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    Involving people in the decision making of the NHS

    Simon Collins at HIV i-Base reports today that the Conference on Retroviruses and Opportunistic Infections (CROI) has decided to limit access to all conference materials – behind a pay wall –  for up to six months after the conference. As before, copying and distribution of i-Base reports is encouraged and free. But please credit HIV i-Base as source. Here is today’s post about CROI:

    This year, CROI has decided to limit access to all conference materials to delegates or new subscribers for up to six month after the conference. These include abstracts, posters and webcasts.

    Usually, CROI has made all conference material available as an open access resource as soon as the meeting finishes.

    Many people who registered for the virtual conference – and certainly most community delegates – were shocked to learn of this change. A community sign-on letter quickly included more than 200 organisations and individuals calling for the CROI Foundation and the International Antiviral Society–USA (IAS–USA) to reconsider these plans. [1]

    Until 2021, CROI had developed an exemplary model for democratising science and medicine – especially as CROI is the most important of the international conferences.

    Although this might have been suggested as a cautious approach when planning the virtual conference – when there might have been a worry that delegates might not register if the content was available free within a few days?

    Actually, more than 3500 delegates registered for the virtual 2021 conference, only slightly down from last year.

    Also, researchers who present their work at the conference might also want this wider access.

    COMMENT

    Hopefully this retrograde decision to restrict access might be reconsidered by the meeting organisers.

    CROI this year had an extremely dynamic and important programme, also covering COVID-19.

    The quality of the scientific and medical research presented at CROI is actually the reason why broader access is essential. Perhaps sending your own feedback to the organisers could help too.
    https://www.croiconference.org/contact-us

    Reference

    1. Community letter to the Conference on Retroviruses and Opportunistic Infections (CROI) regarding access to presentations and abstracts. (10 March 2021).

    Links to other websites are current at date of posting but not maintained.

    Comments Off on CROI 2021: Community call highlights CROI 6-month pay wall rather than usual open access
    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

    HIV i-Base continue to report on COVID-19 research and treatment as a supplement to HIV treatment research and information.

    Copying and distribution of i-Base infomation is encouraged – and free – but please credit HIV i-Base as source. You can see this Q&A here or read it below:

    Q&A on COVID vaccines: are they safe and effective?

    The following questions were for a community UK-CAB workshop on COVID vaccines. Answers by Angelina Namiba and Simon Collins.

    Are vaccines against COVID-19 effective?

    Yes, any approved vaccine has been very carefully studied in  a wide range of people.

    These first vaccines are highly effective. Both the Pfizer and Moderna vaccines prevent COVID symptoms in 95% of people. They also prevent severe COVID-19.

    These vaccines are much better than first thought possible. Early in 2020, a vaccine would have been approved if it was only 50% effective.

    Which vaccines are being used in the UK?

    The only vaccine that is currently approved in the UK is called BNT162b2.

    It is made by Pfizer/BioNTech. It was approved in the UK on 2 December and in the US on 12 December 2020. A second similar vaccine, developed by Moderna/NIH has just been approved in the US. It will also be approved in other countries too. The EU plans to approve these two vaccines within the next few weeks.

    However, other vaccines are being used in UK studies (see below). These include a vaccine from Oxford University and Astra-Zeneca called ChAdOx1. Another study using a Janssen vaccine is just starting. As new vaccines are approved we will add them to this page.

    Why should I get a vaccine?

    The main reason to get the vaccine is to protect yourself against COVID-19.

    COVID-19 can be deadly – it is much better to be protected. Even people who recover from COVID-19 often have symptoms that last for many months. This is called long COVID and is still being studied.

    If you have been offered the vaccine it is because of your personal level of risk. The vaccine may also protect your friends, family and contacts at work.

    Is my risk high enough to need the vaccine?

    Yes, there is only a limited supply of these vaccines. In the UK, for at least the next few months, you will only be offered the vaccine if your personal risk is high.

    This will be because of your age and your health or because you work in a high risk job.

    Do I have to get the vaccine?

    If the vaccine is for your own health, then this is always still your choice. You do not have to have the vaccine.

    Please talk to your doctor if you have any worries or concerns. Or if you’re unsure about having the vaccine.

    If you are offered the vaccine because of your job, not having the vaccine might affect the work you can do.

    Are vaccines against COVID-19 safe?

