proposal is well intentioned but I fear it is not the answer.

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