Category Archives: Public Health



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
Emeritus Professor
General Practice and Primary Care
University of Glasgow


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.”


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 or Jo Josh, BHIVA, on 07787 530 922 or

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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.



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.



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’”.



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.



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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On 7thAugust The Guardian published a major story on the theme of the billions of pounds of NHS contracts going to Richard Branson.

The following day there was only one letter on the subject – from Virgin – saying that the saintly Richard has been misrepresented, that he loved the NHS and, if he ever made money from health, it would all go back to the NHS.

A letter in response to the original news item remains unpublished. This is what it said:

Your headline (Virgin awarded almost £2bn of NHS contracts in the past five years, 6 July 2018) comes as no surprise to NHS campaigners in Wirral who sounded the alarm on the champion tax avoider’s local presence eight years ago. Most patients don’t know of his unsavoury involvement as Virgin Care covers its presence in a partnership with twenty local GPs named Peninsula Health. The annual contract is usually relatively small but repeated questions to the partnership and the local clinical commissioning group have failed to establish the size of any surplus and how it is distributed between the partners. But that is almost irrelevant. It was clear from the start that Branson, gurning happily in his sunny tax haven, was playing a long national game using sometimes innocent doctors and unknowing sick people as his pawns, willing to sustain losses knowing that a well-placed partnership would be in an excellent position to profit when the engineered collapse of the NHS sent CCGs and councils scurrying for rescuers. And now it’s happening. Wirral councillors and doctors who should know better are repeating the new NHS mantra that hospitals are not safe and people in one of England’s poorest places should be responsible for their own health. Ambitious GPs are coalescing into “primary care homes”, Wirral is experimenting with “apps”, and the charge is on to further undermine the hospital service and substitute on-line triage and “urgent care centres”. Meanwhile Wirral Council and CCG speak with one voice on health and their soon to be “pooled budget” will reveal its horrors when one picks up major shortfalls in the other, one or other goes bankrupt and surcharged councillors wonder how they got into this mess. It happened when they accepted the logic of NHS England’s “five-year forward view” and Branson’s approach to probity. There was scorn when campaigners noted that “sustainability and transformation partnership” translated as “slash, trash and privatise”. Now the reality has dawned.

Nor did this response to the Virgin Care puff piece see the light of day:

I am grateful to Nick Fox for putting me straight (Letters, 8 August). I apologise for confusing Sir Richard of Tax with St Richard of VHS (Virgin Health Services). I had assumed Richard was the chap whose attempt to sue Lancashire County Council after he failed to win a children’s care contract was thrown out by a judge. And clearly not the person who took £1.6m from the NHS after legal action against the NHS in Surrey. And nothing to do with Jeremy Hunt, the former health secretary, who personally intervened to encourage the controversial takeover of NHS hospitals in his constituency by Virgin Care in 2012. It’s all turning out wonderfully.



There have been bacteria on this planet for at least the last 3.5 billion years. For the entirety of our species’ existence we have relied on bacteria to aid us in breaking down food, whilst being helpless to guard against their wrath whenever we had a bacterial infection. It wasn’t until the late 19th century that more powerful microscopes lead us to understand what bacteria were and how the infections spread, in what was known at the time as ‘germ theory.’

Understanding how bacteria made people unwell led us to greatly improve hygiene; with large government programmes to build sanitation systems, doctors started to wash their hands and utensils, and people started to drink clean water. These changes, along with other medical innovation, lead to dramatic improvements in people’s health: in 1900 one in every 125 Americans were killed every year by infection and life expectancy was just 46; by 1941, it had risen to 65 and the number of people dying annually from infections had fallen to just one in 500. It was in this year that humans finally took the upper hand in our battle to stave of infection, when a research team in Oxford demonstrated how penicillin can cure bacterial infections. By 1955 just one in every 1670 Americans were killed by infections annually (the rate has plateaued since then).

Over the next few decades, antibiotics transformed modern medicine, not only allowing us to treat people who had bacterial infections, but also creating a safety net for other areas of medicine. Doctors can now treat other illnesses through surgery or by using drugs that have the unfortunate side effect of greatly lower immune systems (such as chemotherapy), with the knowledge that if someone picks up a bacterial infection, it can be treated.

Sadly, however, this was not the end of the story. Every time bacteria come into contact with antibiotics there is the possibility that through a process of natural selection, they may evolve to evade the drugs, creating what is referred to as ‘superbugs’. These superbugs can often not be killed by antibiotics. They have altered their membranes so the antibiotic cannot get into their cell, developed efflux pumps to remove the antibiotic from their system or learned to make enzymes that break down the antibiotic. In the early years of antibiotic development researchers were able to come up with enough new antibiotics to replace the ones that we had lost to resistance, but this is no longer the case. There has not been a new class of antibiotic able to treat gram-negative bacteria since the 1980s. This has led to a slowly-building crisis that kills 58,000 neonates in India every year and about 1.5 million people globally. If we do not start to take robust action against superbugs, then we are looking at returning to an era where bacteria are once again a major killer for which there is no cure.

In our recent book Superbugs: An Arms Race Against Bacteria,’ Will Hall, Jim O’Neill, and I look at the scientific, economic, and political failures that have led us to the point where antibiotics are ceasing to work, examine what will happen if we fail to act, before outlining the policy interventions that we think are required to keep us ahead in this vital arms race. In short, we need to new antibiotics to replace those lost to resistance; but more importantly we need to slow down the rise of resistance by preventing people from becoming sick, having better prescription practices when people become ill, and stop the environmental pollution from agriculture and manufacturing that sees antibiotics pumped into the environment.

