Category Archives: Professional opinion

Alice Peterson, (2019) If you were Here, London, Simon and Schuster


This is a novel around Huntington’s Disease (HD).  That in itself is a rarity.  Readers may wonder if a novel on such a subject can work.

Central to the plot are three women of different generations.  The first in grandmother, Peggy.  Her husband died of HD in the period before the book is set.  The next generation is Beth. Like her father she also died of HD.  However, her voice is important for the plot through her diary.  The youngest is Beth’s daughter and Peggy’s granddaughter Florence, known as Flo. Each of the women has a distinct voice.

A novel needs a degree of tension to keep us turning the pages – often an unresolved issue.  A standard ending is to draw together the threads to resolve the problem.

On the face of it the issue does not sound as if it can carry a plot.  But it does.  Flo lives, works and loves dealing with a real-life issue.  The central issue is should Flo have a DNA test to reveal if she has the disease?  Since HD is autosomal dominant there is a 50% chance that her mother has passed it on.  Other things being equal (which they are not), if a sufferer has children, they also each have a 50% chance of inheriting the disease.  We need to add to that the possibly around 10% of cases that arise spontaneously.

In many genetic disorders there are unambiguous benefits to diagnosis, in the UK newborn children are tested routinely for Cystic Fibrosis.  HD is more problematic.  As is revealed through the actors of the novel, HD hits home later in life and is incurable. The progressive nature and very unpleasant later stages may be a blight hanging over a young person.  Would such a person want to know?  The test could bring relief and a happy future. Or it could be a sentence of an early death preceded by suffering.  Can you live with the uncertainty and just get on with life?  Or would it be better to be able to plan the way forward?  This is a real dilemma for those with the family history.

We focus on young Flo and her very full life.  She is a real three-dimensional woman as are the people around her.

The debates and guilt associated with previous decisions hang over the young.  The counsellor is a vital part of the plot and her contribution is excellent.

In the mix of the traditional approach to this disease is the genetic revolution.  This is an area of medicine which is changing fast.  The clinical trial referred to in the book is ongoing.  Not mentioned, however, are other useful approaches.[i]

Can it work as a novel?  Yes! It is dynamic, it flows, it tugs on the heart strings.

Would it be of use for people with a family history of HD?  I feel that it would.  A great deal of information is communicated without being heavy.  It is shown through the characters not preached by an authoritative voice.

[i] See: Philip R. Reilly  (2015) Orphan: The Quest to Save Children with Rare Genetic Disorders: The Quest to Save Children with Rare Genetic Disorders, New York, Cold Spring Harbor Laboratory Press



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We welcome comments on this article which has come out of the Reclaim Social Care Campaign. It is not SHA policy, but it raises important questions relevant to both social care and the NHS.

This is a wide field in which a variety of species flourish, some of which are dangerous invasives. We need to cultivate systematically to ensure that what grows in this field is healthy, productive, and not a threat to other growth. We need to be able to classify, in order to isolate rogues, and then eradicate them. We need to be able clearly to identify some of the more rampant plant life, in order. maybe, to consider techniques of pruning.
I come to this view of the wider challenge from an interest in cultivating a little patch in this field – one area that I think is growing some special and healthy new life. My patch is occupied by a Community Interest Company. This organisation safeguarded one local piece of our National Health Service, by propagating it and preserving it from being hybridised – merged– a with a completely different plant that would have taken us over. We have created an organisation that is of our community, for our community, and owned by our community.
I am a fervent supporter of the NHS, especially having, for 15 years, suffered under the US excuse for a health system. I have been a member of the Labour Party since 1972. The principles of the NHS, as promoted by the Labour Party from 1948, are not negotiable, but there are different ways to organise to support those principles. I believe that there are freedoms in a CIC organisation that make it easier to maintain some aspects of health and social care in conformity with those principles – not everything in the way the NHS organises itself and runs its staff and services is perfect. My purpose in writing this paper is to try to distinguish the different types of possible organisation, to identify the healthy growth points, and also rogue growth.

I start with a straightforward definition:
“A simple definition of “public sector provider” in this context is: one that is constitutionally owned by the community or the State and operates not for profit.”

If one were to operationalise that definition, one would be able to draw a line across one large sector of our field – often called “The Third Sector”. If I understand that term correctly, it contains both charitable bodies and the range of different social enterprises. My simple definition, once operationalised, would separate those two parts of that Third Sector: charitable bodies are accountable through Boards and the Charity Commission – they are not “constitutionally owned by the community or the State”.
The largest part of our health field – diminishing and under threat, but the revered sector whence proliferate (or struggle) the heirloom crops – is defined by the phrase “constitutionally owned by the State”. It should not be hugely difficult to operationalise this definition, in which “State” could be national or local.
That leaves, I think, the cultivators of two sections of field to be pinned down: commercial cultivators and the social enterprises. The word “enterprise” – a word sullied with muck in some horticultural circles – creates a confusion for some, but I think my first definition, with its reference to “constitutionally owned by the community”, serves to draw a line between private enterprise and “mutual enterprise”. I think that an operational definition of private enterprise is achievable.
That leaves the mutuals, or social enterprises. That is a field with subdivisions. Those dividing lines have been traced by Geraint Day and Mo Girach, among others -The semantics of the ‘Big society’: Social enterprises, mutuals and co-operatives, NHS Alliance, August 2010. One subdivision contains CICs, like the one I am associated, whose constitutions place ownership in the hands of not just the workers in the mutual, but the whole community.
There is a programme in this for a whole load of research, I guess:

I would like to ask readers of this paper:

a) If they find the subdivision of the field proposed above useful
b) If they know of any work that pushes forward on defining some of the boundaries in a way that generates precise facts
c) If they know any facts that would give a more accurate version of the numbers guessed in the left-hand part of the diagram above

