Category Archives: Professional opinion

PROTECT ALL FRONTLINE HEALTHCARE WORKERS

31/03/2020 cllralanhall BlogPress Leave a comment

Personal Protective Equipment, known as PPE is in demand. There are reports that there is a shortage in hospitals and care facilities.

The Daily Mirror reports that hospitals listed as having shortages include Rotherham General Hospital, Bristol Children’s Hospital, Hillingdon Hospital in Uxbridge, Royal Devon and Exeter Hospital and at St Thomas, Lewisham and two other unnamed hospitals in London.

“The correct PPE must be made available at every site that might require it. This is vital in order to protect our patients but also to protect the lives of the life-savers.”
DAUK’s Dr Natalie Ashburner in @DailyMirror @nashburner#COVID19 #testNHSstaffhttps://t.co/Mhd2UISZeF

— The Doctors’ Association UK (@TheDA_UK) March 19, 2020

The view from the NHS frontline is explained here:

https://youtu.be/WphmagWsCUI

Dr Samantha Batt-Rawden, an intensive care doctor and president of the Doctors’ Association UK, told Nick Ferrari that more doctors will die unless they get proper equipment.

In a further twist, healthcare workers who raise their concerns are facing being “gagged”. Helen O’Connor, GMB says in The Guardian “It is scandalous that hospital staff speaking out publicly face being sacked by ruthless NHS bosses

who do not want failings in their leadership to be exposed. Suppression of information is not just a matter of democracy, it is now a major public health issue.”

The Local Government Association has sent a letter to the Secretary of State for Health, Matt Hancock MP. It says that there is an urgent need for Government to move faster in making PPE available for the adult social care sector. Sufficient supplies that are of acceptable quality are needed immediately. Councils and their provider partners also need concrete assurances about ongoing supplies for the days and weeks ahead.

Councillor Alan Hall has written to the Director of Public Health for Lewisham seeking reassurances for both hospital and social care staff locally. The full letter is below:

Catherine Mbema
Director of Public Health – Lewisham

Dear Catherine,

I have been informed that the lack of Personal Protective Equipment for cleaning staff at Lewisham Hospital is a real concern. Trade Unions say that there is a shortage of supply and that staff are very worried. It has been described as “a total nightmare”.

As the Public Health Lead across Lewisham, I would be very grateful if you could raise the shortage of supply with the NHS and the Hospital and reassure us that PPE will be available.

Whilst I write, personal carers have reported shortages and inadequacies nationally. Can an assurance that all Lewisham Council and NHS staff have been provided with effective PPE?

May I take this opportunity to thank you and your team for all the incredible work that has been placed upon you. I have always campaigned against Public Health cuts and the short sightedness of this is surely been borne out now.

Kind regards,

Alan

Cllr Alan Hall

In an article on the United Nation’s website, there is a chilling message:

“COVID-19 will not be the last dangerous microbe we see. The heroism, dedication and selflessness of medical staff allow the rest of us a degree of reassurance that we will overcome this virus.

We must give these health workers all the support they need to do their jobs, be safe and stay alive. We will need them when the next pandemic strikes.”

Please help: NHS Staff need adequate PPE now https://t.co/XLsLDNaz5g via @socialisthealth

— Alan Hall (@alan_ha11) April 1, 2020

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COVID-19 Pandemic

The SHA wants to contribute to the tremendous national and international debate about controlling and mitigating the worst effects of the COVID-19 pandemic. We will base these thoughts through the lens of a socialist society, which advocated politically in the 1930s to create the NHS in the UK and for other socialist policies, which see the social determinants of health being as important as the provision of health and social care services as we strive for a healthier and fairer society.

This blog will be the first of a series and will cover

 

  1. A global crisis
  2. The Public Health system
  3. The NHS, Local Government and Social Care
  4. Funding for staff and facilities
  5. Staff training, welfare and support
  6. Vulnerable populations
  7. Assuring Universal Basic Income

 

  1. A global crisis

This COVID-19 pandemic has already been cited as the greatest public health crisis for at least a generation. The HIV/AIDS pandemic starting in the 1980s had a much slower spread between countries and is estimated to have caused an estimated 25-30m excess deaths so far.  The potential scale of this type of respiratory viral infection pandemic with a faster spread means we should probably look back to the 1957 Asian flu pandemic and indeed the 1918 post war ‘Spanish flu’. The 1918 pandemic led to an estimated 40-50m global deaths and was when there was also no effective vaccine or treatment for the new variant of flu. So basic public health hygiene (hand washing), identifying cases and quarantining (self isolation) are still important. We recognise this as a global challenge, which requires global solidarity and the sharing of knowledge/expertise and advice.