All of these problems are held back by market failures. In order to prevent the rise of resistance, public health officials often rightly try to limit the sales of new antibiotics – the more valuable a drug the stronger the impulse to protect it is likely to be. This is problematic because innovators make greater returns the more of their product they sell though their patent system, which uses price and volume as a proxy for societal value. We need a new system for rewarding antibiotic producers that incentivise new drugs without encouraging companies to oversell.

Sanitation systems need to be improved in almost all low and many middle-income countries, so that people stop becoming sick. When we prevent illness then people will not need antibiotics. For example, at the moment, 1.7 million children die annually from diarrhoea or pneumonia, and research indicates that simply by getting people access to soap we could more than half this number. This is not just a problem in resource-constrained environments: in the US, research suggests that while 68% of people wash their hands after going to the toilet, only 5% did so thoroughly enough to remove all the bacteria on their hands.

Finally, with diagnostics and pollution we need to find ways of getting decision makers to internalise the societal benefits that accrue from good antibiotic stewardship. Regulation or taxation should be used to stop the environmental pollution of antibiotics. Rapid diagnostics can greatly improve prescriber practices, but there is a lack of investment into this area, and often when these diagnostics exist they end up costing more than the antibiotics, and so people do not use them. This means we are ignoring the societal benefit of using diagnostics to keep resistance at bay.

First published by the British Politics and Policy blog

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In the year that celebrates the 70th anniversary of the ‘national treasure’ that is the National Health Service, this meeting of the Manchester Medical Society is more than timely. The origins of the NHS are rooted in the fight for social justice which runs not only in Manchester, Liverpool and the NorthWest but across the industrial and commercial north of the country. Next year here in Manchester, we will be commemorating the bi-centenary of the Peterloo Massacre in which 15 people, including one John Ashton, protesting about the poor social conditions and lack of suffrage, were slaughtered in a cavalry charge. This was a defining moment in the development of our democracy, the extension of suffrage and in due course to the extension of public services for the whole population.

On 5 July 1948, Aneurin Bevan, Minister of Health and midwife of the NHS inaugurated its first hospital, The Park, in Davyhulme in Trafford; and today, as we speak, former Health Minister and now elected Mayor of Greater Manchester, Andy Burnham is leading the charge for devolution and integration in partnership with the borough councils of this major conurbation. Along the M62 in Liverpool, William Henry Duncan, the country’s first full-time Medical Officer of Health pioneered a dynamic Victorian town hall based public health movement. His work has in recent years inspired a renaissance of public health going far beyond this region, a renaissance of importance when we come to looking at what the future holds in the next 70 years, not least with the long overdue move to devolution of government in arguably the most centralised country in Europe.

This talk will be in two parts. In the first, I will draw on my recent Lancet article of Nicholas Timmins’ formidable review of the first 70 years of the NHS to set the scene and identify some key challenges [1Ashton JRSeven decades of fighting the five giants: a work in progress. Lancet. 390 (10111): e47e48; 2017. DOI:10.1016/S0140-6736(17)32913-6[Crossref][Google Scholar]]. These challenges must be addressed if our grandchildren are to be able to benefit from the NHS and the Welfare State in their later years. In the second part, I will lay out my own conclusions based on a lifetime within the NHS and my experiences of trying to ensure that a balanced approach to prevention, treatment and care underpin the pursuit of social justice within a whole systems set of arrangements and characterised by visionary local leadership.

On 1 December 1942, queues stretched from his Majesty’s Stationery Office along High Holborn in London. By lunchtime all copies of Sir William Beveridge’s ground breaking report, Social Insurance and Allied Services  had been sold. It was much the same story elsewhere. In Liverpool, my father secured the two volume report that today takes pride of place in my study. Beveridge’s report sits alongside work by others who have guided me in my career: Brian Abel Smith, Douglas Black, Ann Cartwright, Karen Dunnell, Margot Jeffries, Jerry Morris, Richard Titmuss, Peter Townsend and many others associated with the London School of Economics and the London School of Hygiene and Tropical Medicine.

In the introduction to his report, Beveridge enunciated three principles that provided a framework for all that was to follow. First, in supporting the importance of learning from past experience, he spelled out that sectional interests (of doctors), should not be allowed to stand in the way of what was ‘a revolutionary moment in world history….a time for revolutions, not for patching’. Second, he was clear that social insurance – the focus of his terms of reference from Prime Minister Winston Churchill – was only one part of a comprehensive policy of social progress, before going on to declaim his most famous and Bunyonesque passage:

It is one part only of an attack upon five giant evils:

(1) upon the physical Want with which it is directly concerned
(2) upon Disease which often causes that Want and brings other troubles in its train
(3) upon Ignorance which no democracy can afford among its citizens
(4) upon Squalor …
(5) and upon Idleness which destroys wealth and corrupts men.

Finally, the principle of cooperation between the state and the individual was made explicit.

…..the state in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual…

Details of the Beveridge plan were broadcast throughout the day by the BBC in more than 20 languages. Copies of the report were dropped into France and circulated among the troops. Later, they were used by the Workers’ Educational Association in theatres of war as educational material that was subsequently held to have contributed to the election of the Labour government in 1945.