Once we have divided up the field in a manner that commands some agreement, we can then consider different ways of dealing with different plant species. Even the more aggressive plants might have their uses, if we can refine our horticultural techniques. I believe that there is a lot of mileage in looking at this horticulture from the point of view of risk management. If one can be clear about the risks involved in handling each type of plant, one can be more confident of training each plant to grow to maximise its useful productive capacity. Leaving this (rather seductive) metaphor behind – what one needs to aim at is to understand the types of contract each type of organisation can sustain in a way that optimises their capacity for good, and minimises the risk of bad.
I believe that we can get a long way by distinguishing between contracts in which the best way forward is to share risk between commissioner and provider – those are not safely handled outside public sector partners. But there are also opportunities for what I would call “segregated risk” contracts, where we might watch private enterprise do what it is best at, without massive risk.
But that is another discussion.

And there is a third related discussion we could have: in addition to an operational – i.e. useful – definition of the concepts discussed above, it would be advantageous to come up with legal definitions of some of these concepts. Here are some of the challenges encountered in searching for legal definitions with reference to a CIC:
• The CIC may be “owned” by the citizens of the community/Borough/town, but …
• What are the implications of “ownership”?
• How is the CIC accountable to the owners?
• Our CIC has a Membership Council – community and staff, but …
• Are the members of the Council representatives?
• … of whom?
• What is the “membership”?
We tried launching a membership drive, but foundered on the fact that there was nothing we could offer “members” that we didn’t want to give them simply as one of our population of potential or actual service users. We eschewed the practice of our Acute NHS Foundation (and many other Foundations) – of simply “signing up” everyone who comes through the door, in order to create an artificial “membership” number.

• What if some services are also offered in other communities? What if the organisation is willing to expand into other places it the circumstances are propitious?
• How does one characterise membership in locations where the organisation plays a minor role in the range of care?
• and on and on
The efforts of the CIC to represent the needs of its community may be completely genuine. The CIC may know that the core, at least, of its community is the citizenship of the community/Borough/town that it serves, and that may be enough for pragmatic purposes. It is better to have a practical rationale for pressing forward with doing good, rather than getting too caught up in definitions.
But, if there are readers out there who can help with legal definitions, or examples, or processes for enacting representative monitoring, then please share.

The risk for some social enterprises is that they can be captured by the profit motive or by the private sector. This is a risk that increases as money gets tighter. There are ways to have insurance against that threat, and not necessarily in terms of formal accountability and representativeness. One approach is to mount a diligent programme to embody the principles of organisation in the whole organisation – all members of the staff – and to ensure that principled continuity is not dependent on a small group of founders.
The CIC of which I am a Community Governor has some very creative approaches to ensuring continuity, principle and direction in this way. But that is yet another story.

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Brexit is opening the door to NHS chaos in so many ways. But we are now presented with a new threat.

There have been concerns for many years, often expressed in this column, that the 2012 Tory design of the NHS opens the way to privatising not only services but also commissioning itself. Fighting the impact of the 2012 Act and its offspring such as ACOs/ICSs has been paramount. By shrinking the state at the same time as imposing austerity, the Tories have created the conditions for increasing mortality rates. This appears to be taking place now.

But Brexit has opened a new front: The Ideal US-UK Free Trade Agreement – A Free Trader’s Perspective.

Striking trade deals independent of the EU is the Brexiteers’ dream. This document shows how it can become a nightmare for the NHS.

The paper was released in September and is a US/UK collaboration of right-wing institutes fronted by the Initiative for Free Trade and the Cato Institute. MP Daniel Hannan is a co-author……………………

The aim is to open all sectors of the economy to investment from business. It should open all services markets without exception to competition.

They say: “The ideal FTA is one that removes all barriers to trade in goods and services, opens up all sectors of the economy to investment and, ultimately, goes as far as possible to remove all administrative impediments to integration of the economies of the parties without encroaching on the sovereignty of governments to pass laws and regulate in the public interest in ways that do not discriminate against foreign goods, services and companies”

They call for “zero restrictions on competition for government procurement.”

They have a particular interest in health services.

“Health services are an area where both sides would benefit from openness to foreign competition, although we recognise any changes to existing legislation will be extremely controversial. Perhaps, then, the initial focus should be on other fields such as education or legal services, where negotiators can test the waters and see what is possible. That said, we envisage a swift, time-tabled implementation of recognition across all areas within 5 years.”

There it is – a blueprint for privatisation, starting with what they deem softer areas like education and moving on to the NHS within 5 years.

The document goes into some detail about how such a Free Trade Agreement would deal with a range of other arenas and issues.

Milton Friedman, one of the principal architects of the current neo-liberal world order now failing the world, said: “There is nothing as powerful as an idea when its time has come. I say that time is a crisis, actual or perceived. When the crisis occurs, the actions that are taken depend on the ideas lying around.”

Hannan and his co-conspirators are seeding these ideas so that they become available when needed.

Beware Brexiteers bearing false promises – many were hoodwinked by the lies about massive NHS investment. Trade Agreements are likely to offer similar attractive lies. We must remain vigilant against these crazy and dangerous proposals.

Published with acknowledgements of GP Magazine.


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It may not be actually necessary to abolish the term ‘patient activation measure’. It is such an unappealing term anyway, it is hard to feel that patients themselves, despite free tickets as campaigners and leaders to industry-sponsored conferences, wish to be perceived as ‘activated’ like washing machines.

The idea that patients are not passive recipients of medical advice is a crucial one, but that is not the issue.

