Category Archives: Public Health

This article was first published by Simon Collins at HIV i-Base on 2 September 2019.

On 2 September 2019, leading HIV charities including HIV i-Base and the UK-Community Advisory Board (UK-CAB), published an open letter to Rt Hon Amber Rudd MP in her capacity as Minister for Women and Equalities, calling for an urgent intervention to include sexual health in the upcoming Government Spending Round. [1]

In England, the responsibility for sexual health was disastrously shifted from the NHS to local authorities, whose public health budgets have been cut in real terms by £700 million over the last five years.

These cuts have directly reduced access to sexual health services, where many people are unable to routinely access treatment and testing due to limitations in allocation of daily appointments.

Many of these cuts disproportionately affect lesbian, gay, bisexual and transgender (LGBT+) and black and minority ethnic (BAME) communities, and young people.

A similar joint letter calling for increased funding for sexual health was also sent today by LGBT+ groups from the Labour, LibDeb and Conservative parties.

Last year, a review of services in South London reported that 1 in 8 people with symptoms were being turned away from sexual health clinics. This included 40% who were under 25 years old and 6% who were under 18.

References

  1. Green I et al. Urgent request to intervene: Funding for sexual health services. 2 September 2019.
    http://www.tht.org.uk
  2. Collins S. Almost 1 in 8 people with symptoms turned away from sexual health clinics in SE London: 40% are under 25 and 6% under 18 years old. HTB 01 May 2018.
    http://i-base.info/htb/33968

Please see this Press Release from BASHH (British Association of Sexual Health and HIV) and BHIVA (British HIV Association) from October 2018: Government funding cuts leave sexual health and HIV care at ‘breaking point’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Please circulate this as widely as possible.

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The Socialist Health Association (SHA) notes the public health green paper – Advancing our health: prevention in the 2020s, which was published on the 22nd July by the Cabinet Office.

 

We believe that this is a missed opportunity, which ignores much of the evidence on what works best to improve people’s health and wellbeing. Doing something at the level of communities, such as changing an ‘obesogenic’ environment, is more effective and much better value for money, than doing something one by one for individuals..  The paper also largely ignores the impact of poverty and the gross and worsening inequalities in health. At a time when the Government wishes to unite the country, this again betrays its inability to put first the health and wellbeing of all communities.

We support the recognition that health is an asset and a composite health index should be used at Cabinet and across government departments in their planning and investment decisions. We also strongly support the goal of a smoke free country by 2030 but believe that this will need strong regulation and taxation policies. We also support the removal of barriers put in place of water fluoridation, which is an effective way of promoting oral health in children and thus their dentition for life. Finally we support the strengthening of food and drink regulations in respect of salt, sugar and fat content but look to committing to specific measures such as the sugar tax for milky drinks and beverages.

40 years after the Black report on ‘Health Inequalities’ (1980), there is still too little commitment to address poverty. Poverty exacerbated by years of austerity, has resulted in reducing life expectancy and increasing infant mortality. There is no shortage of expert evidence and advice such as the Marmot reports which point to investment in the first 1000 days of life, early years education, the need to have a living wage and a society which enables ageing well. We need to see a strategic commitment by government to abolish child poverty, support parents in the early years and ensure that people have access to jobs that provide a living wage for families.

The Green Paper disappoints too in drawing back from a purposeful commitment to regulate and use taxation to shape the powerful commercial determinants of our health, such as the food and drink market.  We do not see the evidence for change unless linked with regulation (salt), taxation (sugar) and pricing (alcohol unit price). Similarly the rapid growth in gambling driven by advertising on television and social media and enabled by the digital world will require urgent legislation to prevent the growth in harm caused by addiction and consequential debt.

The SHA has recently published our own ‘Prevention and Public Health policy’ endorsed by the Central Council (available at www.sochealth.co.uk), which unlike the government’s Green Paper gives priority to the Climate Emergency and Planetary Health as well as prioritising addressing the social determinants of health.

The Green Paper makes individuals responsible for their own health in a way which will exacerbate the health outcome gap between the rich and poor. There is strong evidence for achieving better health outcomes through implementing interventions on the social, economic and environmental determinants of health and wellbeing. The emphasis on genomics, big data and artificial intelligence (AI) is misplaced in population level prevention policies, although we agree that these areas are exciting and need further research and evaluation

More recent evidence over the past 20 years of the Climate Emergency – the 21st century public health challenge – also needs to be a high priority for prevention and public health.

SHA 26th July 2019.