The WHO, which is part of the United Nations, needs our support and is performing a very beneficial role.  This will be especially important for those Low Middle Income Countries (LMICs) who often have unstable political environments and weak public health and health systems. Remember the Democratic Republic of the Congo who have only just seen off their Ebola epidemic, war torn Syria and the Yemen.

The USA and other high-income countries should be unambiguous about recognising this as a fundamental global pandemic requiring collaboration between countries along the principles of mutual aid. The UN and WHO need our support and funding and we look to international financial organisations such as the IMF/World Bank to rally around in the way that the world banking system showed they could in their own self inflicted 2008 financial crash. The WHO has recently referred to Europe as the epicentre of the pandemic and we urge the Government to put aside their ideological objections and co-operate fully with the EU and our European partners.

 

  1. The public health system

The UK itself is in a relatively strong position with a national public health service, which has focus at a UK level (CMO/PHE), scientific advisory structures (SAGE), devolved governments, municipalities and local government. The NHS too still has national lines of control from NHSE to the NHS in England and the equivalents in devolved countries. The Tory ‘Lansley’ reforms in England destroyed the health authority structure below national levels (remember the former Strategic and District Health Authorities) but at least PHE has a regional organisation and Local Government have Directors of Public Health. We regret the fact that the 10 years of Tory austerity has depleted the resources in PHE and Local Government through not funding the PHE budget adequately and not honouring the public health grant for local authorities. We hope that the recent budget will mean that the public health service and local government does receive the financial and other resources required to help lead the pandemic response. Pandemics have always been high up in the UK risk register.

 

  1. The NHS, Local Government and Social Care

We are grateful that despite the privatisation of many parts of the NHS in England we still have a recognisable system and a culture of service rather than profit within our one million or so staff and their NHS organisations. We were pleased to hear the open ended funding commitment from the Chancellor at the last budget and urge that leaders within the NHS in England and the devolved countries use this opportunity to try to mitigate the underfunding over the last 10 years and implement the emergency plans that exist and calibrate them to deal most effectively with this particular viral threat. Any debates about further privatisation of the NHS needs to be taken off the agenda and let’s not use the budget money to prop up the private sector but requisition capacity if that is what is needed and compensate usage on an NHS cost basis. We want to protect the NHS from the risk that the NHS Long Term Plan proposals for 44 Integrated Care Schemes opens up the risk of US styled private insurance schemes.

 

  1. Funding for staff and facilities.

It will of course be difficult as a result of the staffing crisis that has been allowed to drift over the past 10 years with shortages of NHS workforce of 100,000 of which 40,000 are nurse vacancies but also includes doctors and other key staff. We and our Labour Party colleagues have been reminding Tory Ministers  that it takes 10 years to train a medical specialist so you cannot whistle them up or poach them from other poorer countries. The government needs to abolish their proposed points based immigration regime and indeed the compulsory NHS insurance of £650 per adult which is a huge disincentive to come here and work in the health and social care system.

Hospitals and other health facilities in the UK take time to plan, build and commission. We can of course learn from Wuhan in China where they built a 1000 bedded hospital in weeks! Our own war preparation in the late 1930s when industry shifted production rapidly from civilian to military supplies is another exemplar. Despite the negative impact of 10 years of Tory austerity we urge the NHS to embrace this opportunity to invest in staff, supplies and facilities needed to manage the effects of the pandemic. Creating strategic regional NHS bodies will ensure that capital and revenue resources committed from the centre are used optimally and equitable to meet population needs in collaboration with local authorities.

 

  1. Staff training, welfare and support

Front line NHS and social care staff will need our support over this time. We must ensure that working practices protect staff as much as possible from the risks in the workplace. Training and provision of Personal Protective Equipment (PPE) is vital and employment practices will need to adapt to the changing situation. Lets not forget social care workers, dentists, optometrists and district nurses who are part of our front line. Staff will need retraining if doctors and nurses are to be diverted to unfamiliar roles as we will need A&E, pandemic pods and intensive care unit capacity to be enhanced. Sadly, we now have a significant workforce who work for private contractors as part of the Tory privatisation of the NHS. We need to ensure that they have the same employment safeguards, minimum pay levels, sick pay and the health and safety entitlements as NHS staff. This is the time to renationalise such services back into the fold.

 Patients with existing long-term conditions remain in need of continuing care as will patients presenting with new life-threatening conditions such as cancers, diabetes and circulatory diseases. NHS managers will need support to organise these different services and decisions to postpone non-urgent elective surgery to free up resources. What also makes sense is testing novel ways of supporting people digitally and by teleconferencing to reduce attendance at NHS premises. This can be rolled out for Out Patient provision as well as GP surgeries. The NHS 111 service, and other online services  and the equivalents in the devolved nations can easily be overwhelmed so pushing out good health information and advice is being done and needs to continue. The public and patient engagement has always been at the heart of our policies and can be rolled out in this emergency utilising the third sector more imaginatively.