For many people, like my father, an insulin – dependent diabetic on low income with a growing family, the security offered by the prospects of comprehensive social security, including access to health care, was transformative. To academics at the London School of Economics and the London School of Hygiene and Tropical Medicine, the Beveridge Report was a bible for post-war reconstruction and an opportunity to put their intellectual muscle to work for the common good. They were to occupy an influential place in government policy – making that would last some 30 years before the Thatcherite revolution of the 1980s. The subsequent fashion for market – based solutions at all costs in the corridors of Whitehall swept away the consensus of solidarity that had emerged from pre-war hardships and the dark days of the fight against fascism in the Second World War.

By the time Nicholas Timmins published the first edition of The Five Giants: A Biography of the Welfare State [1995] that consensus was more than frayed at the edges after 11 years of Thatcherism and the rise of rampant free marketeers. As summed up by Julian le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics, the welfare state had been hit first by an ‘economic hurricane’ and later by ‘an ideological blizzard’. The demographic challenge was still to come. The ambition of the war-time generation to build a better future for their children was under attack in a cold climate. In returning to the fray with his new edition of ‘The Five Giants’, Timmins has taken on the monumental task of not only bringing his earlier work up to date but also of synthesising some 70 years of social policy in the UK, covering some of the most complex and interlocking areas that between them account for two-thirds of government expenditure.

Timmins describes his magnum opus as lying somewhere between ‘1066 and All That’ and Gibbon’s ‘Decline and Fall of the Roman Empire’. In agreeing with this assessment, I would add Salman Rushdie’s ‘Midnight’s Children’. Rushdie’s novel, in tackling the theme of India’s transition from British colonialism to independence through the use of magic realism, touches inadvertently on the surreal nature of many of the Shakespearean plots, subplots, and recurring themes to be found in ‘The Five Giants’. Through his device of a spiral treatment of health and social services, education, social security, housing and employment, Timmins provides a perceptive and comprehensive analysis of the British welfare state. I have long held that nobody should be allowed near the National Health Service who has not at least studied Richard Titmuss’ introductory lectures on social administration, written in the post-war period; to that essential bibliography, I would add this second edition by Nick Timmins.

Reading Timmins’ book I felt at times like a dying man with the whole of my life passing before me: hard times and rationing, mum counting every penny, national dried milk and welfare orange, the death of King George VI and the Coronation of Queen Elizabeth II, primary school in Liverpool with more than 40 children in a class in prefabricated huts, school milk and dinners, 6 weeks in Alder Hey Children’s Hospital with suspected meningitis, passing the 11+ examination while my brother failed it and was consigned to an underfunded and undervalued secondary modern school, constant interaction with the NHS for my dad’s diabetes, the discovery of the teenager during the Beatle years, and getting into medical school with a full grant. Then later as a doctor in the 1970s at the tail end of paternalism with ex-colonial administrators and later after the Griffiths Report of a new breed of general managers on huge salaries and flash cars, watching the slow descent of the UK into crisis followed by the rise of monetarism and oscillating nostrums that sapped the energy, without leading to sustainable change in the NHS.

This social history is all documented in Timmins’ truly remarkable book.

He chronicles the battles between different world views, veering between soap opera and epic, with ideology frequently trumping evidence; shallow rhetoric and narrow managerialism in place of authentic leadership, an increasing infatuation with keeping ministers happy in the Westminster bubble, a loss of focus on serving the people and being accountable to them, not least after the abolition of the Regional and District Health Authorities.

Nevertheless, at its heart the flame was kept alive, an enduring ambition to provide social security and freedom from fear for the whole population – for the many, not the few. Nick Timmins lays bare many of the underlying paradoxes, contradictions, and recurring challenges that underpin the muddling through so characteristic of UK Government social policy. He exposes the bankruptcy of politicians who seek short-term advantage at the expense of stability, progress and authentic leadership. Timmins’ blow-by-blow account of former Secretary of State for Health Andrew Lansley’s destructive and fragmentary NHS re-organisation, the orgasm of re-organisation heaped on re-organisation in an ever more frantic crescendo, captures the biggest threat to the NHS since 1948.

Years ago, in another life as a psychiatrist, I had as a patient a young man who was crippled with an obsessive compulsive disorder manifested by elaborate rituals. One day he told me that he had a plan to expunge his problem once and for all by acting out the ultimate in rituals in a local park. A few days later he returned to see me in great distress; he was half way through his ritual when he forgot what to do next. This image came into my mind most vividly at the height of Andrew Lansley’s structuralist madness.

Flawed Victorian notions such as ‘the undeserving and the deserving poor’, the principles of ‘lesser eligibility’ under which it was necessary to be completely destitute before receiving state help, and ‘the workhouse test’ make an unwelcome re-appearance in UK Government social policy dressed in new clothes (the virtual workhouse of Ken Loaches recent shocking film ‘I Daniel Blake’). In an age where we are functioning in a global economy, policies that will only reach part of the population prevent all citizens from reaching their full potential and put the national economy at a disadvantage.

The search for a unified system of tax and benefits continues. Centralisation proceeds apace dressed up as citizen empowerment. Thomas Gradgrind, Charles Dickens unfeeling character in ‘Hard Times is alive and well and living in the Treasury or the Department of Work and Pensions where knowing the price of everything and the value of nothing appears to be a prerequisite for promotion.