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Introduction

 

The  SHA Council agreed to pull together some of the existing policies on prevention and public health, introduce new proposals that have been identified and put them into a policy framework to influence socialist thinking, Labour Party (LP) manifestoes and future policy commitments. The SHA is not funded by the industry, charitable foundations or by governments. We are a socialist society which is affiliated to the Labour Party (LP) and we participate in the LP policy process and promote policies which will help build a healthier and fairer society within the UK and globally. An SHA working group was established to draft papers for the Central Council to consider (Annex 1).

The group were asked to provide short statements on the rationale for specific policies (the Why?), reference the evidence base and prioritise specific policies (the What?). Prevention and Public Health are wide areas for cross government policy development so we have tried to selectively choose policies that would build a healthier population with greater equity between social groups especially by social class, ethnicity, gender and geographical localities. We have taken health and wellbeing to be a broad concept with acknowledgement that this must include mental wellbeing, reduce health inequalities as well as being in line with the principles of sustainable health for future generations locally and globally.

The sections

These documents are divided into five sections to allow focus on specific policy areas as follows:

  1. Planetary health, global inequalities and sustainable development
  2. Social and the wider determinants of health
  3. Promoting people’s health and wellbeing
  4. Protecting people’s health
  5. Prevention in health and social care

The working group have been succinct and not reiterated what is a given in public health policies and current LP policy. So for example we accept that smoking kills and what we will propose are specific policies that we should advocate to further tackle Big Tobacco globally, prevent the recruitment of children to become new young smokers, protect people from environmental smoke and enable smokers to quit. We look to a tobacco free society in the relatively near future. Whether tobacco, the food and drink industry, car manufacturers or the gambling sector we will emphasise the need to regulate advertising, protecting children and young people especially and make healthy choices easier and cheaper through regulations and taxation policies.

Wherever appropriate we take a lifecourse approach looking at planned parenthood, maternity and early years all the way through to ageing well. We recognise the importance of place such as the home environment, schools, communities and workplaces and include occupational health and spatial planning in our deliberations.

We discuss the NHS and social care sector and draw out specific priorities for prevention and public health delivery within these services. The vast number and repeated contact that people have with these servces provides opportunities to work with populations across the age groups, deliver specific prevention programmes and use the opportunities for contacts by users as well as carers and friends and relatives to cascade health messages and actions.

The priorities and next steps

In each section we have identified up to ten priorities in that policy area. In order to provide a holistic selection of the overall top ten priorities we have created  a summary box of ten priorities which identify the goals, the means of achieving them and some success measures.

This work takes a broad view of prevention and public health. It starts with considering Planetary Health and the climate emergency, global inequalities and the fact that we and future generations live in One World. A central concern for socialists is building a fairer world and societies with greater equity between different social classes, ethnic groups, gender and locality. We appreciate that the determnants of such inequalities lie principally in social conditions, cultural and economic influences. These so called ‘wider determinants and social influences’ need to be addressed if we are to make progress. The sections on the different domains of public health policy and practice sets out a holistic, ecological and socialist approach to promoting health, preventing disease and injury and providing evidence based quality health and social care services for the population.

The work focuses on the Why and What but we recognise the need for further work to support the implementation of these priorities once agreed by the SHA Council. Some will be relatively straightforward but others will be innovative and we need to test them for ease of implementation. A new Public Health Act, as has been established in Wales, but for UK wide policies would make future public health legislation and regulation easier.

The SHA now needs to advocate for the strategic approach set out here and the specific priorities identified by us within the LP policy process so they become part of the LP manifesto commitments.

 

Dr Tony Jewell (Convener/Editor)

Central Council

July 2019

The complete policy document is available below for downloading.

Public health and Prevention in Health and Social carefinaljuly2019

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Patients still make enquiries at busiest hours, despite 24/7 online access

· University of Warwick publishes first independent evaluation of one of the main providers of online consultation platforms

· Targeting services at younger patients and those with general administrative enquiries could be most effective

· “In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes.” Says supervising author.

Patients are using online consultations in the same way they would arrange a consultation via traditional means, a new independent evaluation by the University of Warwick reveals.

Despite this, the study identifies several opportunities to tailor online platforms to specific patient requirements and improve their experience.

Primary care researchers from Warwick Medical School have today (26 March) published the first independent evaluation of one of the main providers of online consultation platforms in NHS general practice. Published in the British Journal of General Practice, it provides independently analysed information on the types of patients that are using online triage systems, how and when patients are using this platform, and what they think of it.

Online triage is a system in which patients describe their problems via an online form and subsequently are telephoned by a GP to conduct a telephone consultation or arrange a face-to-face consultation. Practices aim to respond within one hour of receiving the request.

The researchers examined routine information from 5140 patients at nine general practices using the askmyGP platform over a 10 week period. Highest levels of use were between 8 am and 10 am on weekdays (at their highest on Mondays and Tuesdays) and 8 pm and 10 pm at weekends, mirroring the busiest time for patients contacting their practice via telephone.

