Category Archives: Staffing

Introduction

 

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

 

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

 

The sections

 

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

 

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

 

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

 

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

 

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

 

The priorities and next steps

 

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

 

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

 

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

 

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

 

Dr Tony Jewell (Convener/Editor)

Central Council

July 2019

The complete policy document is available below for downloading.

Public health and Prevention in Health and Social carefinaljuly2019

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Security staff at Southampton General Hospital being attacked in the A&E department is key to an industrial dispute over pay and sickness pay.

Unite, Britain and Ireland’s largest union, said its 21 security staff members were being attacked on a regular basis by members of the public either under the influence of drink or drugs, or with mental health problems.

Unite is currently holding a ballot for strike action or industrial action short of a strike of its members, employed by Mitie Security Ltd, at Southampton General Hospital over pay and conditions. The ballot closes on Wednesday 15 March.

Unite said that Mitie Security was refusing to provide adequate personal protection equipment (PPE), such as stab vests and  safety restraints, even though knife-related incidents are increasing.

Unite lead officer for health in the south east Scott Kemp said: “With cuts to the police force and mental health services, there is a tendency for those suffering from various conditions to be dropped off at the hospital and left to the security guards. 

“The statistics are not easily available as to the number of our members who have been injured. There has been a lack of proper investigation into the incidents over a considerable period.

“The guards report incidents that have occurred on every shift, but the bosses at the University Hospital Southampton NHS Foundation Trust and Mitie Security will only investigate when someone is injured.

“Our members are very concerned over incidents occurring right across the Tremona Road site when there has been little or no support from the police who are under pressure because of government cuts.

“Our argument is that we should not have to wait for someone to get injured before a full investigation is instigated.

“That is why the sick pay arrangements are really important. At present, if the security staff are injured at work, and if the resulting investigation finds in their favour, they get two weeks’ full pay and then two weeks’ half-pay. After that, it is the statutory minimum.

“We have members getting beaten up and then having to return to work after two weeks, when they are clearly not fit to, as to drop down to half-pay would mean missing mortgage or rent  payments and significant financial hardship.

“What we want is enhanced sickness payments for those off work due to being injured protecting patients and hospital staff; proper and transparent investigations into all attacks; and our members having the necessary personal protection equipment.

“Our members are seeking six months’ full-pay, followed by six months’ half-pay for all sickness absences. We don’t think those are unreasonable requests, given the level of violence in today’s society generally.”

Unite said that the demand for an increase in pay from the current £8.64 an hour reflected the stress of the job. The security staff are seeking £10.50 for security officers and £12.16 for supervisors, with additional payments of 50p per hour on night rates; £1 an hour on Saturday and double time on Sunday.

Scott Kemp added: “Our members are at the forefront of providing security and a safe environment for staff, patients and visitors – that’s why Mitie’s management needs to get around the table and negotiate constructively.

“There is now a good window of opportunity for such talks before the ballot for strike action closes on 15 March.”

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Responding to the Health Secretary’s pledge to overhaul mental health and wellbeing services for NHS staff following the launch of a Health Education England review, BMA mental health policy lead, Dr Andrew Molodynski, said:

“Staff are fundamental to the delivery of patient care in the NHS and without a healthy workforce our health service can barely function, let alone thrive.

“Given the current pressures that the NHS workforce is under, the Secretary of State for Health and Social Care’s commitment to improving mental health and wellbeing support for staff is both timely and necessary.

“We know that doctors’ mental health and wellbeing has been adversely affected by the increasing demands of their work and this is true also for medical students who are dealing with stress, fatigue and exposure to traumatic clinical situations, very often without adequate support on hand.

“The BMA recently for greater provision of mental health support for NHS staff as their report¹ found that only about half of doctors were aware of any services that help them with physical and mental health problems at their workplace – while one in five respondents said that no support services are provided.

“While these measures will go a long way to providing much-needed support for NHS workers who are struggling with their mental health and overall wellbeing, more must be done to address the wider pressures on the system, such as underfunding, workforce shortages and rising patient demand, so we can reduce the number needing to seek help in the first place.”

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The Health & Care Professions Council (HCPC) delivered a snub today (Thursday 14 February) by pushing ahead with an ‘extortionate’ registration fee hike, despite receiving a 38,000-signature petition protesting at the 18 per cent increase.
Unite, Britain and Ireland’s largest union, led the protests at the increase from £90 to £106 a year – on Monday (11 February) the union handed in the petition to HCPC chief executive Marc Seale calling for the rise to be scrapped.