But not all politicians are bad guys. Tessa Jowell understood public health as Sarah Wollaston does today, but we are sadly lacking in the kind of leadership which is needed to take us forward to a new era that is fit for purpose. Timmins holds that George Godber and Liam Donaldson have been England’s best Chief Medical Officers. (I would add Donald Acheson) The civil servants in the Department of Health have often been dealt a poor hand in having to deal with contradictory political demands. Having worked closely with Duncan Nichol in our Mersey days I can attest to Duncan’s imagination and support for creative innovation and Simon Stevens is doing his best to unravel the mess that Lansley left behind. At the very beginning Churchill supported Beveridge, whilst the ambivalence of The British Medical Association was worthy of a contortionist.

And in the end many of the questions about how to provide population – based security out of general taxation remain, the ideological and the demographic. Of these, the demographic should be the most straight forward, and the Health Service must adapt to the needs of an increasingly elderly population – after all we have had over 30 years of knowing what was coming! The interdependence of the five giants is just as great today as it ever was. If we are to use our resources to optimal effect for the whole population, we need that interdependency to be understood by those charged with serving the public; we need citizens who understand it too. Timmins book provides a basis for that curriculum and is essential reading for all would-be public sector leaders.

In the second half of this talk, I will describe my conclusions about the agenda for such leaders that can carry us forward for the next 70 years.

So with Nick Timmins and ‘The Five Giants’ in mind we might ask ‘So what is the question that the constant tinkering is supposed to answer?’ The incessant reorganisation and obsession with structure to the detriment of function; the flirtations with privatisation and our fixation on the grossly unfair arrangements that are to be found in the USA where even the Health Maintenance Organisations such as Kaiser Permanente only cover employees; the constant threat of the introduction of regressive health insurance as an alternative to a system funded out of progressive taxation where there is pooling of risk. Meanwhile, we choose to ignore the experience of other countries, such as Finland, which have long since achieved the necessary transformational changes, within modest budgets, to put themselves on a sustainable path.

The starting point is how to optimise the health and well-being of the whole population, equitably, through a system of social security and welfare provision funded out of general taxation. It is daily apparent that essential services, services that make for a productive and healthy population [water and sanitation, energy, mass transit, education, housing and health] are too important to be left to the market, something that Richard Titmuss would have argued passionately 50 years ago. Ironically, we have been here before, as the recent demise of Carillion should remind us. Over 100 years ago the main utilities, including the gasworks and tramways were taken into municipal ownership, as later were coal mines, iron and steel and the railways because as essential services they could not survive without effective public interest oversight. In the fashionable dash to market-based purism that followed in recent decades, the public has become increasingly aware that the most obvious impact of privatisation has typically been the addition of around 10% to bills to satisfy the expectations of shareholders, without adding to the satisfaction of consumers. Health Services are no different, as the huge increase in transaction costs in the NHS over the past 30 years demonstrates. The distress of patients, workers and families that follows market failure from care homes to hospital construction is a price that the public is increasingly not prepared to pay. The burden imposed by the Private Finance Initiative is now seen for what it is: short sighted and obscene. Where were the voices of restraint at the seats of power when those decisions were being made? And those such as Alison Pollock who raised the alarm were ridiculed, vilified and disparaged.

If we ask why the NHS and similar systems in other countries arose in the first place, we find that an ethical impulse was often secondary to the imperatives of Empire and Industry, not to mention the actual survival of elites. In Germany, the ethical argument was made by Neumann in 1847 ‘The State argues that its responsibility is to protect people’s property rights. For most people the only property which they possess is their health; therefore the State has a responsibility to protect people’s health’. So much for the ‘Nanny State’. In fact, it was Bismarck, who, fearing revolution among the young men drawn into the cities by rapid urbanisation in 1848, the year of revolution in Europe, and fearing the spectre of the guillotine from France, implemented reforms in social welfare. In this country the extension of primary education in 1870 was motivated by the realisation that we were falling behind Germany and our European competitors. The consequence of finding that 40% of working class recruits to fight in South Africa in 1899–1902 were unfit for military service led to concerns about ‘how the country could maintain an Imperial Race and contain Germany’ and a comprehensive programme of action was proposed which included:

(1) A continuing anthropometric survey
(2) Registration of still births
(3) Studies of infant mortality
(4) Centres for maternal instruction
(5) Day nurseries
(6) Registration and supervision of working pregnant women
(7) Free school meals and medical inspection
(8) Physical training for children, training in hygiene and mother craft
(9) Prohibition of tobacco sales to children
(10) Education on the evils of drink
(11) Medical on entry to work
(12) Studies of the prevalence and effects of syphilis
(13) Extension of the Health Visiting Service

I don’t know about you but I am ashamed at the state of many of these essential public health services or their equivalent today, despite having had a National Public Health Agency now for six years. These late Victorian and Edwardian measures owe a great deal to Lloyd George who then built on them with his health insurance scheme in 1911, a scheme which resembles that of the American Health Maintenance Organisations which we seem to be so infatuated with despite them mostly being restricted to employees and their families. The great breakthrough with the NHS in 1948, three years after the death of Lloyd George’ was extending cover to the whole population, ‘equal access for equal need, free at the time of use and funded out of general taxation.’ The momentum that lay behind the consensus for the implementation of Beveridge was borne of shared hardship during the economic recession of the 1930s and in the Second World War fronts at home and abroad which transcended social class, although not the front between hospital medicine and general practice, private practice in London and medical practice in the rest of the country. In the event, it has been estimated that GPs doubled their pay in 1948 once bad debts had been taken into account. We have seen time and again how enduring is the public commitment to the NHS as a treasured national institution despite the fanatical determination of those on the political right for privatisation, returning time and time again like space invaders unwilling to learn from experience.