    Yes, based on the results from large studies, any approved vaccine will also be very safe.

    For example. the Pfizer vaccine was studied in more than 44,000 people without any serious side effects.

    There are only a few situations when this vaccine needs to been given more carefully. This includes people who have a history of serious allergy reactions to different foods or medicines – as with other vaccines. In this case the vaccine should only be given where there is medical support in case this reaction occurs.

    How do we know the vaccine is safe?

    Technically, no medicine or vaccine can be proved to be safe! This is because we can’t measure safety, we can only measure risk.

    So instead of saying something is safe, it is more accurate to describe the risk. With COVID vaccines we can say there is a very low risk of side effects.

    Compared to the very real risks from COVID-19, using the vaccine is much safer than not using it. This is known from research studies in tens of thousands of people. The studies recorded every side effect or any potential side effect.

    Additional safety data comes after the vaccines are used outside of studies. This will include from people who were not included in the main studies. This led to a caution in people with history of serious allergic reactions (see next Q).

    What if I have a history of allergy reactions?

    As in the question above, even people with a history of serious reactions can still use the vaccine. This includes people who have reactions to vaccines, medicines or foods.

    However, if you currently need to carry an anti-allergy syringe, you need to be vaccinated in a clinic in case a reaction occurs.

    Two health workers in the UK with a history of severe reactions did react to the vaccine. Both people have now recovered. More information will be collected on cases like this.

    Can I develop an allergic reaction to the vaccine?

    Yes, although the risk is small and relates to your history of allergies.

    For the Pfizer vaccine, anyone with a history of severe allergy reactions should have the vaccines in a setting that can safely manage reactions.

    What about if I have immune suppression from HIV or cancer treatment?

    Yes, the vaccine is still recommended if you are HIV positive or if you have cancer. This is because of the high risk from COVID-19.

    Although the leaflet that comes with the vaccine includes talking to your doctor first if you have a reduced immune system, this is not related to a safety of the vaccine. It is because the protection from the vaccine might not be as strong.

    This means that even after both doses of the vaccine, it will still be important to be careful, for example by wearing a mask and social distancing.

    As more people are vaccinated, researchers will look at responses in people who were not widely included in studies.

    What if I have other inflammatory or autoimmune conditions?

    As above, the vaccine is still recommended for people living with inflammatory or autoimmune conditions.

    In this, it is very similar to getting a flu vaccine. Anyone who can use the flu vaccine can use a vaccine against COVID-19.

    These include:

    • Inflammatory rheumatic diseases (rheumatoid arthritis, axial spondyloarthritis, lupus).
    • Inflammatory bowel disease (Crohn’s disease and ulcerative colitis).
    • Psoriasis.
    • Multiple sclerosis.
    • Organ transplant recipients.
    • People on chemotherapy.

    This is because of the high risks from COVID-19.

    Although many people with these and other complications were not directly studied in vaccine studies, there is no safety concern. As above, the caution is that the vaccine might not be quite as effective.

    Ongoing research though will be looking at this.

    Does the vaccine interact with other medicines?

    No. There are no medicines that can not be used with these vaccines. If you are taking other treatment, there is no need to stop this to have a vaccine.

    Although it is good to ask about interactions with current medicines, there are no interactions with the vaccines. If you are worried, it is easy to double-check this with your doctor.

    Your doctor will also know your medical history and whether one type of vaccine might be better for you than another.

    Could the vaccine interact with my HIV meds?

    There are no interactions between the COVID-19 vaccines and HIV meds.

    Will my HIV viral load blip when I have the vaccine?

    Technically though, there is not enough results from HIV positive people in the first vaccine studies to report this yet, though this will be reported later.

    However, based on other vaccines this is unlikely to happen.

    Any vaccine has the potential to increase viral load for a short time. This is the same as to any active infection (including flu and colds).  As with the answer to other questions here, it is okay to approach the COVID vaccination as if it was the annual flu vaccine – which is widely recommended for people living with HIV.

    If your viral load is generally undetectable any increase is likely to be very small. For example, with the flu vaccine, it might increase from less than 50 to maybe 80 or 100 copies/mL – and only for a few days or a week. This is too low to affect the risk of transmission.

    Other vaccines, for example for hepatitis B, don’t cause HIV viral load to blip.