When I was asked what I would replace the term ‘patient activation measure’ with, I was of course obligated to look up the accepted definition of “patient activation”. This is helpfully supplied by NHS England.

“Patient activation describes the knowledge, skills and confidence a person has in managing their own health and care.”

It’s perhaps worth remembering at this juncture that reports from leading think-tanks can be, potentially, more like marketing than research. The conflicts of interests in corporate-sponsored products, including in academia and think-tanks, are sometimes not scrutinised adequately. And sometimes the aim of the term is more to do with the appeal of the “brand” in marketing (using concepts such as “brand equity“), rather than a coherent analysis of relevant aspects of the underlying field. The name, although being pithy, has to be commercially attractive, such as “electronic frailty index” or “dementia friendly commnunities”. As such, neither suppliers and purchasers want a semantic discussion of what ‘frailty’ is or what ‘friendly’ means, as long as the supplier can create competitive advantage, and use marketing to create a near monopoly in its use. This potential abuse of power is of course facilitated with capture in well-respected “independent” “think tanks”, or charities. Then someone like NHS England or Public Health England, large QUANGOs or actual government, can enforce the ‘brand leader’, the healthcare equivalent of a Big Mac or Whopper. A debate about the “capture” of public health has been started, but really does need to be continued (see for example an excellent BMJ article), promoted manipulatively through terms such as “pre-dementia”, “pre-frailty” and “pre-diabetes” for example. Rather than encouraging diversity, the market is in fact highly skewed in certain directions, and this ultimately, I feel, is to the detriment of the actual end-user (who, wearing different hats on, might be a “service user”, “consumer” or “patient”).

I suppose that it is ‘human nature’ to want a ‘quick fix’, but the potential problem with all of these approaches is that they are not “person-centred” at all (a much misused and bastardised term, which has its origins in sophisticated philosophy about personhood), but are highly individualistic and victim-blaming. It’s not about wanting to know about people’s life plans – it’s about selling the product to commissioners that activated patients will cost you less once activated. It is not a short distance from a failure of ‘patient activation’ to an ‘avoidable admission’, and thenceforth to being a ‘bed blocker’. This is individualistic victim-blaming. It would be wholly unfair for patients who are genuinely at rock bottom in terms of mood or motivation, or cognitive abilities, through absolutely no fault of their own. Whilst these measures are said to be ‘robustly validated’, there for me is something intrinsically unappealing about homogenising the marked heterogeneity in cognitive and behavioural performance (such as attention, memory or perception) in people living, say, with mood disorders, dementia or schizophrenia. You cannot half believe in ‘parity of esteem’, so equity on patient activation is relevant for problems with physical, social or mental health – despite being addressed with the marketing banner that patient activation can ‘reduce social inequalities’ (a claim which is in legal terms is essentially “mere puff”).

The field of ‘patient activation’ is essentially remarkably reminiscent of ‘consumer behaviour‘, and has very little to do with genuinely person-centred approaches (see for example the work of Prof Brendan McCormack or Prof Jan Dewing).

As Wikipedia says,

“Consumer behaviour entails “all activities associated with the purchase, use and disposal of goods and services, including the consumer’s emotional, mental and behavioural responses that precede or follow these activities.” [9] The term, consumer can refer to individual consumers or organisational consumers. Consumer behaviour is concerned with:[10]

A diagnosis and management has to be at the right time for a patient. This simply is not captured in an entirely reductionist way by a number such as a ‘patient activation measure’. If I wanted a genuine behavioural and cultural change, to empowering patients with less paternalism, I would not trademark or license a manoeuvre (meaning people could not merely copy the name). This is all remarkably reminiscent of the trademarking of ‘dementia friends’. Creating a competitive advantage through a unique selling point is an entirely different approach. And, as with dementia friends, patient activation is infested (yes, strong word) with champions, leaders, ambassadors and award ceremonies. But this is not real cultural change. It imposes a definition of what is ‘normal’ or acceptable, completely at odds at recognising a patient’s own unique circumstances perhaps reflected in the wider determinants of health, such as housing or poverty. A number does not properly encapsulate complexity, which might include complexity in a patient’s beliefs, concerns and expectations. But it is entirely consistent with “a selling snake-oil approach”, where memes such as ‘stratifying the population’, ‘ascertaining risk’, and ‘cutting costs’ have become widespread mantra.  Again, the similarities with marketing are terrifying – compare “population segmentation” say in people who are poor at self-activation with “market segmentation” a distinct population subgroup to whom you could direct marketing for products and services towards. Essentially it is about creating new markets and new industry, or profit and surpluses, and it should be called out really for what it is. The term itself is clunky, offensive, and itself does not promote diffusion or adoption of innovations.

It is also striking that for a term so blatantly borrowed from industry and non-clinical approaches that it offends one of the major principles in management. That is, you should manage according to your resources. One of the major criticisms of ‘payment by results’, based on Cooper and Kaplan’s ‘activity based costing’ in management accounting, was that the collection of data to make decisions would itself be counterproductive due to being resource intensive. At a time when we are reliably told that the clinical workforce is overworked and underresourced one has to wonder about the wisdom of siphoning off resources into proprietary devices (for measuring patient activation or how well your friends and family feel their ‘experience’ went). We are told that resources are scarce, and yet somehow money is always found for pet projects where the evidence arguably can be rather flimsy. And a whole new industry is born – take NHS England’s “advice”:

“NHS England’s Realising the Value programme has also identified five evidence-based approaches that engage people in their own health and care. The five areas of practice are self-management education; peer support; health coaching; group activities that promote health and well-being; and asset-based approaches in a health and well-being context.”