Unite lead professional officer for regulation Jane Beach said: “Today the views of the 38,000 mainly health professionals who signed the petition have been ignored which is very disappointing, given the cogent arguments we put forward that NHS pay has stagnated in real terms while the cost of living has raced ahead.

“The HCPC has given a massive snub to our members’ legitimate concerns about any fee hike.

“We consulted widely with our members who have to register with the HCPC in order that they can work professionally – and they gave the proposed increase a resounding thumbs down. Now they have been given a financial kick in the teeth by the HCPC.”
Unite argued that the increase from October 2019 would be another financial blow to hard-pressed NHS staff, such as biomedical scientists, paramedics and speech and language therapists, who have seen the fees increase by 40 per cent since 2014.

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Last year I told you about a group of 7,000 health professionals who had spent 7 years fighting for their trade union to be recognised by their employer. That campaign has now lasted 8 years. See: https://www.sochealth.co.uk/2018/05/05/solidarity-with-community-pharmacists/

The Boots pharmacists were the first workers in any sector to challenge an employer through the ballot process described in that earlier article (above).  The law requires not just a majority, but that 40% of those eligible to vote, known as the “bargaining unit”, must vote “Yes” to make a difference.  The result was 87% of those who voted (2,826 pharmacists) voted Yes and that constituted 41% of the bargaining unit in favour.  This passed all the legal tests and the blocking agreement with the “sweetheart” union that the company was using to keep independent trade unions out, was ended by order of the Central Arbitration Committee.

To emphasise what an achievement that is, if you measure the BREXIT referendum in similar percentages, of those eligible to vote it was just 37% vs 35%, so getting over 40% of eligible voters to support anything is no small achievement. Despite the clear result, the employer has continued to resist pharmacists’ efforts to secure an independent voice at work in the largest community pharmacy multiple chain.  However, in February 2019 the 7,000 pharmacists can vote again in a further postal ballot and this time it will force the employer to recognise the PDA Union

One of the big issues for pharmacists is the company’s approach to performance management and the union have been hearing from pharmacists about what it means to them.  These quotes from pharmacists illustrate what the PDA Union are trying to fix so that these health professionals can get on with caring for patients.

“In regards to its pay structure and market based pay it should be ashamed. It should be ashamed for its performance review where no person I have spoken to has any idea what it means to be above performing and where the pharmacy advisors, the people on the front lines get no bonus at all unless they are above performing.

Nobody knows what exactly they need to do to be “above performing”. Even if you hit all your targets and are green on the scorecard despite those targets being an increase you are performing.”

 

“I worked under this regime and it is a terrible way to work. The constant threat of a ‘non-performing’ rating is so demotivating and demoralising and it sometimes felt like a personality contest. I challenged it many times (probably another reason I would never win a corporate personality contest) and was told that even if all targets were met/exceeded you could still be classed as non performing so what’s the point!”

Ballot papers will be mailed to pharmacists on Monday 18 February and completed ballots must be returned by noon on Monday 11 March in order to be counted.

Boots directly employs well over 10% of all pharmacists in the country and has many more working occasionally as locums, so this is a significant story for pharmacy, but sadly under reported by the media.  Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

The PDA Union was established in 2008, it is the only independent trade union in the UK which is exclusively for pharmacists.  It received a certificate of independence in 2010.  PDA Union is a member of Unions 21 and affiliated to the Employed Community Pharmacists in Europe (EPhEU) organisation and a member of Health Campaigns Together.  You can follow the PDA on Twitter, Facebook, Instagram and LinkedIN

Written by Paul Day, National Officer at PDA Union.

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Hi friends,

just to say quickly that this looks like a good job opportunity for the right person, don’t know if it’s been circulated already?

https://www.charityjob.co.uk/jobs/neon/organiser-healthcare-/586510

they’ve asked me for recommendations, so if anyone is interested in going for it let me know and i will mention it to them – am seeing someone who is involved in the process this evening (deadline is end of next week)

all the best

Caroline

Editor, openDemocracy UKOurNHS

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Did you know there are a group of 7,000 UK health professionals whose employer has spent 7 years, and who knows how much money, preventing them from gaining an independent voice at work?

What if I told you that part of this situation involves an entity, which is supposed to represent workers, that has signed an agreement with management committing to only “collective bargain” resources for their own officials and committing not to collective bargain for the employment terms of their members?

This is what happened at Boots when the company signed an agreement with the “Boots Pharmacists Association” (BPA) in 2012 and in law this is enough to block an independent trade union, the PDA Union, from following the statutory process for recognition at that employer.