    As a guide, unless you get symptoms from the vaccine, your HIV viral load is likely to stay undetectable. If you get symptoms, any small blip is likely to be undetectable again within a week.

    Can the vaccine interact with estrogen and/or testosterone treatment?

    There are no interactions between the COVID-19 vaccines and estrogen and testosterone.

    Are the vaccines safe in pregnancy?

    Great question. So far there is little data because pregnancy was an exclusion for the main studies. But if you are pregnant, the vaccine is still recommended.

    Also, women will still have become pregnant during these studies – and certainly afterwards. These data will all be collected during the study.

    When these data are available they will be widely publicised.

    Other studies are looking at vaccine responses during pregnancy.

    Are the vaccines safe in children?

    So far vaccines have only been studied in people who are aged 16 and over.

    Further research is planned to look at younger people.

    What is in the vaccine that they are going to offer me?

    None of the COVID vaccines in the UK contain any live viruses. There is no risk of catching coronavirus from the vaccine.

    The active parts of a vaccine though only use a protein from the outside of the coronavirus. Or they tell your boby how to make these proteins.

    This will not cause an infection though.

    Vaccines also include other ingredients that help the vaccine work. For example the Pfizer vaccine contains traces of sodium and potassium. This is sufficiently low to still be called sodium-free and potassium-free.

    It also contains sucrose and this, together with all other ingredients, is listed on the patient leaflet that you get before the injection. This is also online now if you want to check first (see fruther information in the final question).

    How is the vaccine given?

    The Pfizer vaccine is given as an injection into your upper arm. A second booster dose is given again, three weeks later. You reach the best protection seven days after the second dose.

    Do I still need to social distance after the vaccine?

    Yes, so far, it is still better to reduce the risk of catching coronavirus.

    A few people might not be protected by the vaccine. We also don’t know how long protection will last. You might also still become infected without symptoms. You could then pass this to other people.

    Even after the vaccine, please continue wearing a mask. Please continue recommendations for social distancing.

    Can I get COVID-19 from the vaccine?

    No. This is easy to answer.

    There is zero risk of getting COVID-19 from the vaccine.

    The vaccines do not contain coronavirus itself.

    What are the symptoms/side effects from the vaccine?

    Most side effects to the Pfizer vaccine were mild or moderate.

    Very common side effects were similar to getting the flu vaccine. They generally got better within a few days. These were reported by more than 1 in 10 people.

    • Pain at injection site.
    • Tiredness.
    • Headache.
    • Muscle pain.
    • Chills.
    • Joint pain.
    • Fever.

    Common side effects included injection site swelling, redness at injection site, and nausea. These were reported in less than 1 in 10 people.

    Uncommon side effects, in less than 1 in 100 people included enlarged lymph glands or just generally feeling unwell.

    Am I going to get sick with the COVID-19 vaccine like the flu jab?

    No necessarily, but maybe. So far the COVID vaccine is similar to getting a flu vaccine. And just like the flu vaccine, the response will vary for different people.

    The question above shows that symptoms are similar to the flu vaccine and are nearly always mild.

    Should I wait to see how people similar to me react first?

    This is a good question – and sounds very reasonable. But within a week or two another 500,000 people will have used the vaccine in the UK.

    Any serious concerns will be reported long before you are likely to be offered the vaccine.

    However, if you are okay leading a very isolated life, then waiting is a choice. But if you still want to interact with people, then waiting will be more risky than having the vaccine now.

    How long will protection last?

    This will only be known with more time. Protection should last for at least a year and hopefully a lot longer. Some vaccines, for example hepatitis B and tetanus only need a boost every ten years.

    Which vaccine is best?

    So far, all the leading vaccines look very good. Getting access to any vaccine now is more important than which vaccine you use.

    What if I already had COVID-19? Does it matter where this was severe or mild?

    People who already had COVID-19 are still recommended to use the vaccine. It doesn’t matter how severe or mild this was.

    Will my GP or HIV doctor give me the vaccine? Can I choose?

    Who gives you the vaccine will depend on which vaccine is being used.

    The Pfizer vaccine will generally be given at health centres or hospitals. This is because of limits in how it can be stored.

    If you are offered a different vaccine in the next month or two, this might be given by your GP. This is early stage for the vaccines but it is unlikely to be your HIV doctor. You are not likely to be able to choose.