I don’t at all disagree with the idea of patients informed about their own conditions making wise choices about improving their health and wellbeing. The term is awful and pejorative, and should be scrapped. It implies that there exists a large group of patients who deliberately want to remain de-activated, rather than the fact that the system as a whole, such as underfunding of the NHS and social care, has ‘deactivated’ them. I wonder how many clinicians in their millions of interactions daily are thinking, ‘I wonder how activated she was today?’. If you’re a member of the Royal College of GPs, you could be asking “Was Enid sufficiently activated today?”

Above all, I am surprised at the lack of sensible discussion about this. We can all do better than this?






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The Health Policy & Politics Network (HPPN) is successor to the Politics of Health Group that has been run for the last 20 years or so in the form of a special interest group of the Political Studies Association. HPPN has now become independent in order more easily to encourage interdisciplinary working. HPPN aims to provide a forum for the reporting of research and analytical discussion about any aspect of the politics of health, health care policy or health services management and to facilitate the development of informal and collaborative relationships between academics and interested practitioners working in the above fields.

We invite submission of paper presentations to our one-day event at Keele University on 24th April on any topic related to health politics, policy or management. Speakers will be allocated 20 minutes plus 10 minutes for discussion/questions.

To propose a paper, please submit an abstract to Calum Paton ( by 1st March 2014.

To register to attend the conference, please fill in and return this Booking form

Fees & accommodation:

There is a small conference fee of £35.  For those needing an overnight accommodation, the cost is £41 per night (B&B at Keele Management Centre).

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First published in Tribune  Saturday, October 19th, 2013

In his speech to this year’s Labour conference, Shadow Health Secretary Andy Burnham confirmed that if the party wins the 2015 general election, he will introduce legislation to repeal the Health Act 2012 in the following Queen’s Speech. He did concede that a repeal bill would keep some of the act’s clauses – for example, retaining those of them that created “new entities” such as health and wellbeing boards. His proposed bill would also amend the role of clinical commissioning groups (CCGs), so they would be focused on designing services “clinician to clinician”, rather than commissioning them.

Burnham’s speech was music to the ears of all who love and value the National Health Service.

Andy Burnham

Andy Burnham at the head of the Save the NHS Demonstration

The coalition’s NHS reforms have been a disaster on all the fronts. The deeply damaging effects of the changes have been to distract and fragment an NHS already facing severe financial pressures. The reforms have ignored the central problem for health systems – how to merge social care for fast-ageing populations with the traditional diagnose-and-treat approach – to achieve the Government’s real desired outcomes.

While Andy Burnham’s “whole care person” approach addresses the core issue, the Conservative-led Government has spent more than two years pushing through changes to the NHS in England on reluctant doctors and vulnerable patients. Yet these changes have done nothing to meet the real challenges we face.

The reforms were supposed to transfer control of the NHS’s £100 billion to the family doctors, or GPs, on the front line. Bizarrely, as hospitals have begun to fail and treatment waiting times rise, Prime Minister David Cameron and Health Secretary Jeremy Hunt now choose to blame those very same doctors for all the ills of the NHS.

In past 21 months, £10.7 billion worth of our NHS has been put up for sale, while 35,000 NHS staff have been axed, including 5,600 nurses. Half of our 600 ambulance stations are earmarked for closure. One-third of NHS walk-in centres have been closed and 10 per cent of accident and emergency units have been shut. The A&E departments are performing at a 10-year low. The morale of the NHS family is at rock bottom. Their pay has now been frozen for two years under the coalition, and they have also been forced to accept a major downgrading of their pension benefits. Freezing and squeezing pay is heaping financial misery on more than a million NHS workers. At the same time, the NHS is going through a massive reorganisation, with staff having to deal with job cuts, rationing and ever-increasing patient numbers.

What kind of message does all this send to health workers about the value this Government places on their work? And what incentive is there for young people to join the NHS when those who currently work in it are so undervalued?

A failing NHS will only help to boost private healthcare insurance for those who can afford it, signalling the death knell for a universal healthcare service, free at the point of use.

There has been a noticeable change in the Government’s attitude to the NHS. It has become openly critical of the service while giving a nod to the right-wing media to launch an unprecedented attack on it. They have seized on the problems at Mid-Staffordshire and 14 other failing trusts to make a general attack on the whole of the NHS in order to justify their plans to reorganise and privatise the service. Government policies are designed to open up health to corporate parasites. The introduction of “any qualified provider” means that private companies must be allowed to bid to provide a range of health services.

In Greater Manchester, for instance, NHS commissioners have drawn up a list of 24 approved providers for diagnostic services. Of these, more than half are from private companies. This will have a significant impact on NHS trusts in the region. Trusts need the funding from routine diagnostic work to subsidise more complex procedures and emergency services.

The Health and Social Care Act 2012 clearly fulfils all the commonly accepted criteria for healthcare privatisation, and that is why the coalition has imposed it on the nation despite near-universal opposition.

To date, we have seen £1.4 billion wasted on redundancy payments, £7.8 billion on agency and consultancy firms, and £500 million extra in negligence. That’s more than £8 billion that could have been used for patient care.

Private sector providers want to de-professionalise and down-skill the practice of medicine in this country, so as to make staff more interchangeable, easier to fire, more biddable and, above all, cheaper. Private sector providers want to replace doctors with nurses and nurses with healthcare assistants. They especially like to replace skilled staff with computer algorithms, which do not have any employment rights. We have seen where such a “cost-saving” and “innovative” strategy leads in the case of the mortgage market, with money lent for consumption to people who cannot repay it, while small firms are starved of essential funds to weather hard times and expand their business when opportunities arise.

The NHS is one of the most cost-effective, highest quality and most equitable healthcare services in the world. Nevertheless, it now stands on the brink of extinction.