The BPA is on the certification officer’s list of trade unions, but it is not independent. BPA was refused a certificate of independence in 2013. Part of the certification officer’s decision said: “looking at the picture as a whole that there emerges, in my judgement, a clear image of a union that has over the years been drawn into a situation in which it is indeed liable to interference by Boots… tending towards domination or control.”.

Boots is the largest and most well-known community pharmacy business in the UK. The multi-billion pound global enterprise is a vertically integrated business profiting from both wholesale and retail sales of medicines, with much of that coming from the taxpayer via the NHS. The company has tried “everything” to block their employed pharmacists from getting independent representation and that includes the blocking agreement signed in secret with BPA at a time the company was simultaneously talking to PDA Union about statutory recognition.

The good news is that the pharmacists have never given up and last summer six pharmacists, supported by PDA Union, applied to the Central Arbitration Committee to have the Boots-BPA agreement ended. Over 1,000 more employees pledged online to support the application, and after a further legal hearing at which the company and BPA’s joint attempt to give votes to senior managers (if they are a registered pharmacist) was overcome, a ballot is about to be held of almost 7,000 pharmacists working in Boots stores to end the blocking agreement.

The law under which this ballot is happening has never been used before in any sector and the union must achieve 40% of those eligible to vote, to vote in support, hence their #2780pharmacists campaign hashtag.

Ballot papers go out from 10 May and must be returned by 23 May in order to be counted. Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

  • Paul Day, National Officer, PDA Union @the_pda_union
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Yes we need more resources in mental health but not the same old ‘diseased’ bio-psychiatric medical model of mental ‘illness’ and mechanistic Cognitive Behavioural Therapy,  but a social-social public health preventive model of mental distress/health, health workers who firstly tackle the social determinants of health and work amongst the people where the social is not forgotten.

No one is denying the reality of mental distress, also mental distress needs twenty times more resources than at present, but the question is “what type of resources and interventions?” Does anyone ever stop to analysis why mental health issues are occurring. What is the cause that causes the cause to become a cause? Is it diagnosis which is so wide e.g. DSM5, that everyone is now mentally ill?  Is it iatrogenesis? Is it the ideology of austerity? Is it the treatments with so called anti psychotics and anti – depressants? Is it coercive mental health laws?  Is it unfairness, poverty, inequalities? Is it abuse and discrimination? Is it a cruel state, poor working conditions, deregulation and privatization? is it individualising, psychiatrising, psychologising existence so that the social, political, economic, materiality and broad environmental issues conveniently disappear? Is it capitalism, society, which causes so much mental distress? Why are so many people internalising their own oppression, harming themselves? Why not externalise their distress come to voice. There are many people who would like to work in mental health but not one dominated by psychiatry and mechanistic CBT.

Psychiatry is a pseudoscience with a faulty epistemology  and wrong, very wrong, ontology. What is a human being – not just DNA or neurochemical selves. Humans are social beings and how society is socially, economically politically and environmentally (SEPE) arranged influence much including mental health and distress.

Many people who go into the psychiatric system have just normal emotions, reactions to situations, e.g. bullying, all forms of abuse, power-over, lack of autonomy and control, alienation, homelessness, trauma, unfairness and poverty. Many have been drugged (iatrogenesis doctor induced illness) into psychiatric services as Whitaker (2010), clearly and with evidence illustrates over the last sixty years people have been medicalised and damaged.  Psycho-trophic drug giving has ‘sky rocketed’ leading to an explosion of chronic mental health and physical disabling conditions.  Q if the drugs are so good why has chronic mental health conditions increased so much in the last 40 years – madness. No one is denying the reality of mental distress. People suffer suffering is not an illness. Psychiatry is a marriage of convenience with neo-liberalism, big pharm, corporations, governance (control of the populace) – a form of ideological hegemonic power.

Surely all the children in USA/UK now medicalised with toxic drugs aren’t all mad? Did the children ask for these drugs? Do all women and the poor placed in institutions by husbands, families consider themselves mad, are all the Jews exterminated by German psychiatrists in T4 camps did they consider themselves mad? Are all BME groups labelled and tortured by psychiatry would they consider themselves mad?  The Soviet dissidents tortured in Russian and sent to gulags would they consider themselves mad? Are all the people getting on in years and particularly women given electric shock at alarming increasing rates are these people mad?

When you listen to people who have experienced abuse, rape, power-over, poverty, trauma including psychiatric trauma and psychiatric rape, experienced a cruel state, would they consider themselves mad? Maybe nearly driven mad but that’s another issue.