    Why should I get the vaccine if the person giving me the vaccines hasn’t had it yet?

    The decision on who gets the vaccine first are decided by an expert advisory group.

    If this group recommends you get the vaccine, then this is because your individual risk makes this important.

    Will the vaccine stop me catching COVID-19? Or just from getting ill? Or maybe both?

    The vaccine will definitely reduce risk of getting ill, but the answer is “probably both”.

    The vaccines are approved because they reduce symptoms of COVID-19.

    The first studies didn’t measure whether people caught coronavirus, just whether they had symptoms of COVID-19.

    Most mild symptoms later confirmed as COVID-19 were in people who didn’t get the vaccine. Importantly, nearly all the most serious cases of COVID-19 were also in people who got the placebo (inactive) injections.

    Technically, some people might still catch coronavirus and be infectious but without symptoms. This is still an ongoing research question.

    Studies with the Moderna and Oxford vaccines include some results showing that the risk of catching coronavirus is also reduced.

    Is the vaccine safe if I have other health problems as well as HIV?

    Yes, vaccines are recommended in people living with HIV and other health problems.

    The more serious your other health problems, the more important it will be to be protected from COVID-19.

    Can I get the vaccine if I have or have had hepatitis C?

    Yes, vaccines are recommended in people living with hepatitis C or who previously had hepC.

    Is the vaccine safe if I use chems like crystal meth, GHB or mephedrone?

    Yes, the vaccines do not interact with drugs used for chemsex.

    However, taking a break from the chems for the week of the vaccine will make it easier to know whether you get any side effects.

    If the social context for using chems means you are having more partners, the protection from the vaccine will be especially important.

    Is the vaccine affected by ethnicity? Will it affect me differently because I’m black/brown?

    No, vaccines studies include people of different ethnicities. They are created for everyone.

    Ethnicity does not affect immune responses or risk of side effects.

    Are black and brown people more at risk of getting side effects?

    No, as with the question above, ethnicity has not been linked to any better or worse outcomes.

    Have vaccine trials included black and brown men and women living with HIV? Or do the findings just relate to the experiences of HIV positive white gay men?

    Unfortunately, most vaccine studies only included very small numbers of people living with HIV. So far, the ethnicity breakdown of the HIV positive group has not been presented. All the HIV positive participants might be black and brown women.

    For example, the Pfizer study with more than 44,000 people only included about 120 people living with HIV. The results did not show that HIV as any impact on how the vaccines work.

    However, there is a lot more data about ethnicity.

    About 10% of the people in the US sites were black or African American. There were no differences in how well the vaccine worked or in side effects compared to the rest of the study population.

    Who approved these vaccines? Were the interests of my community represented?

    Vaccine are approved by the same organisations that approve medicines. They were approved for all people.

    • This is the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK.
    • In Europe it is  the European Medicine Agency (EMA)
    • In the US it is the Food and Drug Administration (FDA).
    • Other countries and regions have similar organisations.

    Each of these groups is made up of expert advisors who are mainly scientists and doctors but that sometime include community voices.

    The panels are responsible for representing interests of all people who are going to be using these products.

    The FDA is especially open as it publishes the detailed study results online for everyone to read. It also webcasts the meeting that decide on where a vaccine or medicine is approved.

    How do I know I’m being treated equally? How do I know this isn’t experimentation in black people?

    These concerns are very real. Nearly all countries still have structures that are not equal. Many have a history where people were treated differently.

    In the UK, this still affects access to important services that include education and medical care. This is even when there are policies to make access fair.

    However, ethnicity has been linked to higher risk of COVID-19 in black, Asian and minority ethnic (BAME) communities. This actually makes access to the vaccines even more important.

    As all the studies included people from all ethnicities. There is good data to show they are at least as safe and effective.

    COVID vaccines will be offered to people of all ethnicities. As has been seen in the news all ethnicities have the choice to use the vaccine.

    If the government didn’t protect me from coronavirus, why should I trust them with the vaccine?

    Perhaps luckily, the government are not directly involved in either producing the vaccines or in running the studies that look at how well they work.

    The government is also not directly involved in deciding which vaccines are approved.

    Whether or not you use any medicine or vaccine is a decision that you make with your doctor as an individual.

    I’ve experienced racism in the health system and receiving HIV care. How can you tell me this won’t be the same?