Supervising author Dr Helen Atherton, from Warwick Medical School, said: “With online platforms there is an assumption that having a 24/7 ability to make contact with a general practice will cater to those who wish to deal with their health problem at a convenient time, often when the practice is shut, and that being online means they will perhaps share different problems than they would over the telephone or face-to-face.

“In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes. This suggests that patients’ consulting behaviour will not be easily changed by introducing online platforms. Therefore practices should be clear as to exactly why they are introducing these online platforms, and what they want to achieve for themselves and their patients in doing so – the expectation may well not meet reality.”

The NHS Long term plan sets out that over the next five years all patients will have the right to online ‘digital’ GP consultations. The main way these are being delivered is via online consultation platforms. The online platforms claim to offer patients greater convenience and better access and to save time and workload for GPs, however there is currently a lack of independent evidence about their impact on patient care and care delivery.

Patient feedback analysed as part of the study showed that many found the askmyGP system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting.

The study found that two thirds of users were female and almost a quarter were aged between 25 and 34, corroborating existing evidence. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list.

The researchers argue that practices should avoid a ‘one size fits all’ approach to implementing online consultations and should tailor them to suit their practice populations and model of access, considering whether it is likely to add value for their patient population.

Dr Atherton adds: “Individual online consultation platforms are uniform in their approach, patients are not. We found that patient satisfaction is context specific – online consultation is not going to be suitable for all patients and with all conditions and that one approach is unlikely to work for everyone.

“Practices could focus on encouraging people to deal with administrative issues using the platform to free up phone lines for other patients. It could be promoted specifically to younger patients, or those who prefer to write about their problems and not to use the telephone. Clear information for patients and a better understanding of their needs is required to capture the potential benefits of this technology.”

· ‘Patient use of an online triage platform; a mixed-methods retrospective exploration in UK primary care’ published in the British Journal of General Practice, DOI: 10.3399/bjgp19X702197

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It is over 40 years since the Alma-Ata Declaration asserted the crucial role of primary care in the promotion of the health of people world wide. Since then global health policy has attempted to give effect to the Declaration with varying levels of success. The situation has been no different in Wales.

The Wanless Review in 2003 re-emphasised this message. It stated “ …(t)he current configuration of health services places an insupportable burden on the acute sector and its workforce. This is the most expensive part of the system … (t)he primary care sector in turn is not sufficiently resourced or incentivised to keep patients out of hospital though it is hoped that the new General Medical Services Contract (under discussion at the time of this report) will create such incentives.”

The publication of the final report by the Welsh Parliamentary Review on health and social care ( January 2018) shows that this still remains the main challenge. In response the Welsh Government has published A Healthier Wales and a Strategic Programme for Primary Care. Both these policy statements will have to be matched by a determined political will if they are to prove successful.

In 2018 the Wales Audit office stated that “ (b)etween 2010-11 and 2016-17, total health board spending in Wales …. increased from £5.39 billion to £6.32 billion. However, over the same period, recorded spending on primary care as a percentage of total health board spending in Wales ….. reduced from 25% to 22%.This would suggest that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years is not being achieved.” No amount of smart or new types of working will be able to make up for this basic deficit. If primary care is to thrive it needs resources and investment.

This has been highlighted in the number of GPs working in Wales. Between 2004-05 to 2010-11 the number of GPs rose from 1,800 to 2,000. However since then things have been more or less been static until there was a 4% decline between 2016 and 2017. By way of contrast the numbers of hospital consultants has increased by 40% between 2009 and 2017.

However these headline figures do not tell the full picture. While there are now just under 2,000 GPs listed in Wales. Approximately 1,500 of the listed GPs were contractors with the remaining 400+ being salaried. However there is a concern that the official statistics do not present a fully accurate picture particularly in relation to the number of salaried doctors. And there are, in addition, a further 750 doctors working in system who are classified as locums or sessional GPs . This represents a 10% increase since 2016 when figures were first collected.

Vocational training is central to securing a future workforce. The RCGP estimates that Wales needs to have 184 positions to be on a par with the rest of the UK. There has been an increase of 15% in posts over recent years with to 90% being filled but the overall numbers have still to reach UK levels.

The Welsh Government therefore faces a major challenge to increase capacity in its primary care and general practice service. There is abundant evidence that GP workload is increasing both quantitatively and in its complexity. In response there must be an a substantial increase in the workforce as the Welsh Government itself acknowledges the service is not sustainable if it can only survive by the “heroic” efforts of its staff.

