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    Following the Lost Decade of Austerity the NHS is undertaking a process of readjustment and reconfiguration to prevent the service falling over. In primary care the most prominent outward signs are “new models of care” and “Digital First”.

    The new models of care vary depending on locations but at their core is an attempt to divert what might be classed as routine and less serious illnesses from general practitioners so that they can concentrate on more serious specialist work. The focus shifts from the individual GP to a multi-disciplinary teams in its broadest, an often disconnected, sense. The GP is not longer the obvious and uncontested access point to the NHS.

    In the first instance patients are encouraged to take greater responsibility for their own health and its management rather than “bothering” the NHS. This has always gone on but now there are the additional opportunities and pathways for on-line advice and guidance.

    If that fails then consideration should be give to using alternative non-medical practitioners such as “blue light services if deemed an emergency, specialist nurses, physician’s assistants, pharmacists, self-referral physiotherapy, opticians, health visitors etc. And while use is made of these alternative practitioners by very many, a substantial number of patients who feel unwell vote with their feet and take themselves to an already over-pressed Accident & Emergency service.

    For those who cross this initial threshold, access to general practice is increasingly via a triage / “Digital First” portal. From here, it is claimed, patients access the advice, support and treatment they need using telephone, digital and online tools. In practical terms, this means patients should use these tools to access all primary care services, such as receiving advice, getting repeat prescriptions, booking and cancelling appointments, having a consultation with a healthcare professional, receiving a referral and obtaining a prescription. And any patient who wishes to consult their GP must digitally provide an initial description of their problem to a third party and will then wait for electronic triage via a phone or video call. It is only at this stage a face to face consultation may be offered if felt appropriate.

    Much of this has commendable elements if it was part of a strategy where primary care was evolving to meet to meet ever growing and complex needs. Many patients will find the use of “digital consultations” both convenient, time saving and satisfactory. Indeed there is some evidence to suggest that patients may be more satisfied with a digital consultation than the clinician.

    However overwhelmingly that transition to “digital first” is being hastily introduced as a dominant new paradigm of care and as a pressure valve for a service that is already in serious danger of imploding. Most of these changes have been introduced with bullish optimism and little consultation or debate with either patients or the professions involved. The speed of this uncritical implementation has been greatly accelerated by the Covid pandemic – for understandable reasons.

    An increasingly obvious outcome of these changes is a public perception that general practice is no longer a accessible first port of call for either new problems or the management of chronic long-term conditions. And fanned by some Tory politicians and elements in the right-wing press, general practitioners are having to shoulder the blame for this state of affairs in an increasingly hostile atmosphere.

    Some GPs have been dragged into a confrontation with patients on these issues in a way that seeks to minimise legitimate public concern. Such a response may be understandable but it is ill conceived. Both they and their patients must seek to make common cause to address the real underlying problems they jointly face.

    At the core of this problem has been the failure to expand medical capacity in primary care. In contrast to many other primary care professionals or their hospital colleagues, the numbers of GPs in general practice has been static for decades. This failure to increase numbers, linked to the changes in contract preferences of new GPs, has meant that more and more service is being expected from fewer and fewer practitioners. This is not sustainable.

    Jeremy Hunt MP, a former Tory Health Minister ( 2012-1218), has stated that his efforts to increase GP numbers failed, not because extra GPs were not trained but because more experienced GPs were retiring or going part time faster than new trainees arrived. This is a crucial lesson for the current Health Minister Sajid Javid MP.

    Javid’s recent proposals to provide an additional £250m to improve GP access provides some long over-due remediation for years of under-investment. But very worrying there are a range of conditions attached to the payments which most GPs will see as toxic strings. This could drive even more GPs out of the service when the need for them is greater than ever.

    Collectively all of these changes pose a risk to the essence of British general practice. As a gateway to the NHS, general practice had a key role in sorting undifferentiated presenting problems and to make decisions accordingly. GPs become a crucial signpost and the patient’s advocate in an every complex care service.

    The consultation has also been where opportunist preventive and anticipatory care took beyond the presenting problem. And this was the basis for the building of a continuing personal relationship between the patient and their practitioner. Time was of the essence in building this relationship – but time is one thing the present system does not have.

    Instead much of primary care provision is being fragmented into disconnected episodic incidents where continuity and personalisation is sacrificed for a transactional, call centre style of medicine. In this model patients move through the system as quickly as possible with a focus of narrowing  care down to just “today’s problem”.