What can be called mad is a biological and genetical, nonsense aetiology which still prevails. When in the 21 st century today’s scientists are aware of epi-genetics and that genes get switched on and off and are influenced by social economic political broad environmental  issues including poor diet. The genome studies again have found no conclusive findings for biological explanations for mental distress.  Mad is the four ideological myths of psychiatry (chemical imbalance, 1960’s marketed drug ‘illness model of drug action, pseudoscience of diagnosis, biological biomarker myth) and the reality of coercion and iatrogenic mad practices. Another madness is the invention of illness DSM and all classifications, fabrications of psychiatry. Thinking that psycho-trophic drugs will cure mental distress is another madness. Nor providing the social determinants and the prerequisites for health and wellbeing is mad also really a crime against humanity. Psychiatry is a crime an industry of death.

Some people  state it is  naïve to want to abolish psychiatry without putting something in its place  – to abolish psychiatry is a necessary prerequisite for change and it is naïve not to want to do this. Replace it with more doctors of medicine MD’s, they are trained to deal with health problems – adopt a new approach to mental health, a public health approach, adopt community preventative medicine, not dualistic but holistic including changes in SEPE – increase resources for mental distress twenty times fold – not less resources but more. Have a 100% state funded NHS, have no private provision in NHS, have a national work occupation health service in all organisations to promote health and reduce mental distress. But don’t have a national sickness service have a health service.  More up – stream public health measures preventing and enhancing health, a more just society, reduce relative income differences, introduce a universal wage. There are numerous alternatives – open dialogue, exercise, social solidarity, Hearing Voices Network, peer groups, Sorteria houses, dial house in Leeds, activity for life, retreats, safe spaces, quiet spaces, night cafes, more social engagement, better healthy workplaces promoting autonomy control and income and so on. Adopt a social model of health and mental distress tackle alienation. Just stop abuse. Maybe social transformative change has to occur before psychiatry is abolished? Just think if annoyed, angry, discontented, irritable, unhappy, grief stricken, miserable people, put upon people, people disadvantaged, ‘down depressed’ people, agitated people, traumatised people, abused people, decided to use this energy as a catalyst joining alliances to change things, demand a less abusive fairer society, that would upset the status quo.

This author acknowledges the reality of serious mental distress which needs resources but the crucial question is what type of resources. It also acknowledges that some people are happy with present day mental health services and drugs but others are not. Many people are trapped and damaged by the drug regime.

If you get rid of the ideology of psychiatry and psychiatry itself, there will be less stigma more possibilities. One can easily make a case that capitalist society  makes you mad – isn’t education mad, testing children, pressurising children, labelling children – too much I.T  and  social media pressure, too much computer time, sedentary children inducing future public health ‘time-bombs’-  isn’t this madness?

These are not just issues of the past. They are happening now and will happen in the future if psychiatry isn’t abolished. We are drugging people and damaging them, some drug use will still be required, there is a role but use the correct drug induced model of drug action, be truthful with people and use drugs with extreme caution and only mainly short term. Electric shock, psycho-prisons, Community Treatment Orders, harmful mental health laws are still used. Human rights violations are very much still rampant. So who is mad? Surely not the people, surely not children and the poor,  not the politically constructed ‘race’ people.  It isn’t psychiatric neglect but SEPE neglect, social justice neglect, materiality, power and resources neglect and psychiatric abuse. It is also an abuse that there is very little resources for mental distress but these are decisions made by people in power with vested interests in the status quo. Just think how much money we could save without a pill for ever ill. Just think how many people could be saved from chronic disabling mental health conditions, how many children could be saved. This money could be used in mental health on alternative schemes and up –stream public health to prevent health problems.

Here is the crux many people have a vested interest in psychiatry, and the psych industry unfortunately they are also very powerful in a neo-liberal state and the ideology of individualism, a form of social control and it’s an ideal way to make profits.

One person with a similar aim and viewpoint – Bonny Burstow (2015) her latest excellent book Psychiatry the Business of Madness: an epistemological and ethical audit advocates an abolitionist approach.