If you talk to people from countries which have mainly private sector healthcare systems – as we soon will have, too, if the present Government is allowed to complete its reforms – you will find that they regard the NHS as a jewel beyond price: safe, high-quality care available to all, no matter how poor. This is the most civilised accomplishment for which the Labour Party is responsible.

There is even a nationwide activist movement in the United States devoted to trying to introduce an NHS-style model over there. And yet the British Government led by David Cameron and Nick Clegg is itching to convert our NHS from a public service to a set of business opportunities for US-based transnational insurance and health provider corporations. The Health and Social Care Bill is an irrelevance to the real troubles facing the NHS in England.

The terrible state of the healthcare system in the US, even if Barack Obama’s reforms come into play, reinforces the point that the privatisation of state-funded healthcare delivery is not something that is welcome in England – except by big business and those paid to expedite its entry to the NHS.

Ed Miliband should give a firm commitment that, whomever he choose as Secretary of State for Health in 2015, and even if Labour has to enter a coalition agreement after the next general election, Andy Burnham’s pledge to reverse the NHS Bill will be carried out.

I am a retired Senior Nurse. Have qualifications and experience in Trauma and Orthopaedics.
I will generalise.
Care happens 24 hours a day
A&E staff cannot be  seen sitting around doing nothing -image of administrators.
Day Ward Sisters only work 40 hours a week and with days off, holidays, sickness and study are not covering the ward for more than a fraction of a day. Qualified means little if the person in charge has not the experience to care for an acute admission or returning theatre case.
Progressive patient care and pre convalescence or total ward care ?
Mixing clean and dirty cases on the same ward.
The bane of the Nurses station !
Morale which includes good management, job security and team stability.
Handmaidens to Medics and Administrators due to lack of budget control and “hospital management”
Nurses don’t manage hospitals! Consultants and Administrators with no patient care qualifications do.
Hattie Jacques and Barbara Windsor - archetypal nurses

Hattie Jacques and Barbara Windsor – archetypal nurses

Bring back Matron the sort who were in control, and question Nursing CEO’s basic ward experience !
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There has been a strange two-handed legal dance going on for the last year or so. Ministers, and Monitor officials and pretty much anyone in the DH or NHS England you come across says that there is nothing to fear from the Health and Social Care Act. The Act may say that competition will be a key aspect of the NHS and s75 gives it legal force – but ministers and Monitor continue to say that we are all misguided and paranoid. Just wait for Monitor’s formal guidance and you will see there is nothing to fear.

Well, Monitor’s guidance has arrived. It is fearsome and makes competition the default. And worse. We understand that Monitor refuses to publish the legal advice on which they depend.

Here are some key paragraphs with comments.

Consulting the public

Public consultation is not required for tenders to go ahead.

3.2  What is appropriate will depend on the circumstances of the case, but may include consulting publicly on proposals, engaging with local clinicians.

Going to market

Commissioners have to go out to market unless they think they know all relevant providers and can justify their omniscience.

3.3.1 all potential providers that might be interested in providing a service being procured by the commissioner have been given an adequate opportunity to express an interest in providing those services. Commissioners will need to consider what steps they need to take to identify providers that might potentially be interested in providing the services being procured. In some circumstances commissioners may be able to identify interested providers based on their knowledge of the market.

CCGs will have to go to market when contracts end.

3.3.3 For example, if a particular service (such as community dermatology services) is provided by a single provider in a local area, there is no requirement on the commissioner under the regulations to introduce patient choice……, although when the arrangement with the existing provider comes to an end, the commissioner will need to ensure that the process that it adopts to choose a provider in the future is consistent with the requirements of the Regulations.

Avoiding going to market

CCGs must demonstrate why they are not using the market.

3.3.3 However, Regulation 3(4) does require commissioners to consider whether introducing competition and choice and delivering care in a more integrated way could be used to improve quality and efficiency. Monitor will expect commissioners to be able to demonstrate that they have considered whether services might be improved through such means (including by extending patient choice to services where it is not currently available).

Even the section which outlines circumstances in which competition is NOT required makes it difficult to avoid a competitive approach. There are 3 conditions:

  • When there is only one provider
  • When the commissioner identifies the best provider through a detailed review in which all possible providers are offered the option.
  • Where the benefits of competitive tendering would be outweighed by its costs. This will need to be justified.

However, we understand that legal opinion suggests that the second and third bullet points COULD NOT be used – nothing in the legislation or regulations allows for them.

4.2 Three situations are considered in more detail below:

 Where there is only one provider that is capable of providing the services in question.

 Where a commissioner carries out a detailed review of the provision of particular services in its local area in order to understand how those services can be improved and, as part of that review, identifies the most capable provider or providers of those services.

The commissioner would also need to ensure that its engagement with each of the prospective providers is consistent with its obligation to act transparently and to treat providers equally under the Procurement, Patient Choice and Competition Regulations. In particular, the commissioner would need to ensure that potential providers have a reasonable opportunity to express their interest in providing the services in question.

 Where the benefits of competitive tendering would be outweighed by the costs of publishing a contract notice and/or running a competitive tender process.

Anti-competitive behaviour

When will behaviour be anti-competitive and not in the interests of users of health care services? Monitor will judge anti-competitive behaviour through a cost-benefit analysis, not through benefits for patients.

9.3 Where a commissioner’s conduct is in the interests of patients its behaviour will not be inconsistent with the prohibition on anti-competitive behaviour in Regulation 10. In assessing whether or not anti-competitive behaviour is in the interests of health care service users, Monitor will carry out a cost/benefit analysis. Monitor will consider whether by preventing, restricting or distorting competition behaviour gives rise to material adverse effects (costs) for health care service users.

If we find that behaviour gives rise to material costs, we will consider whether it also gives rise to benefits that could not be achieved without the restriction on competition.