 

  1. Vulnerable populations.

In our assessment of what needs to be done we must not bypass the urgent needs of some of our most vulnerable populations. The homeless and rootless populations, many of whom have longstanding mental health conditions and/or substance dependency, are particularly at risk. They need urgent attention working closely with the extensive voluntary sector. Also those populations with long term conditions who will feel at risk if services are withdrawn due to staff redeployment or staff sickness need planning for. Primary care needs to be the service we support to flag up those in need and ensure that their medications and personal care needs continue to be met even if we need to involve volunteers and good neighbours to help out with daily needs such as shopping/providing meals and other tasks.

Undocumented workers such as migrants and refugees are often frightened to use health services for fear of police intrusion. The government needs to make it clear that there will be no barriers to care for this population during this crisis and beyond.

Social care is in need of particular attention. It was virtually ignored in the budget. This sector is at risk in terms of problems with recruiting and retaining staff as well as the needs of the recipients of care and support.. While business continuity plans may be in place there is no question that this sector needs investment and generous support at the time of such an emergency. They will be a vital cog in the wheel alongside home-based carers in supporting the NHS and wider social care system. Those most at risk seem to be the most neglected. Disabled people with care needs have received little advice and no support. Already carers are going off sick and can be replaced only with great difficulty. Those paying for their own care with Direct Payments seem to get no support at all.

With the COVID-19 virus we are seeing that the older population and those with so called ‘underlying conditions’ are at particular risk. We must ensure that this large population do not feel stigmatised and become isolated. Rapid assembly of local support groups should be encouraged which has been referred to as ‘local COBRA groups’. Local government can play a key role in establishing local neighbourhood centres for information and advice on accessing support as we move toward increasing quarantining and isolated households. Again wherever possible the use of IT and telephone connectivity to share information and provide remote support will make this more manageable.

 

  1. Assuring universal basic income.

Finally the SHA recognises that the economy will be damaged by the pandemic, organisations will go to the wall and staff will lose their jobs and income stream. We have always recognised that the fundamental inequalities arise from the lack of income, adequate housing and the means to provide for everyday life. This pandemic will last for months and we think that the Government needs to ensure that we have systems in place to ensure that every citizen has access to an adequate income through this crisis. We pay particular attention to the 2m part time workers and those on zero hours contracts as well as the 5m self-employed. There have been welcome changes in the timely access to the insufficient Statutory Sick Pay but this is not going to be the answer. People will be losing their jobs as different parts of the economy go under as we are already seeing with aviation, the retail sector and café/restaurants. The government needs to reassure those fearful of losing their jobs that they will stand by them during the pandemic. It may be the time to test the Universal Basic Income concept to give all citizens a guarantee that they will have enough income for healthy living. We already have unacceptable health inequalities so we must not allow this to get worse.

 

  1. Conclusion

The SHA stands ready to support the national and international efforts to tackle this pandemic. We assert our belief that a socialist approach sees universal health and social care as an essential part of society. That these systems should be funded by all according to a progressive taxation system and meet peoples needs being free at the point of use.  We believe that a thriving state owned and operated NHS and a complimentary not for profit care sector is essential to achieve a situation where rich and poor, young and old and citizens in towns, cities and in rural areas have equal access to the best care.

We recognise that the social determinants of health underpin our health. We agree with Marmot who reminds us that health and wellbeing is reflected by ‘the conditions that people are born, grow, live, work and age and by the inequities in power, money and resources that influence these conditions’.

The pandemic is global and is a major threat to people’s health and wellbeing. Universal health and public health services offer the best means of meeting this challenge nationally and globally. Populism and inward looking nationalism needs to be challenged as we work to reduce the human suffering that is unfolding and direct resources to meet the needs of the people at this time.

On behalf of officers and vice chairs

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One on International Trade dispute settlements and the other on Social Care.

These are not official SHA policy.

Issues for the NHS during UK Trade deal Negotiations

As socialists we have an almost irreconcilable set of principles

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Responding to the third tranche of inspections from Her Majesty’s Inspectorate of Fire and Rescue Services, Matt Wrack, Fire Brigades Union (FBU) general secretary, said:

On the national view

“This tranche of reports are a complete indictment of the government’s dangerous complacency over the risk of fire, flooding, and other hazardous incidents. Austerity has ravaged our fire and rescue service, leaving residents in many areas at risk. In Gloucester, the inspectorate are clear that changes are needed ‘urgently’, but politicians and fire service management elsewhere must not rest on their laurels.