Revision after consulting the public in four workshops and 14 discussion groups  have recently  come up with a manifesto for change which will be launched in 2017

Revisions Manifesto’s seven visions for change:

  1. To move from a ‘diseased’ bio-psychiatric model of ‘mental illness’ to a social model of mental distress/health. We need for a different approach ‘grounded’ in social fairness, listening, equity and social justice.
  2. To  stop using all psychiatric diagnostic and classification systems
  3. To recognise what we need to achieve good mental health :
    1.  Income, family, friendships, a safe home, opportunity, work, leisure, the arts, spirituality – plus many more which should be defined by individuals and communities themselves.
    2. Recognise oppression in all its forms and develop strategies to combat these at the individual and structural level.
  4. To understand that medication does not and cannot ‘cure’ mental distress.
  5. To work towards socially orientated and democratically accountable types of mental health service provision.
  6. To stop coercion – abolish Community Treatment Orders, ban electroconvulsive therapy  and urgently review all mental health laws.
  7. To challenge the current crude neo-liberal economic system that creates a fertile environment for ever increasing mental distress.

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Wednesday’s budget delivered grim news of poor economic growth over the next few years, compounded by even grimmer jokes. However amongst the cautiously delivered statement seemed to appear one pearl of  policy that should of set every NHS employees heart a flutter. The announcement that funding would be provided to facilitate pay rises for some staff, but this was not the monumental announcement abolishing the pay cap or a U-turn on austerity that some may have hoped for. This announcement came as more of a carrot on a very long string with a few hoops to jump through along the way and it would appear the devil was in the detail. The Chancellor confirmed that this increase in pay would be linked to productivity and pay reform, something that has been mooted before without being fully explained. So the question of whether or not there would be a pay rise has left many nurses, midwives and paramedics scratching their heads.

Union bosses criticised Mr Hammond’s announcement. Unison’s Dave Prentis showed concern that the chancellor was raising the hopes of nurses without putting any extra money on the table, where as the RCN’s Janet Davies warned that any pay rise should not be linked to staff working harder highlighting the fact that nurses have had their pay frozen for the past 7 years and that any increase would only deliver what had been lost. So what could this announcement mean for nurses ?

It is no secret that the NHS faces a funding black hole despite receiving an extra 2.8 billion this budget, with the government hoping the restructuring of services will help plug the gap. Many NHS staff are paid via an agreement called Agenda For Change which allows for universal pay across the NHS as well as providing incremental pay increases linked to progression.

2016 saw Health Secretary Jeremy Hunt embroiled in a row with doctor’s over contracts that many labeled unfair but the government said were necessary to modernise the health service. It is thought that the same will happen again with Mr Hunt setting his eyes on aspects of the Agenda For Change agreement particularly surrounding enhanced unsociable hours payments given for night shifts and weekends when he submits evidence to the NHS Pay review body in the next few weeks. It is  also felt that the Government will attempt to redefine the working day in line with their 7 day service strategy. This could see unsociable hours pay kicking in much later in the evening and being abolished at weekends. Other possible changes could include smaller incremental progression pay rises as well as getting rid of any overlapping pay structures between bands. meaning those nurses who reach the top of their band, don’t progress or rely on extra hours payments may see the long term pay drop further despite any pay increase.

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Over many years we have seen the NHS develop some really stupid ideas. To be fair realising that they were stupid may only have become obvious with hindsight – but not always. Key characteristics of stupid ideas are that they rest of dubious assertions not solid evidence; they make wildly optimistic assumptions; they lack (or refuse to publish) the details of the case; they are not independently assured; they are driven by outsiders (usually management consultancy firms); and those who decide to go ahead are never there to be accountable when everything goes wrong.

Many PFIs, a lot of the ISTC’s, much in Connecting for Health, Commissioning Support Units, Regional Procurement Hubs, outsourcing commissioning (Cambridge, Staffordshire etc), outsourcing patient transport, pay cartels, management franchises, some STPs and so on ad nauseum (literally).

You might say this is the price of being innovative and trying things and that failure is one way of learning. But evidence of any learning from failures is scant.

So, the latest wheeze is wholly owned companies – arm’s length bodies. The ideas around setting up arm’s length bodies is hardly new as it has been done for two decades in local authorities. But some parts of the NHS are determined to ignore all that has been learned.

There are examples of sensible approaches to arm’s length bodies – where the reasoning behind the venture is clear. An example would be some ALMOs set up to manage council housing. One NHS FT has set up a company to better deal with facilities management and some other services using a model that makes some sense.

But what we seeing now in the NHS is the use of such a devise simply to undermine national terms and conditions – with claims that workforce costs can be reduced by 15% (or pluck any figure you like) simply be taking the staff out of the mainstream NHS. This is just like the argument that brought us Circle managing Hinchingbrooke – that a new model of management has to be better and cheaper – which proved eventually to be nonsense.

