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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
London
United Kingdom
SW1H 0EU

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)
Brook
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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That this year is still the 100th anniversary of World War 1 seems to have escaped many people. 1918 was a momentous year, beginning with the onslaught of German Spring Offensive as their armies, freed from the Russian conflict, turned to the west.

Thanks largely to a restored Haig’s strategy and British fighting ability the offensive failed after two weeks. It was the beginning of the end for the Germans. Within 6 months the war was over. Victory had been snatched from the jaws of defeat. But the cost had been enormous, totalling nearly 180,000 British casualties – in just 15 days.

War in the trenches

This year we also celebrate the 70th anniversary of the NHS, and it is the year we must rescue the NHS from the chaos that Jeremy Hunt has plunged it into. Even the most incompetent British general could not have succeeded in demoralising his workforce the way our politicians have. The NHS is one of the largest and most successful organisations in the world. NHS England is five times the size of the Fifth Army, which held back the German Spring Offensive, yet it is treated as a plaything, an organisational laboratory for the neoliberal aspirations of the current government.

This great company could have treated all 600,000 casualties from the Spring Offensive, German and Allied, in just one day. That is how significant it is. Yet the government treats it with contempt, permitting the Secretary of State to behave exactly as the worst general in World War 1, dismissive of the employees, balkanisation of the assets, dreadful planning and supply, and the creation of crisis after crisis which the medical staff, like the exhausted troops in World War 1, have to cope with.

World War 1 lasted four terrible years. The Lansley bill was passed almost exactly 6 years ago on March 20th, 2012. This means that the dire mismanagement has now gone on for two years longer than the tragedy of the war. It now has to stop. We need to dismiss the failed strategy and its “generals”.

corridor medicine

Patients being treated in corridors – Lister hospital, Stevenage (Debs Thompson Facebook)

Where to begin? First, we challenge the obsession with targets, which only the witless and the control freaks deploy. It does not improve performance, but damages patient care in and promotes fear. We provide data showing its failure and the cost of that failure.

Then we demand that the NHS Reinstatement bill is debated and passed.

At this year’s Sheffield Festival of Debate begins with an NHS session on to how we do this on the afternoon of April 25th. It is called Saving the NHS for the Next Generation by stopping The Sovietisation of the NHS, signalling the start of our defence of the NHS – in Sheffield.

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I am just writing this as me. It isn’t going to be the most perfect piece of prose, partly because the information has come from my husband/carer and because I still feel the fear whenever I think about it. My brush with co-payments was traumatising for me, my husband and could have had very serious consequences – including death.

I live with a rare, and potentially fatal condition. It has been what they call “brittle” from the beginning. Nevertheless, I am well insured and of course carry all necessary documents for health treatment in an EU country. What could possibly go wrong??

Early one morning while on holiday in an EU country I started to feel nauseous. This is a warning sign of a crisis. The nausea progressed to projectile vomiting, then voiding, as my temperature plummeted and I began to lose consciousness. My husband phoned the local health centre. They spoke English and he fully explained the danger – left too long my organs will shut down, and the end game is potentially death.

The first words spoken were – “that will cost you 180 euros. “OK” said husband, but he was not at all confident in any system that could put the money first.

“Bring her down to the centre” were the next words down the phone.

“But she is unconscious and covered in sick” said hubby, “I can’t just put her in a taxi”.

“We don’t do home visits” was the response.

“I don’t know the system”, said my husband, “I can’t bring her anywhere, what do I do?”

Well it might seem obvious, but my husband was panicking

“Phone an ambulance”.

Hubby did, and the ambulance came, but the co-payment fiasco didn’t end there.

The ambulance people were caring and somehow got me downstairs and into the ambulance.

We then proceeded to go past at least one gleaming private hospital, slowly down some narrow country roads, and well out of town to the nearest public hospital.

I was off loaded.

Alone with me in a room, hubby was then asked for another co-payment. “just go to the desk”. Imagine if it was your loved one, and you were asked to leave them in a crisis, and alone.

The doctor came and told him to hurry, go to the front of the queue as an emergency, as she wanted to start treatment urgently. Hubby ran.

Once back he could talk about my medical history, allergies and so on. The doctor was knowledgeable, efficient and kind. It doesn’t take long to bring me round from a dangerous situation, and I can usually get home in the NHS in around 6 to 8 hours, but even so, I was told to get a taxi probably a bit earlier than I would have needed/wanted in the UK.

Going home the taxi driver treated us to a very informed chat on how this was a trojan horse and the end of their public healthcare system. A few days before we had a taxi driver talk on TTIP and chlorinated chicken.

If anyone is tempted to think we would do it differently under the current model of defunding the NHS, just think of the brilliant success of the co-payment systems we have already.