When the NHS was established in 1948, the public health picture was on the cusp of change. Infectious diseases, in particular those of childhood were in rapid decline as a result of improvements in living conditions, nutrition and the advent of comprehensive programmes of immunisation. Maternal and infant mortality rates were still high, certainly in comparison with today and life expectancy was a good deal shorter than now. The remarkable transition to a burden of disease characterised by non-communicable conditions and mental health problems was over 20 years away. However, the manifestations of unmet need were soon making an appearance, notably in relation to dental and optical care. As the pharmaceutical revolution proceeded along with a model of care dominated by hospitals, general practice was neglected and public health, temporarily consigned to the history books. In 1974, the arrangements that had placed the UK at the forefront of public health internationally, led by a Medical Officer of Health from the town hall were laid to rest, marking the high point of this chapter of hospital hegemony. Almost immediately, commentators began to argue the case for a renaissance of public health and for a reorientation of thinking, policy, organisation and practice. In 1976, Birmingham Social Medicine Professor Thomas Mckeown, demonstrated the fallacy that modern medicine had been responsible for the dramatic improvements in mortality rates over the previous 100 plus years; rather, most of the reduction in deaths from tuberculosis, bronchitis, pneumonia, whooping cough, and food and water-borne disease had already occurred before effective immunisation or treatment was available. Progress in these areas had probably had much more to do with smaller family size, improved environmental and housing conditions with advances in hygiene and the improved availability of cheap and safe food. Around the same time researchers such as Ann Cartwright, Peter Townsend and South Wales GP, Julian Tudor Hart began to point to the existence of an ‘Inverse Care Law’ in which the most highly trained doctors were to be found in the most privileged parts of the country and those with the worst health were least able to access high quality health care.

Tragically, over 40 years later and despite much hot air and lip service, we have failed to grasp the nettle, even when provided with the logical narrative and increased funding by Sir Derek Wanless. In 2004, Sir Derek persuaded the then Chancellor of the Exchequer, Gordon Brown to cough up significant extra funding for the NHS on the basis that it should be spent on resourcing a fundamental NHS reorientation to one of full public engagement and an upstream focus on prevention. In the event, the money disappeared into the Private Finance Initiative and a massive increase in clinical salaries. Every time dedicated funding has been identified for public health and prevention it has been diverted into balancing the hospital books. For me, the ‘Choosing Health’ monies, which I never saw, as Director of Public Health, was the epitome of the bad faith which emanated from Richmond House to be implemented at the local level. If I had a penny for every time I was told that we would get round to prevention once we had sorted out the hospitals I would be a rich man. And since the creation of Public Health England, another national body has failed to protect the frontline public health budget, standing by whilst the invidiously placed local authorities have diverted funding away from public health programmes such as family planning and sexual health to balance the books for social care.

Since McKeown published his analysis and others fleshed out our understanding of contemporary patterns of health and disease there has been no excuse for failure to transform our organised efforts and arrangements to optimise population health. This year we will celebrate 40 years of the AlmaAta Declaration made in Kazakhstan in 1978 and which underpinned the World Health Organisation Strategy of Health for all by the year 2000, adopted by the World Health Organisation in 1981. Health Services grounded in a whole population, whole system approach, the reorientation of health care towards primary and community care and upstream to prevention, tackling inequalities in health, full public engagement and partnership working and policies that support health within supportive environments; later this year in Alma Ata [now Almaty] these same principles will be revalidated. Finland is one of those countries that was listening when the Declaration was made. A Primary Care Act was passed which defined once and for all the proportion of capital spending to be dedicated to comprehensive primary and community health care. It included networks of modern community health beds, such as modern cottage hospitals linked to state of the art health centres across the country, a progression of high-quality community mental health facilities and general practitioners playing a key role at the front end of hospitals ensuring appropriate admissions. On a trip to the Finnish county of Karelia, with health service managers from Cumbria and Lancashire, where over 40 years ago Pekka Puska led a pioneering whole county approach to the prevention of coronary deaths, we heard of the systematic work that had skilled up the local population to manage common health conditions for themselves and resulted in a reduction in general practice consultations of between 20 and 30%; the Finnish Government itself was no hostage to commercial interests or allegations of ‘the nanny state’ and had been prepared to use the tools available to it in the form of legislation and taxation to create an environment that really did make ‘healthy choices the easy choices’. On that same trip to a country that in the early 1970s had had a notoriously bad diet, devoid of fresh fruit and vegetables, we visited a factory canteen where the workers were tucking in to an appetising selection of luncheon salads.

While this was going on in Finland and some other countries, in this country we were on a treadmill of structural reorganisation. In my 13 years as Regional Medical Officer, we underwent six – one every two years. Just as I had finished building up a team I had to start all over again. When I left the regional job in 2006 I commented that if I had wished to be a removals worker I would have joined Pickfords. I like to think that, together with colleagues here in the North West, we did make an impact in developing the New Public Health, not least in emulating what we could from Karelia with regard to heart disease and non-communicable disease in the absence of systematic government support; and certainly with teenage pregnancy and abortion, HIV and AIDS against central government opposition or apathy, but with the covert support of Chief Medical Officer, Sir Donald Acheson. How different it looks today with the present incumbents in Richmond House and Public Health England; a central team with little interest in public health and a lack of public health leadership in Public Health England, together with an unwillingness to challenge government, whilst neglecting the withering on the vine of local and regional public health since the transfer back to local authorities, now under the cosh of austerity and the centralisation of expertise and funding into a vanity project, a quasi-public health hospital in Harlow.