    This approach will inevitably undermine the personal, generalist and holistic nature of general practice. The initial contact with primary care becomes the lottery of the taxi rank. Remote access will deprive the clinician of many important non-verbal cues and time pressures will mitigate against pursuing broader concerns that are not immediately relevant — though they may have longer term implications for patients’ health and well-being. Instead of being a holistic generalist , the GP is at risk of becoming a “specaloid in episodic care”.

    As the rivets pop throughout health and social care, rising such issues of quality may seem to be an indulgence. To some with immediate and pressing medical problems these concerns could look like worrying about the icing on a cake when there is no bread on the table. But these issues are fundamental way that British general underpins the whole of NHS. If we discard them, particularly in a trivial or cavalier way, the very fabric of the service will be placed at risk.

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    Operose Health – a subsidiary of US healthcare giant the Centene Corporation, which provides health insurance to around 25m Americans – is expanding its portfolio of NHS GP practices to 58 through a ‘partnership’ with major primary care provider AT Medics. Effectively it allows Operose Health to takeover AT Medics.

    Operose Health already ran 21 NHS GP practices, spread from south-east England to the Midlands and north of England – and will nearly triple this figure through the deal with AT Medics. Its existing practices covered around 120,000 patients

    The trojan horse for this takeover is a form of general practice contract called Alternative Providers Medical Services (APMS) contracts. These contracts allow for a commercial tendering process to take place which provides the open door through which for profit corporate bodies can take over the running of the practices on offer.

    The takeover of AT Medics has attracted a lot of scrutiny and debate right across the Labour Movement and within healthcare professional groups. This includes the Labour Party Leader, Sir Keir Starmer. In writing to the the Accountable Officer at NHS North Central London Clinical Commissioning Group Sir Keir stated “Like many people in our community, I want our local health service to be accountable and transparent.” and he asked for greater clarity on how the who Operose takeover took place.

    The APMS contracts only operate in England. SHA – Cymru has written to Labour Senedd Members drawing their attention to the risks of going down the APMS route.

    Some further information on the campaign against the corporate take over of English general practice can be found here.

     

     

     

     

     

    3 Comments

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

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

    The significance is twofold.

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

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

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

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

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

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

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

    I doubt it.

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

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

     

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

    3 Comments

    So here we are in Week 16 of our SHA Blog about how the Johnson government is mishandling and mismanaging – except where it comes to the interests of the profit-making private sector – the COVID-19 pandemic; and why the UK is “world beating” – in terms of the highest death rate from COVID in Europe!

    Test and Trace

    The “teething problems” with the centrally designed, and privately contracted, NHS Test and Trace scheme, continues. It is a privatised system organised through the likes of Deloitte, (Deloitte is one of the Big Four accounting organisations in the world, whose business is in financial consultancy.) These private firms put the NHS logo in their own “branding” to try to build public belief, and confidence, that what they are doing is part of the NHS, and in the public’s interest, when it is a private system making lots of money for private investors: in the way that suits them best, rather than the most efficient way it could be done.  .

    It has had a huge investment of taxpayers’ money to employ 20,000 under-used telephone operators who are poorly trained in the complex field of contact tracing.  The Independent SAGE group reports that one contact tracer told them that ‘out of 200 tracers at my agency we have only had 4 contacts to call over the past 4 weeks’. Speaking to worried people and trying to elicit information about their contacts within a system which has not been able to build trust is a genuine challenge. The familiar GP practice or the local hospital and local authority – in which people really do have confidence – have in this “NHS Test and Trace scheme” had to take a back seat. (Readers will recall from previous blogs that the Independent SAGE group was set up in May to provide scientific advice independent of political pressure, after it was reported that Johnson’s “special advisor” Dominic Cummings had attended, and was believed to have influenced, the Government’s “official” Scientific Advisory Group on Emergencies. )

    Early problems have been identified in the initial design of diagnostic testing. No NHS number for instance, no occupation or place of work recorded, no ethnicity data and test results not being shared with the GP. The Lighthouse labs set up in Milton Keynes, Alderley Park Cheshire, Cambridge and Glasgow are collaborations between pharmaceutical industries (GlaxoSmithKline (GSK) and AstraZeneca), Universities in Cambridge and Glasgow, Boots, Amazon and the Royal Mail alongside the Wellcome Trust. (AstraZeneca owns Alderley Park).