    I am sorry for any previous experiences within the NHS. I am also sorry if you have not been treated fairly in the past.

    Although I can not guarantee this will not happen again, there is a lot of information about how to deal with this.

    I can however provide information on COVID-19 and the vaccines. This shows that the benefits of the vaccine so far are much greater than the risks from not getting the vaccine.

    Why did we get a COVID-19 vaccine so quickly, but there is still no vaccine for HIV?

    There are two answers here.

    The practical answer is that the threat from COVID-19 were so serious that many more resources became available. The urgency of COVID-19 led to a larger budget – and luckily, this has been more effective than anyone first hoped.

    A more technical scientific answer is coronavirus is relatively stable. Unlike HIV the structure of the proteins doesn’t change and so a vaccine based on these proteins with continue to work.

    HIV is still a more difficult virus to overcome because it makes small changes every day. So HIV vaccines that might work very well on Monday will be out-of-date on Friday because of these small changes.

    HIV does have at least 30 approved treatments. These enable to lead long and health lives.

    There are many other infections where we also need new vaccines. Hopefully the advances for COVID-19 will help for other vaccines.

    If vaccines are now available, should I still join a study?

    This is an important question because other vaccines are still being studied.

    In the UK this includes a vaccine from Oxford University and Astra-Zeneca called ChAdOx1.

    Another study is due to start using a vaccine from Janssen.

    Joining one of these studies might let you get a vaccine before you are offered on from the NHS.

    If you do get offered an NHS vaccine after joining a study, you can still use the approved one. The study will tell you whether or not you got the active vaccine. The researchers can also study your response to the second vaccine.

    In practice, new studies will hopefully look at switching between different vaccines.

    If the vaccine is lifesaving, why is not available to everyone in the world?

    You are right, for a vaccine to be really effective, everyone will need to use it. This includes in all countries.

    Many organisations, including the World Health Organization (WHO), have been working all year to also make access fair.

    For example, the international COVAX programme is aiming to vaccinate two billion people during 2021. This includes more than 100 low and middle income countries including across Africa, Asia and South America.

    So optimistically, at some point, everyone will have access.

    In practice, high income countries that could afford the first commercial vaccines have bought most of the first stock.

    But some of the next stock during 2021 – and more importantly newer vaccines – will be available for the COVAX programme. This might not be until later in 2021 and 2022 though.

    Where can I get more information?

    The following links are to different sources for more information.

    i-Base run an information service if you have individual questions that you would like answered.
    https://i-base.info/qa

    i-Base report news about COVID-19 treatment and vaccines in a monthly bulletin.
    https://i-base.info/htb

    British HIV Association (for information about HIV and COVID-19).
    https://www.bhiva.org/Coronavirus-COVID-19

    UK patient information leaflet for the Pfizer/BioNTech vaccine
    (PDF)

    FDA 50-page document with detailed results on Pfizer vaccine.
    https://www.fda.gov/media/144245/download

    YouTube website to watch the US CDC hearings for COVID vaccines
    https://www.youtube.com/playlist?list=PLvrp9iOILTQYiZunwmtiIRt52poVP8D02

    Article on why vaccine is recommended for people with immune suppression and autoimmune conditions.
    https://www.medscape.com/viewarticle/942853

    Website for WHO COVAX programme for global access.
    https://www.who.int/initiatives/act-accelerator/covax

    The People’s Vaccine – a collaboration of large charities including Oxfam.
    https://www.oxfam.org/en/tags/peoples-vaccine

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    The NHS are running a survey on Integrated Care – your views.

    The link to the NHS  Consulation Hub is below.

    https://www.engage.england.nhs.uk/survey/building-a-strong-integrated-care-system/

    Many thanks to David Taylor-Gooby of the North East branch for bringing this to our attention.

    5 Comments

    HIV charities, community groups, health professionals and activists have today written to Matt Hancock, Secretary of State for Health and Social Care.

    They write to express their profound concern at the decision to roll back the Secretary of State’s commitment on PrEP (Pre-Exposure Prophylaxis for HIV) in England.

    Last week it was announced that the budget provided to local authorities for the implementation of PrEP would be reduced from £16 million to £11 million.

    The letter says this budget cut for PrEP jeopardises the ability to fully roll-out the most powerful prevention tool to help fulfil Mr Hancock’s commitment to end HIV by 2030.