Monitor will then weigh the benefits and costs against each other

Any anti-competitive behaviour must be justified by material and clinical benefits. Any restrictions on competition must be necessary to achieve the benefits.

9.3  Monitor will expect commissioners to be able to identify and describe the benefits to health care service users that arise from any anti-competitive conduct and to provide any relevant evidence in support. In deciding what value should be attributed to claimed benefits, Monitor will consider all relevant factors including, for example:

 the materiality of the benefits submitted;

 the period of time over which the benefits will be realised; and

 the robustness of the analysis and evidence that supports the claimed benefits (in considering clinical benefits, Monitor will have particular regard to supporting research and evidence regarding clinical improvements).

Any restrictions on competition must be necessary to achieve the benefits, if those benefits are to be taken into account for the purposes of establishing whether anticompetitive behaviour is in the interests of health care service users.

Contracts must not include any term or condition restricting competition that is not specifically needed to achieve the benefits. So, it may be difficult to use “continuity of care” or “knowledge of the local scene” as reasons for avoiding anti-competitive behaviour.

9.3 Regulation 10(2) clarifies that that an arrangement for the provision of NHS health care services must not include any term or condition restricting competition that is not necessary for the attainment of relevant benefits. Any term or condition restricting competition that is not necessary – for example because it goes beyond what is necessary to achieve benefits (such as a restriction that has a longer duration than is necessary or applies to a wider range of services than is necessary) – will breach Regulation 10(2).

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Thanks to Radiance Health for this useful graphic.  It’s focussed on South London, but the principles are of wider application, and there are many areas with similar problems.

It shows that

  • there is no NHS deficit. The NHS saved £3bn last year. The NHS is in surplus – and the money was given to the Treasury. There is a strong argument for saying that all surpluses should be ploughed back into the NHS, not given up.

The NHS should not be paying for procedures of little value.  We are committed to evidence based medicine. However, the Labour Party showed that PCTs are stopping procedures of good clinical value (such as bariatric surgery and cataracts).  There will always be rationing of medical treament. But it needs to be done rationally and accountably. Continue reading »

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Health professionals speak out

The organization of a health system is a public responsibility. We, health professionals, are concerned with diagnosing, treating and preventing illnesses in our patients. We do this without discriminating on the basis of race, gender or socio-economic status. Our role would be severely restricted and handicapped if care for patients were defined by primarily economic criteria. We do not wish to withhold necessary services, nor do we want to perform services that are medically unnecessary but profitable for health care providers.

In all European countries, the resources are available to provide excellent medical services as the European Union is one of the richest regions of the world. However, we are becoming increasingly concerned that the current political climate within the EU may counter the provision of good medical care.

Health is not a commodity

We note an increasing trend toward privatization of the health system and care organizations, regardless whether the health system is structured by governmental or insurance funds regulations. Increasingly, the health system will be commercialized and health and illness is becoming a commodity.

Privatization means:

  • Public hospitals and institutions are privatized
  • For-profit corporations take over public hospital services and ambulatory centers
  • In governmentally-organized health systems private corporations are allowed to offer and bill for services
  • Profits and surpluses from health care services are generated,  directed to investors and not to the benefit of the public and patients
  • Medical services provided typically by public health care institutions become increasingly limited and curtailed, while the private sector gains and offer these services for extra costs to the patient.
  • Well reimbursed highly technical services are ever-increasing

Privatization of the health system results in the loss of the solidarity principle and greater individual risk of the patients. It also restricts democratic influence, control and participation. The ever-growing pressure of corporations to generate profits leads to subordination of medical priorities to economic concerns and undermines the patient-doctor relationship.

In order to install the principles of a market-oriented health system, the ideology of ‘healthy competition’ is propagated. The for-profit private sector health system and the public system are forced to compete for patients and their care. In this situation, the most efficiently-run hospital is the champion and not the best patient-care oriented hospital. It also introduces the new ideology of competition into the traditional non-for-profit health care fund systems.

The same ideology is given as a reason for commercialization: There is a cost explosion because of medical progress, the growing aging of the population and the rising expectations of the “insured lives”. Because of resource limitations and financial constraints in the public sector, increased competition and privatization are the purported solutions.

However it is a fact that more privatization implies that access to care and quality health services become dependent on private income and resources. The more privatization occurs, the more expensive the health care system becomes – even if life-expectancy and general health status of the populations does not improve (see for example USA). Furthermore, the more privatization occurs the more bureaucratic the system becomes, because only what is “documented” is paid for in a competitive system.

This is our concept of a human society: A human society is characterized by solidarity with its weakest member.

Hospitals are not patient-factories.

The commercialism leads to unacceptable consequences for patients and health care providers. It results health care delivery surplus, the lack of health care services and misguided service and consequently in preventable suffering. In countries with high levels of privatization and economizing of the health care sector unnecessary health care is delivered because it makes financial sense and leads to direct profits. Even new fields of health care deliveries are explored. This can go so far that illnesses are made up in order to create a profitable service need. At the same time the numbers of health care providers are reduced to save labor costs. This in turn leads to more work for fewer providers, resulting in inferior health care for patients.  The commercial principle categorizes patients in lucrative and not-so lucrative patients, who receive different care. This is contrary to the principles of humanity and our professional ethical standards.

As health professionals, we oppose the privatization and commodification of the health care sector.

We demand:

  • Equal access to quality health care for all – irrespective of race, gender, creed or status.
  • Health care financing based on principles of solidarity and equality
  • Sufficient number of adequately-trained and paid health care providers (including contractual and legal guarantees)

We petition everyone, including all patients, to support us in this effort. We demand that responsible politicians stop the growing commercialization and economization of the health care sector and move to reverse this trend.