    They were set up to meet the escalating government targets to get testing up to 100K (Hancock) and then to 200K (Johnson) without Ministers being clear about the strategy for testing and ensuring that results got back quickly to people and local players such as GPs and the local Public Health teams who could act. If the objective was just to get tests sent out in the mail or undertaken by Army squaddies in car parks across the country, in order to get the numbers up for the Downing Street briefings, then there was no need to worry about useful information about workplace/occupation? It is not the consortium of laboratories’ fault, as they are contributing to a national emergency, but the political leadership, which has not taken enough notice of public health professionals who have provided laboratory services and integrated themselves with NHS and local public health teams over decades. Public Health England are faced with the nightmare of quality assuring data sent to them from these laboratories.

    Workplaces

    One reason to worry is that incomplete information can lead to a delay in identifying a workplace outbreak. Returning the test result information started at Local Authority level which is not enough information on which to act. After some pressure the local teams have started to get postcode data. However noting a rise in individual cases scattered across West Yorkshire did not help public health officials pin down the common link: which was that they all worked at the Kober Meat Factory in Cleckheaton! These public health systems need to be designed by people who know about public health surveillance, outbreak management and contact tracing. It works best if the tests are undertaken locally, results go back to GPs and local Public Health teams with sufficient information to associate cases with industries, schools, places of worship, community events or food/drink outlets. This is the level of data that would help the public health team in Leicester who are under scrutiny with ‘knowledgeable’ politicians such as Home Secretary Priti Patel declaring the need for a local lockdown in the city. Speed is of the essence, too, as we know that COVID-19 is being transmitted when people do not have symptoms and is most contagious in the first few days of the illness.

    We have known from international data that meat-processing plants are high risk environments for transmission. This is clearly something to do with the damp, cool working environment, which is noisy and so workers have to shout to each other and are often in close proximity. Toilet facilities and rest areas are likely to be cramped and how often they are being cleaned an issue. Furthermore – as we have learnt from Hospital and Care Home outbreaks – how staff get to work will be important to know, too: for example, if they are bussed in together or car sharing, both of those involve being with other people in enclosed spaces.

    As in abattoirs here in the UK and in other parts of the world, jobs like this are usually undertaken by migrant workers. These workers usually live in cramped dormitory type multi-occupation residences. Low paid often migrant workers, who are poorly unionised, are particularly vulnerable to the COVID-19 contagion whether they work in US meat packing factories or in Germany or indeed in Anglesey (Wales). The 2 Sisters plant in Llangefni for instance has had over 200 workers with positive test results.

    The Tonnies meat processing factory in Germany has had more than 1500 of its workers infected and 7000 people have had to be quarantined as a result of the outbreak. This has had a ripple out effect with schools and kindergartens, which had only recently reopened, having to close again. Unsurprisingly there are stories of the factory being reluctant to share details of the staff, many of whom are Romanian or Bulgarian and speak little German.

    Contact tracing

    The importance of testing and rapid reporting of cases to local agencies was highlighted in a recent South Korean example, where a previously well -controlled situation was threatened by the finding that a series of nightclubs had been linked through one very energetic person. Tracers had to follow up 1700 contacts and be able to control the on-going chain of transmission! While South Korea, unlike the UK, has had a mobile phone app to assist contact tracing, they still depend on the local tracers to use shoe leather rather than computer software to really understand the local patch and the complex community relationships.

    The Independent SAGE group is producing useful analyses and information for us all and has been promulgating the WHO Five elements to test and trace, namely:

    FTTIS – Find, Test, Trace, Isolate and Support.

    All of these are important and the recent example in Beijing shows again how a rapid local lockdown response was used to implement FTTIS and they appear to have managed to contain the outbreak to one part of this megacity of over 20m people.

    Social distancing

    The Independent SAGE has also recently taken a line critical of the government position on social distancing. They say that the risk of transmission in the UK remains too high to reduce the social distancing guidance. They oppose the move from a 2m guidance to 1m plus and say that it risks multiple local outbreaks, or in the worse case a second wave. The pattern of continuing waves of infection has been seen in the USA, where social distancing has been poorly enforced, and in other countries where a significant second wave has occurred such as Iran.