Other reasons offered as a smokescreen are that there are tax benefits or the ability to be more “commercial” or the idea that the shiny new organisations adds new customers which then add income – these are all fanciful and risky. It’s amusing that making profits for one part of the NHS as service provider out of another part of the NHS as a customer is supposed to be sensible.

There is no doubt that this is all about an attack on the workforce. One case set out that “flexibility” was needed, that sickness absence must be better controlled and that new kinds of jobs were necessary – all of which are perfectly possible within the mainstream NHS. Again, the echoes are there from a time when facilities management of various kinds was outsourced simply because the Trusts were unable to manage their staff properly.

Setting up new bodies that are outside the NHS, behaving like commercial companies, setting their own bargain basement terms and conditions and competing for business from other NHS bodies is surely exactly what we are all trying to get away from. The most likely scenario is that the change will cost a lot to implement, will alienate a large section of the workforce and make others fear they may be transferred later. Why not deliver all services through arm’s length arrangements? We could have commissioning Trusts that just meet once a year and place contracts – a nightmare dreamed up by some local authorities.

This is a stupid idea and those who should know better in NHS England and NHS Improvement should step in and stop it, because this kind of outsourcing does not work. Just as they should have stopped the outsourcing of commissioning debacles in Cambridge and Staffordshire or the never-ending saga of the in/out CSUs. Get a grip!

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We need better policy for the NHS. But we are not going to get it if the entire debate is a Manichean point scoring contest conducted entirely in shibboleths and lacking reasonable analysis of alternatives. Too many serious people seem to believe that everything in the NHS would be fine if we undid the Lansley act and spent a bit more money. That analysis is naive, is stopping serious discussion of what the real challenges are and is distracting people from improvement that could come right now.

I went to the recent Royal Society of Medicine event (the one where Stephen Hawking condemned Jeremy Hunt’s selective use of evidence on weekend mortality generating a flood of media commentary). There were a lot of serious, senior thinkers on stage and in the audience. I naively assumed that a debate about the past present and future of the NHS would contain some disinterested assessments of the real problems and their causes. What I found was a desire to blame all the problems on the government and/or longstanding conspiracies to destroy the system. There was a remarkable lack of serious analysis and a widespread belief that every problem would miraculously go away if we simply reversed government policy.

Once you have adopted this position, you are clearly absolved from doing any serious analysis of the state of the NHS and you don’t have to do any thinking about how to improve it. This is a catastrophic position for the NHS as it desperately needs some better thinking about how to improve.

The debate consisted of shibboleths not substance

Here are a few examples of just how futile that debate was.

Richard Murphy made some good arguments about the limits of government spending (in a sovereign currency area, he argues, we don’t need austerity at all). But he then argued that the reason why we have austerity is because of a neo-liberal conspiracy to shrink the state. Maybe some people want to do that, but this government are about as useful as a one-armed trapeze artist with an itchy bum and are not credible organisers of such a conspiracy. Assigning the blame to a deep rooted conspiracy lowers the credibility of the argument and absolves true believers from any further need to engage or analyse the difficult details of policy.

Many speakers, including Hawking, condemned any private sector involvement in the NHS as if undoing it would suddenly improve things. Nobody mentioned that the largest sector of the NHS run by the private sector (the GPs) has the highest patient satisfaction. Supposedly we must have public provision as we can’t trust the private sector’s motives. Somehow, though, the even more severe conflict of interest of working for the NHS while also running a competing profit making enterprise (as perhaps half of NHS consultants do) was raised once and then completely ignored.

Audience members heckled Nigel Edwards for pointing out that the “we must spend a higher % of GDP on health because our neighbours do” argument was undermined by the latest OECD statistics. There are good arguments for spending more but this isn’t one of them. Rather than recognise this, the audience and many commentators prefer to quote the old numbers because they bolster their argument in a way the better numbers don’t.

And a disturbing number of people advocated solutions to the current crisis that involve major legislative and organisational change. So reversing the current Lansley bill to make the Secretary of State directly responsible for the NHS and abolishing the purchaser provider split were widely supported. This is extraordinarily naive for two main reasons. Jeremy Hunt, despite not being directly responsible for NHS management according to the legislation, has been the most interfering SOS in recent history, directing individual hospitals to do what he wants in a way that would make even stalinist central managers like David Nicholson jealous. Secondly, the one thing we are certain of about major legislative and structural change is that it is extraordinarily disruptive and costly to the the NHS in the short term. We have had so many reorganisations in the last two decades that we still don’t know whether any of them have made any sustained difference to NHS performance. Despite this many are still arguing that we need another one.