Non-medical practice staffing levels has increased by over 7% in the last half decade with approximately 2,500 clinical and 5,000 administrative staff now being employed. Despite these increases the RCGP reports that there are still 20% of GPs do not have access to a practice nurse, 35% to a practice pharmacist and 50% to a physiotherapist. This is clearly not good enough.

The challenge in recruiting and retaining GPs also looms large. Both the GPC and RCGP in Wales still insist that “.. (i)t is a fact that the independent contractor model is best for the patients of Wales and is the most cost-effective option for those who hold the purse strings in both Welsh Government and Health Boards. “ But with 20% of GPs already salaried and with almost twice as many more working as locums and sessional doctors there must an urgent need to review the way they work for and with the NHS.

The Welsh Government acknowledges that the contractor partnerships will continue to be the cornerstone of general practice in Wales. But it also accepts that this model it is no longer a preferred option for many new doctors. They are not attracted to the business ethos, financial risks, administrative demands, inflexibility and investment costs which go with being an independent contractor. So while the concerns of independent contractors must be addressed there is also a need for a more diverse range of career options for future general practitioners.

There are some interesting innovations taking place seeks to address this need. The Primary Care Support Unit in the Cwm Taf Health Board has been in existence since 2002. Social enterprise models for care delivery have been adopted in Bridgend and south Powys. But overall they are still too few to achieve the critical mass that is needed to achieve transformational change.

Somewhat strangely the “GP establishment” seems to fear that health boards and the Welsh Government are rubbing their hands in glee at the prospect of becoming direct providers of primary care services. The reality is almost totally the opposite. There are now over 30 directly managed GP practices in Wales but in virtually every case local health boards have found themselves reluctantly obliged to get involved. This lack of enthusiasm for a public service general practice option must be urgently addressed.

The Strategic Programme for Primary Care confirms the Welsh Government’s commitment to delivering primary care services through 64 primary care or clinical networks based on populations of 50-100,000. These networks are tasked with bringing primary and social care services together along with the third sector to cater for the needs of their populations. There is a widespread support for this model both politically and across the professions. The Welsh Government has channelled much of its recent primary care investment through the networks to stimulate local innovation and service improvement. Their success to date is a bit mixed and in some cases they have an uneasy relationship with their local health boards.

Innovation in primary care is also being actively promoted though the £4m Pacesetter / Pathfinder programme which began in 2015 with 24 distinct projects. The objective was to either develop new ways of working or to promote the wider dissemination of new ways of working. The programme received support from Public Health Wales and it is hoped that health boards would mainstream the practice of the successful projects. As these projects come towards the end of their initial phase this is recognised as being critically important. But it has also been appreciated that those areas where services are under the greatest stress are least likely to engage with the exercise.

The Welsh Government has prioritised tacking health inequalities and asserts “..the fundamental Bevan principle that it is clinical need which matters when it comes to deciding treatment by NHS Wales.” In his annual report 2015-16 the Welsh Chief Medical Officer, Dr Frank Atherton, recognised this in stating “ … we make the case that one-size-fits-all health and care services in the traditional sense may not always be the best approach, as they can maintain, and sometimes increase, health inequalities. Instead we argue for an approach which is proportionate to the level of disadvantage which is often referred to as proportionate universalism.” But Welsh Government policy  is at its weakest it comes to outlining how this is to be achieved.

Public Health Wales (PHW) has done a lot of work in identifying health inequalities across Wales and profiling populations to clinical network level. It shows that the difference in prevalence of good health between people living in the least and most deprived areas is already apparent at age 0-15. This gap then grows as age increases, peaking in males at age 65-74 (79% in least deprived vs 52% in most deprived) and in females at age 55-64 (84% vs 56%). And it is in these disadvantaged areas where we also find the greatest prevalence of patients with complex multi-morbidity.

This work by PHW provides an excellent stepping stone for planning the promotion of health and well-being and the delivery of primary care services. But there is little evidence that this is happening on any scale. The Strategic Programme for Primary Care provides a lot of important one-size-fits-all advice for primary care but it only makes the most cursory of references as to how the new, transformed Welsh NHS will address health inequalities on the front line where 90% of health service contacts take place. This is its fundamental weakness.

Welsh health and social care policy strongly argues for a new approach that will put a focus on prevention, which promotes a social model of health and well-being, seeks to address the social determinants of poor health and which will tackle the stubborn continuation of health inequalities. In many policy areas concrete proposals have been put forward to address this agenda. But there in health and social care the details still need to be outlined and put in place.

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

From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

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

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

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

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

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

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

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

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

Ekklesia reports:

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

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

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

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

• The Pre Action Protocol Letter can be seen here

 

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DELIVERED AT JULIAN HART’S FUNERAL — JUNE 16th 2018

 

Julian and I were chatting once about heaven and hell, as you do. He didn’t believe in either, but supposing he was wrong, he thought he might be allowed into heaven, not as a believer, you understand, but for good behaviour.