    The Government is rightly worried about the economic impact of the lockdown and pandemic, but they are sending out mixed messages on social distancing which has led to chaotic scenes on Bournemouth beach, urban celebrations in Liverpool and street parties in many cities. In the USA it has identified the 20-44 year olds as being a group who are testing positive more frequently and we need to send the message out loud and clear that although they may not die from COVID-19 at the rate older people and those with underlying conditions, they are at risk of long term damage to their health and will transmit the virus to other more at-risk people in their families or local communities.

    The Prime Minister always wants to be communicating good news, and needs to beware that the call for more ‘bustle’ on the high streets and ramping up/turbo charging the economy carries big risks of new local outbreaks that will ensure that the Sombrero curve of infection is not flattened, but that we are condemned to live with on-going flare ups across the country.

    Ex Chancellor Kenneth Clarke tweeted recently, in the light of the situation in the UK and the flip flopping on air travel restrictions, that:

    The UK government’s public health policy now seems to be ‘go abroad on holiday, you’ll be safer there!”

    29.6.2020

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

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    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.

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    Death Rates in France

    Tony Cross, formerly of Radio France International (the French equivalent to the BBC World Service), reports from France in www.theravingreporter.com that the number of deaths per day (from all causes, and not just deaths in hospital) has declined from a high point of 600 a day at the beginning of April, to a lower rate than in the previous two years (see the yellow line, compared to the red and blue lines). This is probably due not only to the decline in Covid-19 deaths as a result of the lockdown, but also to the lower rate of road traffic accidents and lower air pollution from road and air traffic. The statistics come from INSEE, the French National Institute for Statistics and Economic Studies.

    Deaths from Covid 19 in the Care Sector

    Meanwhile, in the UK, Ann Bannister, Secretary of Reclaim Social Care, has just posted death figures from the Office of National Statistics covering Care Homes and Domiciliary Care.

    From March 2nd to May 1st this year, there were 45,899 deaths of care home residents, 27.3% involving Covid-19. 72.2% of Covid-19 deaths of care home residents were in a care home when they died, and the rest had been transferred to hospital. This means that over 9,000 deaths were not included in the totals reported in the press, of all the deaths from the virus, because the press was reporting only hospital deaths.

    Covid-19 was the main cause of death of men in care homes who died during the same period, while Alzheimer’s and other forms of Dementia were the main cause of death in women living in care homes, with Covid-19 in second place. However, Dementia and Alzheimer’s were also the main pre-existing condition in deaths caused by Covid-19 in both sexes.

    The statistics for recipients of Domiciliary Care 10 April – 8 May 2020 show that 3,161 clients of care in their own homes died of Covid-19, which were 1990 more than the average over three years.

    Unison North West are planning a Social Care campaign video conference on 26 May. To register email nwepoc@unison.co.uk

    Comments Off on News from the Frontline 17.05.20.

    From Ekua Bayunu, Member of Greater Manchester Socialist Health Association, and selected candidate for Hulme in the next Manchester City Council elections.

    When I joined SHA a couple of years ago I wanted to focus my energies on action against inequalities in the health systems around race, particularly in mental health. We now have evidence of the toxins that were seeping into us from the right, distracting us from actually building effective socialist action on health issues here in Greater Manchester.

    Skip forward and we are slap bang in the eye of the storm of the Covid 19 pandemic and still searching for some strength in our unity to make a difference to our communities. Many of our members are fully immersed in either working on the frontline, in providing care in our institutions, or in volunteering in mutual aid groups, many doing both and I send love and admiration out to us all.

    We lost my neighbour, an elderly Somalian man, to the virus on the last weekend in March. It felt like the storm that was brewing had just swept in and taken one of ours before we barely knew it was coming. Then the statistics started coming in. We are dying in inexplicably large numbers. We? I’m a woman of African heritage, my community is African, South Asian, Working class.

    My close friend, a street away, is a nurse working at MRI, already stressed by the lack of PPE, worrying about her family, the risk she posed to her 3 daughters and husband at home, when she got ill two weeks ago, together with two colleagues from her ward. They got tested. She doesn’t have access to a car, and the only testing is drive-through. No you can’t walk in. No you can’t get in a taxi! She started talking to us about wills and supporting her daughters and all the worries she has for them. Her eldest also works as a nurse, the youngest is only 10. Her cultural background is Turkish, and she knew she might die.