    The HIV sector has requested an urgent meeting with Mr Hancock to discuss his decision to cut funding for this important HIV prevention intervention.

    Please read the letter here:

    Letter to Matt Hancock from HIV sector – PrEP funding July 2020

     

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    Today the Mail on Sunday published an article headlined ‘HIV treatment now costs NHS as much as breast cancer – Fears £606m annual bill for sexually transmitted disease is fuelled by flood of foreign health tourists‘.

    The only views to ‘balance’ the diatribe published in the paper and online was a short rebuttal from BHIVA  (British HIV Association) and NAT (National AIDS Trust) as well as a short statement from NHS England on how costs for HIV treatment are actually reducing:

    A spokesman for the BHIVA said: ‘In the UK, new diagnoses of HIV are now falling because of the success of testing and treatment.’

    An NHS England spokesman said the cost of HIV treatment had fallen £28 million from £634 million in 2017/18 to £606 million in 2018/19.

    A Department of Health spokesman said: ‘We’ve seen a decline of almost a third in new HIV diagnoses in the UK in recent years.

    ‘As with all other serious infectious diseases, we do not charge overseas visitors for treatment for HIV as, if left untreated, there is a significant risk to others in this country.’

    Deborah Gold, chief executive of the NAT, said: ‘The concept of health tourism for HIV treatment is an outdated myth.

    ‘It is actually a problem that we have such long average delays, usually years, between migrants’ arrival in the UK and them accessing HIV testing and care.

    ‘Universal availability of HIV treatment is a cornerstone of the response in the UK. Any suggestion this is a poor use of NHS money, or that access to treatment should be limited for anyone, is outrageous. In fact, it is evidence of the NHS at its best: saving lives and preventing ill-health.’

    UK-CAB (the UK Community Advisory Board) responded to the article via this tweet with the following statement:

    “The UK is a world leader in reducing the numbers of new HIV diagnoses and one of only six countries to have already met the UNAIDS 90-90-90 targets. This achievement would not have been possible without upscaling HIV testing and providing immediate antiretroviral treatment to all people living with HIV in the UK.

    People with HIV on effective antiretroviral treatment cannot pass the virus on to their sexual partners or to their unborn child during birth and pregnancy. The investment in free HIV treatment for everyone with HIV is fundamental to meeting the Government’s commitment to end new transmissions by 2030.

    Stigmatising information like that reported in today’s Mail on Sunday only serves to hinder the UK’s response to the HIV epidemic. Whilst we have made huge strides in reducing new diagnoses by an incredible 28% between 2015 and 2017, the numbers of people diagnosed late is still too high.

    Late diagnosis not only increases the chances of premature death but also heightens the risk of HIV being unknowingly transmitted to sexual partners. We cannot tolerate attitudes which put people off testing and finding out their HIV status.

    People living with HIV should not be pitted against other patient groups or conditions.

    Access to treatment and care for all people living with HIV ensures that individuals can live well and in good health and also stops transmission of the virus to others. Any insinuation that denying HIV treatment to those without ‘settled’ status would be a benefit to the nation’s public health or NHS budgets is nonsense.”

    Please circulate this as widely as possible.

    1 Comment

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

    From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

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

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

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

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

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

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

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

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

    Ekklesia reports:

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

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

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

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

    • The Pre Action Protocol Letter can be seen here

     

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    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.

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

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

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

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

    The main changes to this edition include:

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

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

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

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

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

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

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

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

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

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

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

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

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

    COMMENT

    These comprehensive Standards are very welcome.

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

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

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

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

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

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

    Reference

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

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    QMC

    Nottingham University Hospitals NHS Trust (NUH) is the first NHS trust to achieve the Soil Association’s Gold Food for Life Catering Mark for serving fresh, healthy meals – made with local, seasonal and organic ingredients. The Food for Life Catering Mark recognises food providers who prepare meals which meet high standards of traceability, freshness and provenance. The Gold Catering Mark means that at least 15% of total ingredient spend is on organic ingredients, and that menus make use of ingredients produced locally and in the UK.  77% of NUH’s raw ingredient spend is now on local ingredients. Meat, fresh produce, bakery products and milk are all sourced locally, ensuring security for local suppliers and helping the local economy. Switching to local suppliers has been cost neutral and allowed the Trust to invest £2m per year in local sustainable businesses.