Organisations supporting the European manifesto opposing the commercialization of the health system:

•       Aktion Gsundi Gesundheitspolitik (Switzerland)
•       Basisgruppe Medizin Göttingen (Germany)
•       Federación de Asociaciones para la Defensa de la Sanidad Publica (Spain)
•       International Association of Health policy in Europe
•       Ogólnopolski Związek Zawodowy Pielęgniarek i Położnych – OZZ PiP (Poland)
•       Socialist Health Association (Great Britain)
•       Socialistiska läkare (Sweden)
•       Verein demokratischer Ärztinnen und Ärzte (Germany)
•       Asociación Española de Neuropsiquiatría-Profesionales de Salud Mental (Spain)
•       Medical Practitioners’ Union – Unite (Great Britain)
•       National Health Service Consultants’ Association (Great Britain)

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At the heart of concerns about reconfiguration and the future of our District General Hospitals is the issue around A&E Closures.


A real Accident & Emergency Department must have a genuine 24/7 consultant delivered surgical and medical service.  For a start it must meet the  Royal College of Physicians guidelines so that a consultant physician should always be available ‘on call’ and should be on site at least 12 hours per day, seven days per week with no concurrent duties.  And the admissions unit should have a consultant presence for more than four hours per day, seven days per week doing two rounds per day.  That alone rules out around half the current “A&E”s.  Then add the surgical capability to deal with the vast majority of cases and then the need for 24/7 diagnostics. In reality we have lots of places claiming to be A&E which are unsafe and unsuitable; many so called A&Es are actually already Urgent Care Centres.

And the answer is not spending more money to upgrade those which don’t meet the standards.  Aside from how you pay for it there simply are not enough clinicians, nurses and diagnostic staff to go round.  To be able to justify the high fixed cost of a true A&E and to provide a sufficient volume of patients to justify having 24/7 cover across almost all specialities requires a certain population level. Whilst this is a subject for some debate most think that population is at least 1m, probably more.

Given the needs of rural areas some kind of hub and spoke model has to be obvious, where some patients go to, or are taken to, a local spoke; part of an emergency care system.  The spokes can deal with the immediate needs in any type of emergency in any age group with cover from emergency care doctors 24/7 but may not have full on-site back-up services. A minority of patients may have initial treatment at a spoke and then be transferred using agreed protocols and procedures. Many “A&E”s do not even meet this lower standard.

Despite widespread opposition we already have systems where some patients (such as those with severe trauma or stroke) go direct to a regional or sub-regional unit where possible, or else go to a more local unit for stabilisation before onward transfer.  The evidence shows that going to the right place is better than going to the nearest place.

You then move to the next problem of what to do with some District General Hospitals if they no longer have A&E.  And that is the real issue – what is the best configuration for acute care and how do we get there from where we are today.  But politically we can’t have that debate and the Royal Colleges are not giving us the leadership, at least not yet.

So “downgrade” an “A&E” and protests follow.  It is claimed, always, that lives are put at risk if a local “A&E” is closed and the ambulance has to travel further.  If anyone tries to point out there is less risk overall then they are shouted down.  This just reflects the sad truth that for many years the NHS leadership has totally failed to explain reality and everyone thinks closure = cuts; and it often does!  Maybe the time to rationalise our emergency care was when funding was less of an issue.

The Department of Health fall back on the nonsense that “Changes to local health services are decided and led locally. Local healthcare organisations, doctors, nurses and other health professionals, with their knowledge of the patients they serve, are best placed to decide what services they need for patients in their area.”  This is so ludicrous they should have noticed.  Just about every contentious proposal actually gets referred up to the Independent Reconfiguration Panel and so to the Secretary of State – so hardly local.  Most proposals actually cover various “localities” not just one and there is unlikely to be a “local” voice with any clarity.  The classic is where everyone agrees one of two units must shut and services concentrated in one place – for perfectly sound reasons.  But which “locality” loses its service?  Where is the leadership then?

The whole problem is compounded by the wider mess we have made of what should be a coherent urgent/emergency care system. Most urgent care is primary care, but we don’t invest in primary care. We failed to give the ambulance services the key role they merit and instead fragmented the system using competition for lots of urgent care providers and out of hours GP services and it’s an uncoordinated and confusing mess with ridiculous duplication of systems and processes.

So it’s easiest to get out the placards, join the protests and defend local services.  See you at the barricades.

Irwin Brown

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Health professionals erheben ihre Stimme – Kurzfassung

Die Organisation des Gesundheitswesens ist eine öffentliche Aufgabe. Als Gesundheitsprofessionelle sind wir damit betraut, die Krankheiten unserer PatientInnen zu diagnostizieren, zu behandeln und nach Möglichkeit zu verhüten. Wir sollten diese Aufgabe ohne Ansehen der Person wahrnehmen. Eine Unterordnung unter vorwiegend ökonomischen Kriterien hindert uns diese Aufgaben zu erfüllen: Weder wollen wir PatientInnen medizinisch notwendige Leistungen vorenthalten, noch wollen wir Leistungen erbringen, die medizinisch überflüssig, aber für den Leistungserbringer lukrativ sind.

Diese Bedingungen für eine gute Medizin herzustellen, ist in allen europäischen Ländern möglich. Ist doch die EU eine der reichsten Regionen der Erde. Aktuell erleben wir europaweit eine Entwicklung, die diesem Anliegen entgegenläuft.

Krankheit ist keine Ware

Ob wir ein staatliches Gesundheitswesen haben oder eines, das über Sozialversicherungen organisiert wird, wir sehen überall eine zunehmende Privatisierung und Kommerzialisierung des Gesundheitswesensbzw. der Medizin. Das Gesundheitswesen wird zum Markt, Gesundheit und Krankheit werden zu Waren. Ein wichtiges Moment dieser Ökonomisierung/Kommerzialisierung ist die Privatisierung.