    She is in recovery, but the statistics get worse and worse. The demand for action grows as do the questions and desire for investigation. I read articles in the silo of my social media accounts and watched as it began to break slowly into mainstream media. At first I thought: they are holding back on the narrative, because it doesn’t suit their agenda to highlight how many were dying in service to us all who were from Diasporan African, Asian and other minority communities. We entered this year with forced deportations built on a narrative that these were the communities of criminals and spongers on the state. Suddenly the NHS workforce were our heroes, they put out ads supporting these workers and most of the workers were white. Did you all notice?

    Then as the statistics leaked into a wider societal consciousness, I became openly worried. Information being fed via the television is so absent of any real analysis that it actually begins to shape a eugenicist narrative, which the Prime Minister does little to distance himself from. Our deaths are not real sacrifices based on years of inequalities in education, health care, housing and employment, but gives out a message of our inherent weakness and inferiority! And whilst we all are shut in, angry, confused, needing to have something or someone to blame, in the place of blaming this government for its lack of care in putting profit over people, it is easy to discern they are creating a diversionary agenda.

    It is becoming increasingly clear BAME people are dying disproportionally, on the wards, driving our buses, cleaning our streets, in our care homes. They are presented as the problem, when they are the heroes and victims of the pandemic. Last week the government finally pulled together a commission with PHE to investigate the causes of BAME people dying disproportionally. Do we all assume that the why will lead to how to stop this? To a solution to help us? I can’t.

    Posted by Jean Hardiman Smith on behalf of Ekua Bayunu, Member of Greater Manchester Socialist Health Association

    1 Comment

    Jeremy Corbyn wrote a long letter to Boris Johnson on 31st March.
    As well as wishing him a speedy recovery, Jeremy made some strong points about aspects of the current crisis, and asked for immediate action on:

    • Full PPE now for Health and social Care workers
    • Test Test Test
    • Expand Social Care
    • Enforce Social-distancing and Protection
    • Bolster Support for Workers
    • Lead a Global Reponse

    (the 4  pages of the letter are attached)

    Posted by Jean Smith on behalf of SHA member Diane Jones.

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    The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

    1. Global crisis

    This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

    The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

    Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

    To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

    The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

    Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

    In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

    1. The public health system

    We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

    We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

    The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

    1. Local government and social care

    Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

    COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

    Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

    Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

    1. The NHS

    In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

    The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

    News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

    1. Maintaining people’s standard of living

    We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

    In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

    1. Conclusion

    At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

    24th March 2020

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    The Conference on Retroviruses and Opportunistic Infections (CROI) in Boston is the most important yearly scientific meeting for HIV doctors and the global community of people living with HIV.

    However, this year – and at the very last minute because of the new coronavirus outbreak – the organisers replaced it with a ‘virtual’ conference.

    HIV i-Base, the London-based HIV Treatment Information charity, regularly attends this conference. Simon Collins and Polly Clayden at i-Base always report on the latest scientific research, including on new drugs for both treatment and prevention of HIV.

    But importantly his year, CROI have given open access to a special session on COVID-19 and SARS-CoV-2.

    Here is Simon Collins’ report for i-Base. This includes a link to the special session which contains up-to-date information about the outbreak that can be of interest to all, and not just to people who are HIV positive:

    The special session on coronavirus at CROI yesterday is posted for open-access on the CROI website. [1]

    The 75-minute overview includes four talks and a Q&A at the end.

    A few selected key points include:

    • The highest risk of more serious illness and outcomes (risk of dying) are older age (80>70>60 years old), and having other health conditions (heart, lung/breathing, diabetes, cancer). The risk of the most serious outcomes is 5 to 30 times higher than with seasonal influenza (‘flu’).
    • Implications for people living with HIV are not currently known, other than as for the general population. One speaker included low CD4 as a possible caution. [Note: Due to lack of evidence so far a low CD4 count has not been included as a risk in the recent UK (BHIVA) statement]. [2]
    • Transmission is largely from microdroplets in air from someone during the infectious period (generally from 1 day before symptoms to average 5 days, but up to 14 days after). These can remain infectious on hard surfaces for an unknown time (possibly hours) which is why hand-washing and not touching your face is important.
    • Best ways to minimise risk of infection include washing your hands more carefully and frequently and not touching your face.
    • Soap and water is better than hand sanitisers (and more readily available).
    • Best candidate treatment (so far) is remdesivir (a Gilead compound). This has good activity against a range of viruses in in-vitro studies and is already in at least four large randomised studies.
    • Studies with candidate vaccines are expected shortly – within two months of the virus being isolated – fastest time for vaccine development.
    • The response in China after the first cases were reported was probably much faster than it would have been in the UK. This included:
      –  Within four days of the first reported cases, the suspect source was identified and closed (a seafood market).
      –  Within a week, the new virus was identified (SARS-CoV-2).
      –  The viral sequence was then shared with WHO and on databases in the public domain for other global scientists to use.
      –  Within three weeks of the first confirmed cases, Wuhan and 15 other large cities in China were shut down as part of containment measures.
    • One of the questions after the main talks asked whether SARS was now extinct. The answer explained that SARS is a bat virus, and only 50 out of about 1300 species of bats have been studied so far. So SARS is very likely still around.