Then there is the response to STPs. Simon Stevens (wisely I think) opted to try to do significant change in the NHS without new top-down structural change or legislation. But the panels and the audience broadly disliked the STP plans. Not because they are often poorly thought through or lack evidence that what they propose will work (though this is usually true) but because they are a trojan horse for American style Accountable Care Organisations which are a part of the conspiracy to privatise the system and put profits into the hands of american capitalist scumbags. Once you have a good conspiracy you don’t need to think any more about the actual content of STPs. Simon Stevens is clearly a trojan horse for United Health. Conveniently this absolves anyone from having to engage with the nasty operational details of STP plans (which would be well worth doing given how many consist of fairy-tale wish-fulfillment fantasies).

Many argued that the NHS was facing serious staff shortages. And this may well be true in many places. But Sarah Wollaston’s claim that this might be due as much to problems with retention as it was due to any lack of supply was ignored. The idea that weak operational management leading to high staff turnover might be the core problem didn’t seem to occur to anyone: it’s all about the supply of doctors and nurses and we can blame that on the government.

Again the debate ignored several relevant facts that would require actual analysis and thought. For example the biggest cause of increasing hospital deficits is the reliance of expensive agency staff to fill rotas. That’s not a staff shortage, that’s an inability to recruit or retain people on permanent contracts: a very different problem with the need for very different solutions. And it is hard to reconcile the belief that the major problems in A&E waiting times are primarily a staffing issue with the actual facts. Medical staffing in A&E has grown faster than demand for more than a decade while performance has declined. And it is hard to see how more A&E doctors can magically create more free beds (lack of free beds is the major cause of A&E delays not a lack of staff in the A&E). Anecdotes about the pressures and overwork facing front line staff point to a symptom of the problem not the cause of the problem.

Even the revered Stephen Hawking broke his own rules not to selectively quote evidence. He was right to condemn Hunt for his selective use of data on 7-day mortality. But then he proceeded to recommend NHS policies based on a highly selective analysis of the international evidence. Private provision of services is evil (because the USA’s health system is evil). But many health systems in Europe seem to do well despite much of the provision being run by organisations other than central government. The NHS is being pushed towards private insurance and we must resist that trend. But, though I hate to agree with Hunt on anything, there is no evidence this is happening. Moreover, though private insurance for health funding is bound to be less efficient that funding from taxation (so there is no good reason to move the NHS to that model) there are plenty of systems in Europe where compulsory insurance works well and has none of the damaging effects it has in the perversely badly designed US “system.”

In short the event was not a debate but largely consisted of a bunch of people exploring shibboleths that helped them decide whether they were on the right side in the argument. The trouble with shibboleths is they are arbitrary and irrelevant and seem to form a shield that avoids any need to discuss matters of substance about what policies might actually improve the NHS. Which side you are on is all that matters: whether you have anything of substance to add is irrelevant.

The NHS needs a serious debate on how to improve.

For example, how big should the key organisation units be? Nigel Edwards pointed out that we do have evidence for this and that the best-performing systems have units that are 10 to 20 times smaller than the NHS. If the NHS is run centrally, any policy mistake will affect nearly 60m people. That means mistakes have really big consequences (it also means that there will be pressure never to admit they were mistakes greatly inhibiting the speed of learning). Imagine a system where the organisational units were maybe 2-4m people (we could call them SHAs as we haven’t used that unit name for a while or we could just call them STPs). The scale of mistakes could be limited and the effectiveness of different policies could be compared, greatly increasing the possibility of learning and improvement.

But the audience and panellists would mostly have preferred a centrally-controlled monolithic system where the SOS always magically knew the right policy for everything. The idea that variation and experimentation with policies could be used to greatly increase the amount of learning and therefore drive much faster improvement was condemned as an excuse for a “postcode lottery”. This convenient shibboleth avoided any need to engage with that important issue of how we structure of the system.

Or, consider the problem of variation in quality and efficiency across the NHS. The evidence we have suggest that there is far too much variation and that the system isn’t good at learning from it or improving. The cause of this variation isn’t top-down structures or Jeremy Hunt, it is bottom-up operational management. For example, some parts of the system are good a diagnosing and treating patients who need hip replacements and other parts are not. Most significant improvement in the NHS probably comes because people find better ways to organise and coordinate the work in some single operational area. Even some GPs, who are supposedly overwhelmed because of staff shortages and government indifference, have found that reorganising how they receive and manage patient demand can create a lower workload, faster patient access and much improved patient satisfaction. All without central government having to do anything.