    This means that NUH is able to supply patients, staff and visitors with high quality meals at an ingredient cost price of £4.53 per patient per day – this includes breakfast, lunch, supper snacks and seven beverages each day. NUH operates below the national average for patient day costs.

     

    Sustainable future?

    Means

    “…meeting our needs now…

    …without compromising the ability of others to meet their needs, now or in the future.

    Slow motion emergencies are usually hidden by noise, and our short term political / economic incentives –

    A slowly increasing baseline can suddenly increase the likelihood of extreme events – (those that exceed the red line)

    1.Experience is an important cause of ignorance.

    2.As much of the world becomes “wealthier”, it is often at the expense of others, both now and in the future. “Ecological paradox”

    3.There are very powerful anti-health and anti-fairness forces at work.

    Development as freedom

    To be healthy? means 

    …to have access to, and control over, those things that enable us to live lives that have value, purpose, and meaning…

    Environment

    Creating the right environments for fair health:

    Human environment

    Who produces the greenhouse gases?

    Who bears the burden?

    40,000 early deaths across the UK per annum are attributable to air pollution. (60,000 if NOx from e.g. diesel engines included).  An average 8 month loss of life for every person, especially lung disease and stroke.

    “The opposite of poverty… isn’t wealth…

    Bryan Stevenson

    Bryan Stevenson

    … the opposite of poverty is justice.”

    Growth at all cost increases mental health problems1 and undermines equitable prosperity. The  Nuffield Foundation concluded: “What is striking is that, in a counter-intuitive way, rises in mental health problems seem to be associated with improvements in economic conditions and physical health.”

    Bike

    StepO Meter

    It’s the law

    Climate Summit

    Climate Change Act 2008 and COP21, Paris 2015

    • Implementing the CCA08 is a legally binding agreement
    • An economy that is sustainable, fair and prosperous is not only possible, it’s happening:

    –one third of growth since recession is in the green economy

    –8% of the total economy

    • Off shore wind has halved in price in last 2 years (now cheaper than new gas)

    Public Services (Social Value) Act 2012:

    “…all public bodies in England and Wales are required to consider how the services they commission and procure might improve the economic, social and environmental well-being of the area.”

    Wellbeing of Future Generations Act

    The Global Goals

    Global Goals

    Merchants of Doubt

    More doctors smoke Camels

    Would you generally trust these people to tell the truth? (The Ipsos Mori Veracity Index 2016)

    Who do you trust?

    200 years of public health action

    200 years of public health action

    Priorities for government:

    1.Implement the existing laws that protect conditions that create and protect health and fairness.

    a)Polluter pays, zero carbon incentives, meeting climate change targets by rapid move to 100% renewables and a zero-carbon energy system.

    b)Social value through employment, procurement, investment, partnerships.

    2.Measure value and benefit, not just cost of sustainable interventions that deliver immediate AND long term health benefits (food, energy, travel)

    a)Infrastructure investments  (especially housing, food, and transport)

    b)Supply chains – legally mandated whole supply chain ethical auditing

    c)Alternative to traditional discounting rates of 3%, and 3 year ROI

    3.Redefine community health and prosperity beyond materialism

    4.Report by moving from Financial Reporting to Financial, social and environmental reporting (“Triple bottom line reporting”, “Integrated reporting”)

    This was presented at our conference Public Health Priorities for Labour

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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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    David Cameron notoriously claimed at the April 2014  Welsh Tory Spring Conference that Offa’s Dyke had become “the line between life and death” due to the performance of the Welsh NHS. However fortunately for the truth and honest debate, almost to the day the Nuffield Trust published its comparative study “The four health systems of the United Kingdom; how do they compare?”. It reported :- However, this latest study ….. reveals that while there are few indicators on which a devolved country does better than England or its North East region, the performance gap between England and the rest of the UK has narrowed in recent years. There is little sign that one country is moving ahead of the others consistently across the available indicators of performance.

    Despite being  being caught out, the Prime Minister continued to misrepresent the state of the NHS in Wales. By October 2014, when challenged about the state of the English NHS, he demanded that “ …Let’s have an OECD inquiry … I want a comparison between the Labour NHS in Wales (and England)..” He went on to say that Labour was “ ..totally terrified of (its) .. failures in Wales on the NHS.” Indeed Monmouth Tory MP, David Davies, went so far as to suggest that the Welsh Government was doing everything it could to delay the production of such a report.