The Board of Public Health England is chaired by Sir Derek Myers, the former chief executive of Kensington borough council, where the disastrous Grenfell tower fire occurred last year, the Board itself having been recently recast as an advisory rather than an executive Board. In June last year the Guardian reported that Shelter Chairman Sir Derek and trustee Tony Rice had resigned because of concern over the organisation’s muted response to the Grenfell Tower fire. So what is needed to keep the faith with that noble generation that returned from war and with a bankrupt country delivered a National Health Service that the cynics and those with contrary vested interests said was impossible?

The manifesto to get us back on track and deliver equitable health and well-being to the population within affordable resources has five components which I will briefly outline:

(1) A clear vision. This vision is not rocket science and has been around since Thomas Mckeown and the Alma Ata Declaration 40 years ago. It is a vision of a whole system that tackles the 5 Giants, is rooted in public health and strong primary care which is a partnership with the population it serves. Community-Orientated Primary Care with its roots in Peckham in the 1930s, its adolescence in Johannesburg in the 1950s and a range of documented and persuasive experiments since, not least in Jerusalem, South Wales and Finland show the way. The integration of a whole population approach with the skills of epidemiology and public health alongside clinical and social care and a health literate public has to be the future, especially in the digital age. The combination of an anthropologically Place-based approach and Community Orientated Primary Care is a powerful one. The commercial determinants of health and disease must be confronted by both independent voices for public health and governments for whom the population’s health is more important than commercial interests.
(2) A convincing narrative. The failure of neither government nor managerial leadership to provide a convincing narrative of the future that we need is a disgrace. Much of it has been implicit but the repeated reorganisations and ill thought through dalliance with the private sector has happened because of the failure to describe the future and take people on a transformational journey. When Sir Derek Wanless published his report I managed to get a personal submission into Prime Minister Blair’s Christmas red box which brought together much of the argument presented in this talk and urged him to take a different path. The complacency of his reply shocked me and we have all lived through what has happened subsequently. In particular, I had suggested that he make use of his Directors of Public Health to argue the logical case for change in order to give the politicians the evidence-based justification to see it through. If anything today Directors of Public Health have been even more marginalised when they could be important allies.
(3) Authentic leadership. When Sir Roy Griffiths suggested that Florence Nightingale would be hard pressed to find a satisfactory answer to the question of who was in charge of our hospitals in 1983, the answer was seen to lie with general management. 35 years later it has failed to deliver. Too often, very highly, not to say excessively paid NHS chief executives have failed to provide either leadership or delivery to their communities and have failed to take responsibility when things have gone wrong, often finishing up with national honours en route. In part, their recruitment and training is to blame, and the move to greater clinical management is to be welcomed, but we are still producing chief executives and finance directors who are trained in silos with a narrow range of skills when it would be better for them to be trained in regional multi-agency staff colleges that included future leaders from all the health and social care professions, public health, the voluntary sector, the police, the media, academia and political life to list a few. That there can be chief executives from a range of backgrounds including finance who are unable to make sense of health outcome data or be on top of safeguarding and clinical risk management is unacceptable. As Director of Public Health I battled without success over many years to have health items and health data given the same prominence on Monday morning top team agendas as finance data.
(4) Full public engagement. The medical model of health services that was inherited from the private sector is not fit for purpose. As George Bernard Shaw put it ‘All professions are conspiracies against the laity’ and medicine is no exception. The nature of a profession is that of putting up one’s plate in the high street and seeing those customers who can afford to pay. It is not fundamentally about either a population focus with equity at its heart or empowerment but is about giving away small pieces of expertise in exchange for payment, not wishing to take the bread from its own mouth. The result is the creation of dependency and inappropriate demand that is not in the public interest and results in the deskilling of the workforce. This applies in the relationship between primary and secondary care where innovation of intervention and expertise has tended to remain hospital bound long after it could have been disseminated. Compare the situation with the motor car industry where expensive expertise is to be found in research and development followed by large scale, high quality and economic delivery. We have begun to realise that such a model can apply to long term conditions as well as to surgery. The modern equivalent of the Home Medical Encyclopedia, which my parents depended on before the NHS, is the internet backed up by proper school education in the classroom, by the full range of accessible allied health professionals and by peer led expert patient groups. In public health, there is now mainstream interest in Asset Based Community Development in which individuals and communities are seen as being half full rather than half empty dependent always on professionals coming along to fix them in a state of childlike dependency. It’s time the NHS and its leaders cottoned on.
(5) Adequate resources. Resources in the sense of money are usually the first item to be discussed in relation to the National Health Service. However, the way we frame the questions at the moment there can never be enough money. If we turn things on their head and build a system built on healthy public policies, full citizen engagement and a public health grounded clinical system money is the final question and it is about what it takes to make the system work. In a sense Simon Stevens has been trying to pursue this approach with the five Year Forward View, the programme of Vanguards (incidentally a Trotskyist notion of the leaders having all the answers), and the Sustainability and Transformation Plans which whilst well-meaning have slipped into the Richmond House default position of top down planning in nowadays smoke free, darkened rooms.