But the idea that improvement are possible is essentially ignored in the current debate. Even the idea that there is too much variation across the NHS is regarded as part of the conspiracy to undermine the system rather than an important metric that can point to what needs to improve and how to improve it.

In short, the widespread belief that the current government is the source of all problems has become an excuse not to bother thinking about how the improve the NHS now. Worse, even if the current government is replaced at some point in the future, there will be no good ideas on how to make the NHS better and we will likely be faced with yet another round of disruption that will deliver no tangible improvement when the smoke has cleared.

I’m no fan of Jeremy Hunt who has been a bad SOS. But his opponents are are as bereft as he is of good ideas to make the NHS better. What a woeful place the debate on the future of the NHS has become.

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Healthcare and the National Health Service (NHS) budget were a key element of the Brexit referendum narrative: Vote Leave infamously promised that savings from paying into the EU budget could be spent on health, a pledge from which campaigners have since disassociated themselves. Indeed, the NHS is unlikely to benefit from Brexit – very much the contrary. Indeed, Brexit weakens the financial sustainability of the NHS.

According to estimates from the King’s Fund, in 2015–16 the NHS had the largest deficit in its history. NHS funding has been unable to keep pace with a growing demand for services. These financial constrains come at a time of staff shortages in most British hospitals, which have had to rely, as is common practice, on private temporary contract agencies and, more generally, on private providers who already make up 18% of the NHS spend on community health services.

Leaving the European Union in such a context creates a conundrum for English hospitals. How can they square their need for cost savings with maintaining quality? Better-quality services inevitably mean extra resources, which are not available without extra funding. So Brexit raises questions about the financial sustainability of an unreformed NHS – that is, an NHS without additional money. Leaving the EU will lead to significant restrictions on labour mobility, which can shift labour costs upwards – for example, higher wages will be required to incentivise a declining medical workforce, and more vacancies might need to be covered by temporary staff. In addition, we can expect higher transaction costs for intermediary goods. Brexit is estimated to lead to a reduction of 6.3–9.5 % of national income which will mean even less revenues to fund the NHS.

Effect on the workforce

Even before Brexit, the NHS has struggled to recruit and retain permanent staff. In 2014, there was a shortfall of 5.9%, and in social care 5.4%, rising to 7.7% in care services in the home, and about one-third of all UK nurses are due to retire in the next ten years. The problem is even more alarming when one looks at the GP workforce. A recent report of the Royal College of Physicians suggests that, in 2016, 86% of physicians experienced shortages across clinical teams.

Reducing EU immigration would increase wages on both ends of the wage distribution. In such a scenario, the options available include incentivising EU immigration or expanding health and social care spending in an attempt to transform it into a higher-wage sector, with the aim to increase its productivity. Therefore, the trade-off is between saving NHS funds by hiring health professionals from overseas, or expanding health investment further to incentivise local recruits (with some delay as they are trained).

Brexit may offer an opportunity to get rid of the contentious European Working Time Directive  which limits the maximum amount of time that employees in any sector can work to 48 hours each week. In turn, raising working time limits is likely to cause a deterioration in the quality of NHS employment and make working for the NHS less attractive.  

Effects on patients

The balance of payments associated with free patient mobility seems to have traditionally benefited the UK, given that British expats (who stop using the NHS) tend, overall, to be older than EU residents in the UK – who are on average younger, healthier and more highly skilled. After Brexit, UK citizens are unlikely to have the right to travel to the EU for treatment and therefore will enjoy less control over their healthcare. Furthermore, British tourists might be excluded from the European Health Insurance Card  programme. The only advantage, from a welfare perspective, of restricting mobility is that discouraging it reduces competition between health systems. Hence it could be argued that mobility deters a ‘race to the bottom’ in healthcare investment.

Brexit almost certainly means higher costs for the NHS, especially labour, as I argue in more detail in a recent article in the Journal of Social Policy. As a consequence of Brexit, it will become more difficult to attract qualified staff and other inputs affected by non-tariff barriers (e.g. rules of origin checks, regulatory barriers, border controls etc.), and procurement will become more expensive. Certainly, Brexit does bring some opportunities too – including the possibility of redefining the NHS in new directions. Nonetheless, it takes place in the midst of a process of fiscal consolidation (leading to longer waiting lists, waiting times etc) and will create additional and unnecessary financial pressures.

This was first published on the  British Politics and Policy blog

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