Julian always wanted to be a doctor in a mining village, partly because his father had been a colliery doctor in Llanelli; partly it was the romance of mining practice as popularised in AJ Cronin ‘s novel The Citadel; but mainly it was the sort of community to which he wanted to belong.

And belong he did. As Gerald Davies, one of his patients, said in a BBC documentary , Julian wasn’t aloof like the other doctors, the headmaster and the colliery manager. He lived in the village and shared the common experience.

He wrote about it for medical students, “No one is a stranger; they are not only patients but fellow citizens. From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.”

Julian loved his patients – not romantically, of course. The opposite of love in this context is indifference and Julian was never indifferent. He hated when bad things happened to his patients, especially when they could have been prevented. In his last 28 years at Glyncorrwg, there wasn’t a single death in women from cervical cancer.

In his book A New Kind of Doctor, he described a man, invalided out of the steel industry after a leg fracture, aged 42. With no further use for his big muscular body, he had become obese, had high blood pressure and cholesterol, got gout and was drinking too much. 25 years later, Julian described how, after 310 consultations and 41 hours of work, initially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes. He described this as the real stuff of primary medical care.

At a seminar in Glasgow, we asked Julian what happened next. The man had died, of something else, a late-onset cancer I think, but when Julian told us this, there was a tear in his eye. His patient had become his friend.

This was Dr ‘art, without an “H”, as known to his Glyncorrwg patients. None of this explains why Dr Julian Tudor Hart became the most famous general practitioner in the history of the NHS.

In 1961 with large numbers of very sick people, huge visiting lists and a nearby colliery that was still working, the Glyncorrwg practice was extremely busy. His initial base was a wooden hut. It took five years to reach a stable position.

He was the first doctor in the world to measure the blood pressures of all his patients. Famously, Charlie Dixon was the last man to take part, had the highest blood pressure in the village but was still alive 25 years later. Julian became an international authority on blood pressure control in general practice and wrote a book about it which went to three editions and was translated into several languages, with a companion book for patients.

What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years he showed that premature mortality was almost 30% lower than in a neighbouring village – the only evidence we have of what a general practitioner could achieve in a lifetime of practice.

It’s said that behind every great man there is an astonished woman. Behind Julian, was a great woman. When Deborah Perkin was planning her BBC documentary, the Good Doctor, (which we keep showing to medical students and young doctors), I said to her, there is something you have to understand. There’s two of them. Mary was his partner and anchor every step of the way.

Glyncorrwg was the first general practice in the UK to receive research funding from the Medical Research Council. Mary and Julian had both worked with Archie Cochrane and his team at the MRC Epidemiology Unit in Cardiff where they learned a democratic type of research in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. And so, in Glyncorrwg, there was the Shit Study, the Pee Study, the Salt Studies and the Rat Poison Study, all with astonishing high response rates.

Julian counted as a scientist anyone who measured or audited what they did and was honest with the results. Brecht’s The Life of Galileo was his favourite play and he often quoted Brecht’s line, “The figures compel us.” Julian didn’t pursue scientific knowledge for its own sake. His research always had the direct purpose of helping to improve people’s lives.

He had a talent for the telling phrase. His Inverse Care Law stated that the availability of good medical care tends to vary inversely with the need for it in the population served, or more simply, People without shoes are clearly the ones who need shoes the most.

When Sir Keith Joseph, a Conservative Secretary for Social Services, announced that
“Increased dental charges would give a financial incentive to patients to look after their teeth,” Julian commented, “The government has not yet raised the tax on coffins to reduce mortality, but Sir Keith is assured of a place in the history of preventive medicine.”

Julian’s friend and fellow GP, John Coope from Bollington in Lancashire, admired Julian’s nose for what mattered in the published literature. In his book The Political Economy of Health, that magpie tendency was on display, the footnotes comprising one third of the book and worth reading on their own. A Google search could never assemble such a mix. Goodness knows what readers made of it in the Chinese translation.

He lectured all over the world – in the US, Australia, Kazakhstan, Italy and Spain in particular. Julian could deliver formal lectures but for brilliance and exhilarating an audience he was at his best in impromptu, unscripted exchange.

When principles were at stake, Julian could argue until the cows came home. In his younger years he took no prisoners. A famous medical professor reflected that he had been called many things, but never a snail.