These five major components of the change we need must be backed up by a proper population evidence base, appropriate capacity and capability, and arrangements, curriculae and institutions that are fit for purpose. In turn, this has significant implications for our understanding of the values and cultures of a wide range of professional groups, their ability to work collegiately across agencies and as equals with members of the public. It would help if politicians had proper induction into the issues along with the officers who they must work with and if there was clear water between the public and private services and self-interest. But the most important element is co-productive, ethical and challenging leadership at all levels and across the whole system.

Here, in Manchester and in the North generally where there is increasing anger at the failure of our centralised national system of government to deliver, not only on the NHS but with tackling all five Giants and beyond Devolution can bring hope. Andy Burnham and Steve Rotherham, the great cities and counties working together as Leaders of Place can use soft and convening power with an outward focus to transform life for millions. They can push the boundaries free from the fossilised processes that hold us back and provide accountable voices for local people; early examples of the momentum for change that is building include homelessness, environmental sustainability, the need for a living wage and the obscenity of very high pay and inequality. Mayor Bloomberg in New York has given us a flavour of the potential of an elected mayor in championing public health and I have personally witnessed the power and influence of 1000 such first citizens committing themselves in cities across Latin America.

I have had the privilege of working with the World Health Organisation Healthy Cities initiative, which now involves over 1400 cities worldwide, for the past 32 years. Next month  February 2018) in Copenhagen there will be a summit of elected city and metropolitan mayors from around the world marking a new phase of political leadership at the city level. The focus will be on six P’s:People, Place and Participation; Peace, Prosperity and the Planet. Beveridge’s five Giants are now a global threat; by working together not just here in Manchester but in concert around the world we can keep the faith with those who gave us the NHS on 5th July 1948.

This was the Telford Memorial Lecture at Manchester Medical Society – 31st January 2018.

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On 15 April 2018 Doctors of the World (DOTW) and the National AIDS Trust (NAT) issued a joint statement that called on NHS Digital to immediately stop sharing patient details with Home Office immigration authorities.

DOTW and NAT believe that sharing confidential patient information with the Home Office will deter vulnerable migrant groups from seeking antenatal care or urgent care for infectious diseases.

Here is the DOTW statement:

MPs repeat demand for an end to NHS Digital sharing patient data

The House of Commons Health & Social Care Committee has, for a second time, called on NHS Digital to immediately stop sharing patient details with the immigration authorities. Expressing deep concern about the Government’s approach to sharing confidential patient information, a report released by the Committee on 15 April stated: ‘we believe that patients’ addresses, collected for the purposes of health and social care, should continue to be regarded as confidential.’

The report also states the Committee’s lack of confidence in the leadership of NHS Digital, citing the failure of NHS Digital to act independently of Government and its disregard for the underlying ethical implications of this data-sharing.

Currently, the Home Office receives information about patients from NHS Digital, the body charged with safeguarding patient data. The data is used to trace migrants, which creates a climate of fear where vulnerable people – including pregnant women and those who have been trafficked – are too afraid to access healthcare.

DOTW (Doctors of the World) UK and NAT (National AIDS Trust) have been campaigning for an end to this practice since it came to light in 2014. Both charities gave evidence in the Health & Social Care Committee’s initial hearing on the issue.

Lucy Jones, Director of Programmes at DOTW, said: “In our clinic, day in day out, we see the incredibly harmful impact the data-sharing deal has on our patients. It has reached a point where people do not want to give the NHS their contact information out of pure fear. While confidentiality is in such a precarious state, mothers are not accessing the antenatal care they need, public health is put at risk, and we fear this is only going to get worse”.

“Doctors of the World UK stand with the Health Select and Social Care Committee in opposing this dangerous information-sharing deal between NHS Digital and the Home Office, and are thrilled the Committee has taken such a strong stance. This view is also shared by the British Medical Association[1] and the Royal College of GPs[2]. As a healthcare charity, we believe in the right to healthcare for all. Yet this immoral deal works to scare some of the most vulnerable people in society from seeing a doctor.”

Deborah Gold, Chief Executive of NAT said: “It is scandalous that our data is being shared and our privacy corroded with less and less justification. As an HIV charity, we understand the importance of treating infectious conditions and limiting the spread of epidemics. When people can’t trust the NHS with their data, that good work is undone and we face a public health risk. There is nothing to be said for this practice, which deters people from accessing healthcare.

“Data sharing should have been stopped when the Health & Social Care Committee first called for it, and it certainly should stop now they have, for a second time, demanded an end to this short-sighted and unethical practice.”

Sign our #StopSharing petition to support our NHS Doctors and tell NHS Digital they are NOT Border Guards:



The Commons Health Select Committee says:

Dr Sarah Wollaston MP (Chair): NHS Digital are an organisation that the public need to have absolute confidence will respect and understand the ethical principles behind data-sharing [and they] have not shown us at all that this is part of what [they] are considering’.

Dr Paul Williams, MP for Stockton South and a practicing GP, questioned “what advice would you give to clinicians about what they should inform their patients so that this information is classed “with consent”?’

Luciana Berger, the MP for Liverpool, Wavertree urged NHS Digital to reconsider, calling the deal ‘a matter of life and death’ for an extremely marginalised and vulnerable patient group. 

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

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

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

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

The main changes to this edition include:

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

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

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

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

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

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

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

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

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

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

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

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

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


These comprehensive Standards are very welcome.

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

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

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

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

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

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


BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.