    COMMENT

    Currently, the most important things for people living with HIV are:

    1. To make sure people have enough medications – including at least one month spare. If travelling where there might be a risk of quarantine, to take additional meds with you to cover this.

    2. As recommended by BHIVA, sensible hygiene precautions (hand washing and not touching your face etc). [2]

    3. Avoid or delay any non-essential or non-urgent hospital visits.

    4. Special caution for those who are older or who have multimorbidities – which are prevalent in HIV.

    References

    1. Special session on COVID-19. CROI 2020, 8–11 March 2020.
      https://special.croi.capitalreach.com
    2. BHIVA. Comment on COVID-19 from the British HIV Association. 27 February 2020.
      https://www.bhiva.org/comment-on-COVID-19-from-BHIVA
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    A Healthier Wales (June 2018) is the Welsh Government’s response to the  Parliamentary Review of the future of Health and Social Care in Wales. It promises a programme of transformative whole system change with a move to a service that focused on health, well-being and prevention – a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality.

    A key part of the this transformation will be delivered through local primary and community care clusters working with both Local Health and Regional Partnership Boards. There will be a shift in services from general hospitals to regional and local centres with primary and community care delivering a expanded range of professionally led services. In October 2019 the Wales Audit Office (WAO) published Primary Care Services in Wales which evaluated progress with a particular focus. on strategic planning, investment, workforce, oversight and leadership, and performance.

    The WAO report acknowledges the work that the Welsh Government and NHS Cymru is doing to achieve the level of transformation that is needed. A National Primary Care Board and a National Director has been appointed to provide a focus and impetus to drive this agenda forward. A Primary and Community Care Development and Innovation Hub has been formed with the support of Public Health Wales which is also providing guidance to improve clinical network governance. And at health board level designated directors or senior operating officers provide a lead for primary care with work being undertaken to develop a national evaluation framework which can be used to measure progress at a local level.

    These initiatives have been supported by a number of funding streams that operate at all levels in Wales from the National Transformation Fund and the Integrated Care Fund to a National Primary Care Fund. These resources are allocated in a variety of ways including to clinical networks and practices to promote change and innovation including “pathfinder” and “pacesetter” projects operating at a grass roots level.
    But despite all of this the WAO concludes that change has not happened as quickly or as widely as intended and has outlined a number of reasons why this has not happened. This is acknowledged in the Welsh Government’s own National Integrated Medium Term Plan (2020-23)

    A key component of the Healthier Wales approach is The Strategic Programme for Primary Care was launched in November 2018. It is based on the new “Primary Care Model for Wales”. This outlines what it  regards as the main components of a good primary care system. These key components include informed and empowered citizens, self-care, stronger community services, new first points of contact for patients including triage to ensure they are seen by the appropriate healthcare professional, better urgent care arrangements and stronger multi-disciplinary working.

    There is much to commend in this New Model but the WAO points out that it has emerged with little public consultation. This lack of debate and discussion means that in many respects there is a lack of clarity as to the purpose and direction of the New Model.

    In the “old model” GPs were the initial point of contact and gatekeepers for virtually all other health services. In the New Model the GP will continue to provide the first port of call for some patients but many patients will also be able to directly access many alternative community based professionals, thus freeing up GP time to see the sickest patients and those with complex chronic conditions. These alternative practitioners will include pharmacists, physiotherapists, opticians, dentists and members of mental health teams.

    The emergence of this New Model seems to be driven by necessity and is a pragmatic response to the sustainability challenges facing general practice rather than an evidence based evaluation of the key elements that a holistic general practice and primary care service would require . This sustainability challenge is caused by the combination of the growing workload in general practice, changing work and contractual patterns as well as signficant recruitment difficulties.