Dr Miriam Stoppard arrived in the village to interview Julian for her TV programme, determined to cast him in the role of a doctor who made life or death decisions concerning his patient’s access to renal dialysis and transplant. They battled for a whole afternoon, Stoppard trying to get Julian to say things on camera that fitted her script. He defied her, ending every sentence by mentioning how much dialysis and transplant surgery the cost of a single Trident missile could buy. She went away defeated and empty-handed.

I was surprised once at Paddington station to see him with a copy of the London Times. He was no fan of the Murdoch press. On boarding the 125 for South Wales, he laid out the newspaper as a tablecloth and over it spread a messy, aromatic Indian carry-out meal. If businessmen in their smart suits wanted to sit next to us, they were very welcome.

Standing for election to the Council of the Royal College of General Practitioners, Julian topped the poll. What he offered GPs was a credible image of themselves as important members of the medical profession – alongside specialists, not beneath them.

Julian was humble in himself but ambitious for his ideas. He accepted with ambivalence the honours and sentimental treatment that came with age but he never lost his edge, and if we are to celebrate his life it should be by holding to the principles he held dear.

The work of a general practitioner is immeasurably enhanced by working in, with and for a local community, for long enough to make a difference.

Everyone is important, the last person as important as the first, and the work isn’t done until everyone is on board.

Julian was the “worried doctor”, anticipating patients’ problems, not waiting for them to happen, and then avoiding them by joint endeavour.

Drawing on his reading of Marx, he saw health care as a form of production, producing not profits but social value, shared knowledge, confidence, the ability to live better with conditions, achieved not by the doctor alone but by doctors and patients working together. Patients were partners, not customers or consumers.

The NHS should never be a business to make money but a social institution based on mutuality and trust – the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In re-building society, co-operation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.

My daughter Nuala met Julian many times. Losing him as a person, she said, was like the Mackintosh Building at Glasgow School of Art, burning down. We lost someone dear, a big part of our lives, an institution, a one man “School of ‘Art”, full of life, light and creativity.

Julian’s gift to us today is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the present challenge of how we follow and give practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us do.

 

Professor Graham Watt
MD FRCGP FRSE FMedSci CBE
Emeritus Professor
General Practice and Primary Care
University of Glasgow

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Unite Press Release

Immediate release:  Wednesday 7 November 2018

Vote for Cornwall’s children’s services to remain in-house applauded by Unite 

Cornwall Council’s decision today (Wednesday 7 November)) to keep children’s services in-house, and not to outsource them, has been hailed as ‘a significant victory’ by Unite the union.

The council’s cabinet voted to adopt the option – outlined in its One Vision blueprint – to keep children’s services in-house from April 2019.

However, Unite warned that the possibility of parents paying for health visitors to carry out vital health checks on their babies and children still remains as the ‘means tested charging’ wording is in the One Vision document.

Unite regional officer Deborah Hopkins said: “We welcome the decision of the council’s cabinet to keep children’s services in-house and not outsource them to a separate company.

“It is a very significant victory for the people of Cornwall and a big set-back for the insidious privatisation agenda.

“We welcome the council’s announcement that parents won’t be means tested when they require children’s services, such as a visit from a health visitor.

“However, that possibility is still within the wording of the One Vision framework and until that is finally jettisoned from the document, Unite will be following developments in the weeks and months ahead very closely.

“Unite is keen to work collaboratively and constructively with the management of children’s services to ensure the best possible outcomes for families and children in Cornwall, which is one of the poorest counties in England.”    

The other option that councillors rejected today was for a so-called ‘alternative delivery model’ by a company that is separate from the council with the potential to make profits from parents.

The introduction of charging is in the document’s section on Drawing on funding opportunities where one proposal is: ‘Introduce means tested charging for a range of family support services’.

About 235 health visitors and school nurses are transferring into a Cornwall Council integrated children’s service in April 2019, to work with a multi-disciplinary team, alongside services for families and young people.

A recent survey revealed that nearly 20 neighbourhoods in Cornwall are among the 10 per cent most deprived in England, according to The Index of Multiple Deprivation.

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Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’

 

Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.

 

Reduction in prevention, cytology and mental health services

Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.

 

STI screening and HIV testing

More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.

 

PrEP availability and reproductive health

The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.

 

Impact of separation of HIV and GUM on staff and services

Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.

 

Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”

ENDS

Editor’s notes:

  1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
  2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
  3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or simon.whalley@mandfhealth.com or Jo Josh, BHIVA, on 07787 530 922 or jo@commsbiz.com.