The Care System has always been co-payments for the less poor. I will not say the rich, as demands for some contribution are made to many we would not consider that well off. The situation is dire: abuses of human rights, starvation diets, neglect; the list goes on. There are repeats of the TV programme “Waiting for God”. Not even the wealthy can ensure they are not being herded and milked for the benefit of the shareholders. It is the law.

Then there is dentistry. I was warned years ago that dentistry was the pilot for the NHS direction of travel by a totally distraught dentist, who felt his patients no longer came first, and the less well-off would be excluded. Hubby has paid £600.00 for dentures (just a couple) under the NHS system. They are not fit for purpose. Treatment is basic now, and in my town people are often seen with big gaps and rotten teeth. The old pull it out by using the door trick has even re-appeared. It is tempting to go private if you have the money, and friends have paid thousands to private dentists, though they are against the concept.

Co-payments will have the most terrible impact on the sick, disabled and poor. They will be excluded, frankly, so the worried well can have blue fitted carpets and no queuing. It will fix the NHS in the same way as taking those truly needy cohorts out and shooting them would also fix it – just it’s more acceptable/less obvious.

I have not heard a single person as a patient under the co-payment scheme who isn’t well off express that they liked it. Quite the opposite, and I work with healthcare staff and academics in the US and Australia. They know it puts their lives on the line.

Like dentistry a “reasonable” co-payment will soon start to look like quite a chunk of your money – loads more than we all first thought. And for what? This was posted on our SHA Website and I’ll repeat it here:

NHS Dental Care Faces a Severe Collapse

One of the health concerns neglected by the NHS is dentistry regardless of the fact that teeth matters as much as any other part of our body. As revealed by the British Dental Association in September 2016, the NHS had to bear a cost of £26m when around 600,000 people in a year made nugatory appointments with GPs over dental issues. Though this statistic has resulted in ridicule, yet in all honesty, it is the government, not its citizens, who should be embarrassed.

It is the NHS bills that are drawing patients away from the official government system and driving them toward GPs for their dental problems. As indicated by the BDA’s new analysis, this practice might soon outclass government financing as the main revenue source for NHS dentistry.

The NHS charges for dental services were first instituted in 1951 to bring down the demand. The BDA has named these charges as “health tax”, which veil actual trims in the service and debilitate the patients most needing care. Due to the incurred charges, about 1 of every 5 patients has deferred treatment as per the official findings.

The government funding for the NHS has been cut down by £170m since the Tories first made it to No 10, and it is hoping that patients should constitute the shortage. In 2016, dental charges were climbed by 5%, and they are anticipated to take the same hike even this year too. Considering the 16 years of time, it is assumed that majority of the NHS budget for dentistry will be financed by patients instead of the central government. But what is the use of the NHS if it is not a free service at the required time, and treatment isn’t according to one’s need but ability to pay?

Children are entitled to avail free NHS dentistry – but even they are being pulled down by the government as it is unable to meet the demand and offer enough dentists. Earlier in 2016, a letter was signed by more than 400 dentists exhorting that dental care in Britain is falling to the levels of “third world”. According to them, the NHS dental system in England is ill-equipped for the purpose. These crises are of grave nature; about 62,000 people mostly including children turn out to be at the hospital each year due to tooth decay; half of the adults haven’t been to a dentist for the past two years; and one of every seven kids hasn’t gone to a dentist since the age of eight.

People in Britain are already paying higher bills for fundamental care, and add a bigger sum of a dental budget by submitting these charges than their correlates in the devolved countries – systems of which have become less dependent on charge income throughout the recent decade. To deal with this gap, the BDA is sending information posters to more than 8,000 NHS dentists all through England to help picture patients’ feedback on the eventual fate of the charge.

When dental charges were made a part of the NHS in 1951, Nye Bevan who was the formulator of the NHS resigned from the service in protest. Today, after sixty-five years, the service is damaged by inadequate investment, exaggerated charges, and a shortage of dentists. There is a genuine need to form a government-funded NHS dentistry which wouldn’t rip off the patients. However, as of yet, we are going in the other direction of which the consequences will be borne by lower-income Britons.

Co-payments in health to me sound very much like the position refugees are suffering under this government according to the latest briefing by Asylum Matters. I have approached them to ask to reproduce the paper and recommendations, and been given the go ahead. This will follow shortly.

Finally: Imagine:

You have a heart attack in a local park. You and your partner set off in the ambulance only to discover that you must pay, and your wallets and cards are locked up at home. Precious time is lost chasing the money. Your partner is scared you will die when they are away getting the plastic.

You just gave every bit of spare funding you had for the youngest child/grandchild to access university for 3 years, and then you get cancer (or another serious and maybe longer-term condition). It is might be difficult to fund all these co-payments to your GP and specialists. It is not worth a blue carpeted half empty waiting room. Under the current defunding you won’t get that anyway. I have loads of co funding horror stories from the USA.