    This New Model is intended to provide improved access “to services”. This is bound to be seen as preferable to having no access at all but of itself it may not be the most optimal configuration or care pathway. This range of “front doors” into the health service will inevitably lead to discontinuity of care, fragmentation and a lack of co-ordination.

    Continuity of care is a key characteristic of quality primary care. It has two mail elements, horizontal continuity as a patient / service user utilises a range of services as part of a holistic response to their needs and longitudinal continuity based on ongoing personal care is delivered over time. Both are important but the former seems to have primacy in the current articulation of the New Model.

    Delivering horizontal continuity depends on having good team work supported by an infrastructure that goes with the grain of seamless care across professional and organisational boundaries. This will require health and regional partnership boards as well as local clinical networks working more effectively together supported by shared personal care records and a robust IT system.

    Longitudinal continuity and quality care is built on long term personal relationships. But these relationships will struggle to develop and mature if patients and service users face a variety of diverse professionals whenever they attempt to use the service. “Time” is at the heart of these relationships both in terms of having the time to listen and work with patients in line with their needs and also it is only over time that a continuing personal,professional relationships can be built.

    General practice is under continuing and unsustainable pressure but despite this the workforce is not increasing in line with need and list sizes are static. This, in part, explains the pressure to promote the New Model of primary care but that will never be an adequate solution without a substantial increase in crucial front line workers particularly GPs. The Welsh Government has launched a number of initiatives to increase GP numbers including a welcome increase in training posts  but neither it or the WAO seem to be willing to move much beyond the traditional parameters of the solutions being offered by the medical “establishment” such as GPC Wales or the RCGP.

    There are between two to three dozen health board managed practices in Wales as well as 778 sessional / “locum” GPs working alongside 1,964 GPs principles. But despite this large salaried GP workforce there is no overall strategic policy in place to promote their professional development or retain them in clinical practice. Initiatives such as the establishment of a GP Locum Register are a step forward but much more needs to be done in the face of the evidence that the independent contractor option is no longer the preferred model of work by very many GPs.

    Already the Auditor General for Wales pointed out that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years has not being achieved. If the changes that the Welsh Government and NHS Cymru have put in place do not achieve a  rebalance in resource allocation then little new will happen. In addition the WAO also expressed concern at the lack of transparency in the way that primary and community care is funded. This makes it very difficult to monitor any real shifts in resources is taking place with is a precondition to achieving transformational change.

    Apart from the reasons outlined in the WAO report there are additional problems in monitoring where NHS resources are actually allocated. The creation of larger health boards in Wales in 2009 has meant that a certain level of sensitivity has been lost allocating resources. The Welsh Government’s commitment to clinical networks, which cover about 50,000 people, is an opportunity to address this loss of sensitivity as well as providing a more meaningful population size to monitor health inputs and outcomes.

    Over recent recent years health and social care spending has has increased between 4.5 – 6% which is generous compared to the pressures on the overall Welsh Government budgets. These increases must be used to provide the headroom for a meaningful transfer of resources towards primary and community care. As the WAO suggests a transparent framework is needed to monitor this transfer.

    This framework should include a rapid move towards a 10% allocation of NHS resources to primary care services. This should be linked to the creation of at least an additional 200 GPs in post in Wales as a matter of urgency so that average list sizes will be reduced to Scottish levels with more easily accessible time being available for patients.

    Health boards and clinical networks, working with Public Health Wales, must monitor where these resources go locally to ensure that there is a clear focus on addressing health inequalities and the Inverse Care Law.

    Primary health and community care teams must be strengthened both address current health and care needs both at the individual and wider community level. And where traditional models of delivery, such as the independent GP contract, are failing to deliver, health boards must take direct responsibility. Progress cannot be held back by the speed of the slowest.

    The latest NHS Planning Framework (2019-22) specifically asks that health boards should place a particular emphasis on prevention, reducing health inequalities, the new Primary Care Model for Wales, timely access to care and mental health. However it does so at a fairly high level and only give very broad indications as to what it expects it health boards to deliver. In this context, the WAO report’s recommendation of a more explicit accountability framework should provide for greater focus and accountability.

    In a Healthier Wales the Welsh Government expected to demonstrate early impacts over three years. We are already half way though this time frame and, as the WAO report shows, much more now needs to be done to deliver against that ambition.

    5 Comments

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

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


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

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

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

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

     

    Jeremy Corbyn’s Labour speech in Northampton is clear:

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

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

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

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


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

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