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

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

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

 

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

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

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

 

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

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

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

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

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

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

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

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

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As the NHS passes its 70th birthday the recent report from the Health and Social Care Committee on Integrated Care could find little wrong with the direction of travel within the health service. While critics might cavil about the threat of further privatization, the Committee argued instead that the service was entering a new phase of collaboration rather than competition. Notions about the Americanization of the NHS were misplaced, due in part to the terminology surrounding Accountable Care Organizations, while the somewhat less than transparent introduction to this new phase had added to the confusion. Such problems could however be remedied by a “clear and compelling narrative” developed by the Department of Health, NHS England and other associated bodies, which would reassure both patients and taxpayers that the path of transformation was sound, sustainable, and in their best interests.

The Committee also argued that clarity could be more readily achieved by developing this narrative from a patients perspective, rather than focusing on systemic transformation. Such a perspective would focus on “how patients experience the health and care services they use”, and that what matters is that providers, whether public or non-statutory, “create coherent and comprehensive services, share information, work together and put patients’ needs, priorities and goals at the centre”. Indeed one can anticipate the content to be apolitical, dull, and with cross-party consensus and a new ‘NHS Assembly’ lending extra layers of concerned neutrality towards the co-design of the forthcoming 10-year plan.

 

HOMOGENEITY

In order to contest this it’s essential to identify the real guiding narrative for transformation, one which, while not always transparent, is overtly politicized and global in reach. It’s arguable that such a narrative already exists, is securely in place and has been for some time, and seeks to reconstruct healthcare systems to benefit transnational capital. Led by a transnational capitalist class with few, if any, allegiances to domestic staples, particularly re-distributional welfare, the aim is to impose a kind of global homogeneity of healthcare organization. Such standardization will attempt to safeguard and simplify investment strategies, and to embed corporate control of both purchasing and service delivery within rapidly evolving ‘mixed economies’ of care.

Homogeneity also gives meaning to attempts at trade deregulation; the TTIP, for example, would be somewhat limited if domestic systems weren’t fully investor compatible. The use of capitated budgets for ACO providers, for example, is expressly geared towards private investor interests, as the upfront capital can be invested in the global markets, with returns on equity in excess of 16%.

The insistence on fiscal austerity has accelerated such changes, transcribing the demands of financial regimes onto healthcare systems via the concept of sustainability. This not only permits a reframing of what care is to be available, but also a radical reframing of the delivery system. It was no surprise, for example, that the World Economic Forum’s (WEF) year long deliberations on healthcare followed the announcement by Standard & Poors in January 2012 that national healthcare systems must demonstrate sustainability in order for their economies to maintain credit ratings.  Workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London that year, were, according to the WEF, “remarkable in their consistency of vision”, advocating, for example, delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”. In other words, what’s happening to the NHS is being reproduced on a global scale.

It’s also important to identify chains of command within these processes, and, owing to its economic strength, a key role is played by the US. Not only will US corporations be privileged, but also the standard template mentioned above builds upon the country’s main organizational format: that of ‘managed care’. Private insurance-led and with minimal recourse to federal programmes, managed care also involves a range of hospital- or physician-based provider networks. And it’s no accident that prior to his appointment as Chief Executive of NHSE, Simon Stevens led the Global Health Division of the US’s largest insurer, UnitedHealth, and was also chair of the WEF’s Steering Group on system sustainability. The interoperability of transnational and US ambitions isn’t always so clearly expressed.

 

TRANSLATIONS

As mentioned, the WEF’s reports were released in early 2013, and Stevens’ first main task for NHSE was in producing the Five Year Forward View in late 2014. Conceived as an overall appraisal of the NHS, the centerpiece of the Forward View was the introduction of new care models, namely the Trust-led Primary and Acute Care Systems (PACS), the primary care-led Multispecialty Community Providers (MCPs), and the more radical variant, the system-wide Accountable Care Organization (ACO). Such formats would be test-bedded across England in a series of vanguard sites offering examples of how these models would shape up in practice.

One such example is the South Somerset Symphony Programme. Led by Yeovil District Hospital NHS Foundation Trust (FT), the project is an advanced PACS vanguard in all aspects of the FYFV’s vision, incorporating radical changes in workforce, infrastructure and partnership arrangements. Working relationships have been established with Somerset CCG and Somerset County Council, as well as partnerships with other providers, and commissioners are working on similar approaches for the rest of the county with the aim of establishing a countywide ACO by 2019.

In terms of finding private partners for the new model, the FT was guided by the US-based global consultancy, Oliver Wyman, a company that “serves clients in the pharmaceutical, biotechnology, medical devices, provider, and payer sectors with strategic, operational, and organizational advice”. Private partnerships with the Trust now include those for services in diagnostics, digital services, online booking and management, ophthalmology, and in elective care. The last named is provided by ASI, the international arm of Amsurg, the US’s largest operator of day case facilities. The FT also partners Interserve Prime in a ‘strategic estates partnership’, to develop a wide range of retail outlets as well as a nursing home, GP practice and pharmacy, all of which, according the Trust’s CEO, could be run by the private sector.