    However despite all this rhetoric the report, “OECD Reviews of Health Care Quality: United Kingdom 2016”, was published in February 2016. And it concluded that from the limited country specific data available “… no consistent picture emerges of one of the United Kingdom’s four health systems performing better than the other.” In short, again, there was no evidence to support Cameron’s claims about the relative performance of the Welsh NHS.

    The line between fact and fiction.
    In his response to the publication of the review the Welsh Health Minister, Prof Mark Drakeford said “This report is the line between fact and fiction. Any claims of one nation having a second-rate NHS compared to others simply do not reflect the facts. The time has come for a real, mature debate about the future of our health services.” Can we expect Mr Cameron please take note?

    While the OECD showed that each administration needs to improve its performance, in relation to Wales it concludes that continuously improving quality of care is deeply established and widely shared across the Welsh health system. And where things are not going well, the Review felt that the Welsh Government’s “Escalation and Integration Framework” was a robust tool for quality assurance and intervention.

    These are important messages as for most of the last half decade Welsh Tories have been arguing for a total “Keogh style” review of the NHS in Wales with the implication that the NHS in Wales is in some sort of systemic melt-down similar to the situation in Mid Staffordshire NHS Foundation Trust. The OECD review shows no evidence to support this denigration of the Welsh health service.

    How the planning system is working.
    In stating that all of the UK shows an improving picture, there are still a number of areas where the NHS does need to do better. This applies in different measure across all of the four administrations not least in Wales.

    The OECD Review reports that Wales no longer operates an internal market but uses a “planned” system underpinned by the principles of “prudent health care”. While the prudent health care principles give an important sense of direction to the Welsh NHS, the under-performance of health boards linked to an imbalance in favour of local autonomy means that there is room for improvement in planning health care delivery.

    A greater sense of national purpose is needed which could be achieved by butressing the prudent health care approach with a clear action plan and by strengthening the use of the three year Integrated Medium Term Plans (IMPT).

    Inequalities and primary care.
    Welsh Health Boards are still adjusting and learning about their new planning role. The Review believes there is a need to give an increased emphasis to primary care as part of a wider agenda of tacking health inequalities. Both these areas have been judged to suffer from relative neglect under the new “planing” regime. This could be a consequence of the relatively weak role that the primary care sector and patients have in the planning system e.g. there are no GPs on the Health Boards by right.

    Developing the role of primary care clusters (PCCs), covering populations of 50-250,000, could have a significant potential in this regard. And the latest investment by the Welsh Government in PCCs is an important step forward. The clusters will provide opportunities to broaden the range of services and expertise that patients may access in a primary care setting. In addition the clusters provide a workable population base for more sensitive health care planning where the local expertise of front-line clinicians can be usefully captured by the planning system.

    Patient power.
    The OECD seems to take the somewhat ideological view that the lack of a market in health care in Wales  diminishes patient choice and influence compared to English. However, in making this point, it is acceptes that the geography and demography of Wales does not allow for a ready translation of the English experience.

    Faced with this lack of “patient power” it recommends a strengthening of patients’ voices. More effort should be spent on capturing the patient experience. While coming at it from a different perspective, this is in line with the SHA Cymru view that we should “ use the visible hand of public accountability to improve standards rather than rely on the invisible hand of the market”.

    Wales has retained its Community Health Councils as the patients’ voice within the NHS. It has been through a number of changes to improve its effectiveness down the years thought it is still debatable that they are fully fit for purpose. The Review recognises the need for CHCs to be more effective in the way they hold the service to account and articulate the views of patients. In improving its focus on these tasks there is a question as to whether CHCs add any value to NHS quality by continuing with their on-site inspection activities.

    Collaboration rather than abusive rhetoric.
    The four health administrations are doing things differently across the UK. New and innovative ways of doing things are being developed. The OECD acknowledges that this diversity provides an important learning opportunity that is being neglected by all four administrations. In part the lack of an agreed set of performance parameters and a lack of professional and political will is preventing this from happening.

    Rather than using these differences as a cynical party political ploy, as the Tories have been doing, this form of engagement and collaboration seems a better way for the the National Health Service across the UK.

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