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SRH sector join forces and call on SoS Jeremy Hunt to strengthen local authorities’ SRH mandate

Key SRH and public health stakeholders such as FSRH, BASHH, BHIVA, FPH, NAT, THT, FPA and Brook have sent an open letter to Secretary of State Jeremy Hunt highlighting the challenges currently faced by the sector.

The open letter puts forward a set of recommendations, including fully-funded SRH services based on the needs of the population; delivery of SRH services by local authorities in accordance with nationally recognised standards such as FSRH, BASHH and the new BHIVA standards; enhanced accountability mechanisms, among others.

The letter comes in the footsteps of a call for evidence launched by the Department of Health and Social Care (DHSC) on the impact of local authority public health prescribed activity. It is now over four years since public health duties transferred back to local authorities, and the Government wants to take stock of the regulations to consider whether the current arrangements set out in the 2013 regulations will, in the future, be fit for purpose. This is given added relevance by the announcement in December 2017 that the Government intends to replace the ring-fenced public health grant with local authorities’ own business rates retention funding from 2020.

You can read the following letter in full here on the FSRH website:

The Rt Hon Jeremy Hunt MP
Secretary of State
39 Victoria Street
United Kingdom

18th April 2018

Dear Secretary of State,

Sexual and reproductive health sector call to strengthen the public health framework

The sexual and reproductive health (SRH) sector strongly welcomes the Government’s call for evidence on the impacts of the current prescribing regulations for local authority public health activity. This is a much-needed stock-take of the existing framework following the radical changes resulting from the 2012 Health and Social Care Act which transferred public health responsibilities from the NHS to local authorities.

We represent hundreds of thousands of healthcare professionals who work within the current public health framework as well as service users and the general population whose needs must be considered first and foremost in public health policy.

The implementation of the existing public health framework has brought challenges, and these have undoubtedly been exacerbated by significant cuts to the public health grant. Financial pressures have impacted on local authorities’ ability to even maintain the current levels of service provision, and evidence points out that budget reductions are leading to unacceptable variation in the quality and quantity of services available to the public.

Strengthening the SRH mandate by enhancing the scope of prescribed activity and accountability mechanisms is vital to ensuring that key services are consistently provided across the country. However, much remains to be done to tackle regional inequalities. Cuts, coupled with fragmented commissioning, have had a severe impact on access to contraception, including emergency contraception. They are also undermining the delivery of effective sexually transmitted infection (STI) prevention, testing and treatment services, which is especially concerning considering the recent explosion in syphilis rates and the continued spread of antibiotic-resistant gonorrhoea. The significant pressures caused by the cuts are limiting patient access to SRH services across the country and are ultimately jeopardising health outcomes as a result.

Non-prescribed public health activities have faced significant service cuts too (for example, HIV prevention funding in areas of high prevalence dropped by a third in two years). This strongly suggests that any potential removal of the public health grant ring-fence will inevitably lead to further redistribution of funds to other equally-as-pressured parts of the system. We are also concerned that the proposal to fund public health through locally retained business rates in 2020 could compound health inequalities in socio-economically deprived areas. With increasing uncertainty surrounding local authority financing, it is vital that the public health framework is strengthened to ensure that SRH services are truly open-access and available to all, so that health inequalities are not deepened.

We would therefore like to bring to DHSC’s attention a common set of recommendations agreed on by the SRH sector which are important to strengthen the effectiveness of the SRH mandate:

1. That sexual and reproductive healthcare services are fully-funded based on the needs of the population.

2. SRH services must be delivered by local authorities in accordance with nationally recognised standards in SRH, such as FSRH, BASHH and the new BHIVA standards, guaranteeing high-quality SRH care. These standards should be expressly referred to in the mandate to protect services from being compromised by cuts to budgets and politicisation at local authority level. We would particularly like to see DHSC and PHE collaborate on strengthening the SRH mandate for use at the local authority level.

3. For tools to be developed to support local authorities to assess the impact of their prescribed activities on health inequalities, such as inequality impact assessments.

4. DHSC to ensure that joint working happens in practice, supporting local authorities and Clinical Commissioning Groups with their SRH commissioning responsibilities in line with the collaborative and whole-system approach to commissioning outlined in PHE’s ‘Making it work: a guide to whole system commissioning for sexual health, reproductive health and HIV’.

5. Given the APPG for Sexual & Reproductive Health’s Inquiry findings that there is a lack of clarity with regards to accountability in the current system, that existing accountability mechanisms are enhanced, enabling the Secretary of State to hold local authorities to account in their devolved delivery of his public health responsibilities.

6. That PHE has stronger enforcement powers to enable the agency to act on the findings and analyses it produces and to hold local authorities and commissioners to account for their performance.

7. Accountability lines must be further developed if the business rates retention system is introduced in 2020, with further consultation in this regard.

We are clear that changes are needed to make the public health regulations work now, and to ensure that they are fit for the future. We urge the Government to consult further on specific changes and to do so in the context of clear proposals for how public health responsibilities will be funded in the future. It is essential that the sector has further opportunity to scrutinise the framework in this context.

Finally, we strongly encourage the Department to take fully into account the detailed recommendations set forth in our individual responses.

Yours sincerely,

Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists (FSRH)
National AIDS Trust (NAT)
British HIV Association (BHIVA)
Family Planning Association (FPA)
British Association for Sexual Health and HIV (BASHH)
Terrence Higgins Trust (THT)
Faculty of Public Health (FPH)

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It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.


Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

Obesity and malnutrition

I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

NHS funding

Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

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