Also assisting in the transition to an ACO has been Optum, the UK arm of UnitedHealth. The Trust’s document, ‘Join the Revolution’ is worth quoting in full:

“As (we) move towards an outcomes based contract in April 2017, the creation of an ACO is core to its effective delivery. The ACO model born in the US market is new to the UK, and as such we have partnered with globally experienced Optum who are guiding our journey into this new world. The partnership initially for a 9-month period is helping to plan, design and communicate the way the ACO’s will work, and critically financially model the value of managing a budget for the whole population of Somerset over a 10 year contract period”.

As mentioned, commissioners aim to extend this approach to the whole county, with Optum supporting other peers in the locality. As a Kings Fund document points out, the CCG envisages restructuring its services so that it can play “a more strategic role in overseeing the system, and expects a ‘managed services organization’” – such as Optum – “will sit within the ACO and act as its ‘engine room’”.

 

TEXTBOOK

While at first sight the scale of change in Yeovil is surprising, a close reading indicates it’s more textbook than anomalous. According to the Kings Fund, Optum, currently “supports GPs and provider groups in delivering new care models, including through offering analytics, actuarial support, decision support for clinicians and support for contracting”. Which, it has to be said, sounds remarkably like a health insurer. One of Optum’s clients is the Modality Partnership, which while it began in Birmingham, now straddles several counties, and is perhaps the leading MCPs vanguard. Some of the new care models “saw strong benefits of partnerships with private providers such as Optum because they could offer capital investment to support transformation, particularly if the government is less able to provide this investment in future”.

Similarly for PACS vanguard sites in Birmingham, Airedale, Fylde and North Tyneside, the Oliver Wyman company helped introduce “proven care models from other countries, customizing them to local needs, and then implementing them”. One of Oliver Wyman’s senior partners, Crispin Ellison, served in the Prime Minister’s Office, where he “identified new care models for health and community care” that “drew on best practice innovation in public and private sectors globally, as well as lessons learned in implementing major change initiatives”.

At a conference held by Wymans in London several months before the publication of the FYFV, all the trusts and CCGs from the above mentioned sites were present, alongside representatives from NHSE, Monitor, 10 Downing Street, and several other authors of the forthcoming narrative on integrated care.

Interestingly Wymans has a regular advert in LaingBuisson’s ‘Healthcare Markets’, the UK’s leading journal for the private healthcare industry. Under the banner ‘Transform Care: Implementing New Models to Improve Care and Value’, the company offers “To build sustainable solutions that are patient/ customer focused, health and social care systems need to optimize outcomes and experience, while delivering on value. We help clients transform care through the development and implementation of innovative, proactive, patient-centred models that address gaps and inefficiencies in our current delivery system”. The narrative used for both private and public sectors is interchangeable.

The company may also invite local NHS ‘leaders’ to its annual conference in Chicago, which brings together CEOs from major corporations – over 50% C-Suite in the blurb – who are “committed to the market transformation that will migrate $1 trillion to new players, new industry segments, and traditional companies that are delivering better health value”. The companies involved in the 2015 event included the insurers Blue Cross, Humana, Anthem and UnitedHealth, as well as various big pharma companies and Walgreens and Wallmart. It also included the CEO of Yeovil Foundation Trust.

 

ENDPIECE

In a blog to accompany its submission to the Health Committee, the Kings Fund, which also acted as chief advisers to the report, said, “there is no evidence that private providers of clinical services are taking on a bigger role in areas that are furthest ahead in developing accountable care”. It also said that while the proposed ACO contract may in theory open the NHS to companies from the US to compete to deliver care to NHS patients, this was “highly unlikely in practice”. As the examples above attest this is simply not the case. The range of private healthcare provision in Somerset is remarkably extensive, so much so in fact that the vanguard can no longer be considered a public entity. US companies it would appear are not simply offering services, but providing capital investment, acting as brokers for other private providers, and also acting as de facto commissioners of care at a county-wide level. It would appear that the ‘engine room’ of change for the English NHS is firmly transatlantic.

In its conclusion the Health Committee thought that too much emphasis had been place on wider processes at work within the NHS, and had come at the expense of more accessible interpretations of the changes deemed necessary to keep the health service afloat. As such, the Committee argued that there “needs to be a clearer narrative to explain the direction of travel: what are these reforms trying to achieve; what does the end state look like; what are the risks and what the benefits for patients and taxpayers”. There is a clear narrative involved, developed in the meeting rooms and conference centres in Chicago, Davos, and other loci of power, which pursues a US-led transnational agenda. And it’s one that does not aim to benefit patients.

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