Privatisierung bedeutet:

  • ehemals staatliche oder gemeinnützige Krankenhäuser werden privatisiert;
  • große Klinikkonzerne, als Aktiengesellschaften organisiert, übernehmen zunehmend die stationäre Versorgung und dringen in den „Markt“ der ambulanten Versorgung ein;
  • in ehemals staatlichen Gesundheitswesen können private Anbieter Leistungen anbieten;
  • Gewinne aus Gesundheitsleistungen fließen an private Kapitalgeber und werden damit dem Gesundheitswesen entzogen und verteuern es so für die Gesellschaft;
  • medizinisch notwendige Leistungen werden aus dem Leistungskatalog des staatlichen Gesundheitswesensbzw. der Sozialversicherungen ausgegliedert und müssen privat bezahlt werden;
  • hochtechnisierte Leistungen, die gut honoriert werden, kommen zunehmend zur Anwendung.

Privatisierung führt zu gesellschaftlicher Entsolidarisierung und Abwälzung des Krankheitsrisikos auf die Individuen und sie beschränkt demokratische Einflussmöglichkeiten. Der Druck von Gesundheitskonzernen, Profite machen zu müssen, ordnet medizinische Prioritäten zwangsläufig ökonomischenbzw. betriebswirtschaftlichen unter und untergräbt das Arzt-Patient-Verhältnis.

Um diese Prinzipien systematisch im Gesundheitswesen zu verankern, werden Mechanismen kapitalistischer Konkurrenz unter der beschönigenden Bezeichnung „Wettbewerb“ implementiert: So konkurrieren private Anbieter mit öffentlichen und gemeinnützigen. Krankenhäuser konkurrieren untereinander um Patienten. Nicht das medizinisch beste Krankenhaus ist der „Sieger“ in diesem Wettbewerb, sondern das betriebswirtschaftlich am erfolgreichsten arbeitende. Auch bei gesetzlichen, sozialen Krankenversicherungen ist das Konkurrenzprinzip eingeführt.

Begründet wird diese Kommerzialisierung überall mit den gleichen ideologischen Formeln: Es gebe eine Kostenexplosion durch den sogenannten medizinischen Fortschritt, die Überalterung der Bevölkerung aber auch durch die gestiegene Anspruchshaltung der Bevölkerung. Angesichts knapper Ressourcen der öffentlichen Hand seien Einsparungen notwendig und diese am besten durch mehr Wettbewerb und Privatisierung zu erreichen.

Tatsache aber ist: Je mehr privatisiert wird, umso mehr hängen Zugang und gute Versorgung der Bevölkerung vom eigenen Einkommen ab. Je mehr privatisiert wird, umso teurer wird ein Gesundheitswesen – ohne dass die Lebenserwartung und der Gesundheitszustand der Bevölkerung besser ist als anderswo (siehe USA). Und: Je mehr privatisiert wird, umso bürokratischer wird ein System, denn nur was dokumentiert wird, wird im Wettbewerb auch bezahlt.

Das ist nicht unsere Vorstellung von einer humanen Gesellschaft. Die Humanität einer Gesellschaft zeigt sich an der Solidarität mit ihren schwächsten Mitgliedern.

Krankenhäuser sind keine Patientenfabriken

Die Kommerzialisierung hat unakzeptable Konsequenzen für PatientInnen und Beschäftigte im Gesundheitswesen. Sie führt zu Über-, Unter- und Fehlversorgung und damit zu vermeidbarem Leiden. In Ländern, in denen die Ökonomisierung schon weit fortgeschritten ist, führt sie dazu, dass häufig nicht medizinisch indizierte Leistungen erbracht werden,  da aus betriebswirtschaftlichen Gründen neue „Geschäftsfelder“ erschlossen werden müssen. Das geht so weit, dass Krankheiten für diesen Zweck regelrecht erfunden werden. Gleichzeitig wird zur Realisierung von Profiten immer mehr Personal abgebaut. Dies führt bei einer extremen Arbeitsverdichtung für die Beschäftigten zu einer schlechteren Versorgung für die PatientInnen. Die Ökonomisierung selektiert Patienten in lukrative und weniger lukrative PatientInnen, die unterschiedlich behandelt werden. Dies widerspricht den Grundsätzen der Humanität und unserem Berufsethos.

Als Gesundheitsprofesionelle sprechen wir uns aus gegen die Ökonomisierung und die Privatisierung des Gesundheitswesens aus.

Stattdessen fordern wir:

  • einen gleichen Zugang zu medizinischer Versorgung für Alle qualitativ hochwertige Versorgung für Alle – ohne Ansehen der Person
  • eine solidarische und gerechte Finanzierung des Gesundheitswesens
  • ausreichendes, gut ausgebildetes und ordentlich bezahltes Personal im Gesundheitswesen (mit gesetzlicher Regelung eines verbindlichen Personalschlüssels)

Wir fordern die Bevölkerung, Patientinnen und Patienten auf, sich mit uns für diese Ziele einzusetzen. Wir fordern die verantwortlichen Politikerinnen und Politiker auf, den Zug der Ökonomisierung und Kommerzialisierung des Gesundheitswesens zu stoppen und zur Umkehr zu zwingen!

Europäisches Manifest gegen die Kommerzialisierung des Gesundheitswesens

Unterzeichnende Organisationen:

Verein demokratischer Ärztinnen und Ärzte (Germany)

Socialistiska läkare (Sweden)

Socialist Health Association (United Kingdom)

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