“With no national standards and no national infrastructure coordinating fire and rescue service policy, residents inevitably face a postcode lottery of fire safety.

“While fire service bosses must be responsible for any failings, so too should the politicians who have starved them of funding, resources and boots on the ground. Our service is collapsing – it’s plainly unsustainable.”

On Grenfell

“The inspectorate’s verdict that London Fire Brigade’s senior management has been slow to learn from the Grenfell Tower tragedy will make worrying reading for firefighters, who have faced unfair criticism while others, including those in government, have no been held to account. It will also be deeply concerning for the Grenfell community and all of London.

“Grenfell must be a turning point for UK fire safety – anything less is completely unacceptable. The inquiry’s vital recommendations must be implemented quickly in London, but they also must be implemented in every fire and rescue service in the country.”

On equality and culture

“It’s shameful that not enough is being done enough to improve equality and diversity in our service. Progress has all but flat-lined under this government – and a severe lack of recruitment and the scrapping of equality targets is largely to blame. We need to recruit more firefighters – and we need to make sure they reflect the communities they serve.

“We are also deeply concerned about toxic bullying and harassment from management in many fire and rescue services. Firefighters give their all to keep the public safe – it’s disgraceful that certain fire service bosses have thanked them with intimidation. We urge any firefighter affected to contact their FBU representative.”

Notes:

The FBU is the trade union representing the overwhelming majority of firefighters in the UK and serves as the professional voice of firefighters and the fire and rescue service. The union is a core participant in the ongoing Grenfell Tower Inquiry.

The FBU’s initial response to the publication of the Grenfell Tower Inquiry phase one report is available here: https://www.fbu.org.uk/news/2019/10/30/fbu-response-grenfell-tower-inquiry-phase-1-report

The FBU launched its Grenfell: Never Again campaign on the second anniversary of the fire, with five demands: 1) the removal of all flammable cladding; 2) retrofitting sprinklers wherever a risk assessment deems necessary; 3) ensure a strong, democratic voice for tenants; 4) reverse the cuts to firefighter numbers and fire safety officers and; 5) create a new national body to oversee the fire and rescue service. For more information, please see here: www.fbu.org.uk/grenfell-never-again

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A major fire at a Travelodge in Brentford, London, today saw more than 100 firefighters respond.

Matt Wrack, FBU general secretary, said:

“This fire is yet another sign of this government’s utter failure to get to grips with our fire safety crisis. Two years on from Grenfell, there has still been no comprehensive programme testing building materials.
“The approach so far has been the agonisingly slow removal of one particular kind of cladding, but that barely scratches the surface.
“The Tory manifesto made no new policy proposals to tackle the fire safety crisis – just more of the same indifferent inaction. They have slashed the fire and rescue service and could not even bring themselves to mention it in their manifesto. Their record is nothing short of shameful.
“We need to bring together firefighters, government, tenants, and the fire safety industry to properly implement the Grenfell inquiry recommendations and get to grips with this crisis before we have another tragedy.

Media contact: Joe Karp-Sawey, FBU communications officer

joe.karpsawey@fbu.org.uk

Notes

The FBU recently called for a forum of all those needed to drive through sweeping changes to UK fire safety, writing to representatives from the government and shadow cabinet, the London Fire Brigade, the National Fire Chiefs Council, the Mayor of London, the Local Government Association, the first ministers of Scotland, Wales and Northern Ireland, fire safety bodies and the Grenfell community. For more information, please see here: https://www.fbu.org.uk/news/2019/11/25/firefighters-call-forum-implement-grenfell-inquiry-recommendations

The FBU is the trade union representing the overwhelming majority of firefighters in the UK and serves as the professional voice of firefighters and the fire and rescue service. The union is a core participant in the ongoing Grenfell Tower Inquiry.

The FBU’s initial response to the publication of the Grenfell Tower Inquiry phase one report is available here: https://www.fbu.org.uk/news/2019/10/30/fbu-response-grenfell-tower-inquiry-phase-1-report

The FBU launched its Grenfell: Never Again campaign on the second anniversary of the fire, with five demands:

1) the removal of all flammable cladding;

2) retrofitting sprinklers wherever a risk assessment deems necessary;

3) ensure a strong, democratic voice for tenants;

4) reverse the cuts to firefighter numbers and fire safety officers and;

5) create a new national body to oversee the fire and rescue service.

 

For more information, please see here: www.fbu.org.uk/grenfell-never-again

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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?

 

@dr_shibley

 

 

 

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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 (c.paton@keele.ac.uk) 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.

2 Comments
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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