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atbaei via Getty Images

“NHS funding growth is much slower than the historic long term trend.”

“Real terms funding per person will go down in 2018/19 and 2019/20.”

“The public are concerned for its future.”

“There is likely to be continued pressure on waiting times for routine care and some providers’ waiting times will grow.”

The words above are not taken from a Labour press release or a critical speech in Parliament, but from a new NHS England Plan, Next Steps on the NHS Five Year Forward View, which was published this week.

The document confirms that the NHS does not expect to meet the A&E target, to see 95% of patients within 4 hours, which Jeremy Hunt described as being “critical for patient safety,” for at least the next year. It also sets out plans for another round of rationing of treatments and the abandoning of the 18 week waiting target for surgery.

The document, gloomy though it is, provides a realistic assessment of what is and isn’t achievable within the financial constraints that the NHS is operating in. Nor is it entirely without positives such as the welcome ambitions around cancer care and mental health, which Labour fully endorses, though the chasm between Government rhetoric and reality in these areas is huge.

It also very clearly does confirm once again that despite repeated assurances from Theresa May and Jeremy Hunt, the NHS has not been given the funding settlement that it asked for and patients will pay the price.

You would be right to expect that a frank assessment of the challenges facing the NHS, coupled with a plan for new governance arrangements and departure from nationally agreed targets would receive forensic scrutiny in Parliament. You would expect a detailed statement from the Health Secretary, followed by questions from MPs about why NHS funding has not kept up with demand and why a “critical” target will be missed for another year. You would expect an answer from Jeremy Hunt as to whether he considers the NHS Constitution is still actually a document that is binding on Government.

Unfortunately, this announcement came on the first day of the Easter recess, so there was no statement and no scrutiny. The Health Secretary who wants to deliver a 7 day NHS has also once again gone missing at a time when serious questions are being asked about his stewardship of the Department for Health.

The most striking thing about the new plan is the confirmation that not only did the 2012 Health and Social Care Act waste billions of pounds, it has also been an abject failure. The payment by results system is being quietly shelved, while there is a desperate rush to replicate the functions of the Strategic Health Authorities that the 2012 Act scrapped.

This second reorganisation is happening much less publically than the first one. Whilst there was some publicity surrounding Sustainability and Transformation Plans, there has been much less coverage of the Vanguards or the move towards Accountable Care Organisations which feature heavily in the new document. The Healthwatch guidance on ensuring that local people have their say recommends that organisations should “involve local people from the start in coming up with potential solutions.” Based upon this test, the exercise has already been an abject failure, while there are also question marks over whether changes on this scale could be open to legal challenge without further legislation. Will the abandoning by the Government of the 18 week waiting time target for treatment also lead to a legal challenge because the NHS Constitution has been broken?

However, possibly the most alarming prospect thrown up by this reorganisation is reference to the establishment of Accountable Care Organisations, which the plan says will lead to commissioners having “a contract with a single organisation for the great majority of health and care services and for population health in the area.” We will be seeking urgent confirmation that the ‘single organisation’ will be part of the public sector.

The concern is that this opens the door to huge contracts to private providers as the lack of a clear legal framework for these new commissioning arrangements makes a challenge likely if they are not given the same opportunity to bid as public sector bodies.

Finally, the statement “some organisations and geographies have historically been substantially overspending their fair shares of NHS funding” which “may mean explicitly scaling back spending on locally unaffordable services” will send a chill down the spine of anyone who works or is currently a patient in the NHS. They will know that services are already stretched to breaking point and this move to single out sections for further cuts could well push parts of the health service over the edge. We deserve better than the future strategy for the NHS being reduced to an exercise in expectations management.

Follow Justin Madders on Twitter: www.twitter.com/justinmadders
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Responding to a report published today (Wednesday) by the House of Lords select committee that criticises the ‘short-sightedness’ of successive governments for failing to plan effectively for the long-term future of the health service and adult social care, Dr Mark Porter, BMA council chair, said:

“This report highlights what we have been saying – that the NHS desperately needs a long-term strategy to deal with the funding and staffing problems threatening the delivery of high-quality care. For too long successive governments have based health policy on short-term measures that do not benefit patients or staff in the long term. This is especially evident in cuts to funding for public health which this report identifies as short-sighted and counter-productive. The NHS is at breaking point and this can only be relieved through increasing investment based on a realistic assessment of what is needed to meet the health and social care needs of current and future generations. We need politicians of all parties to come together to agree a long-term approach and put an end to political game-playing with the NHS.

“The committee is right to identify the serious and ongoing problems in recruiting and retaining NHS staff, and the morale damage of years of ongoing pay restraint. Only last week, doctors got yet another real-terms cut in pay despite working harder than ever before. At a time when GPs are unable to keep up with the number of patients coming through the surgery door and hospital doctors are working under impossible conditions, our government should heed the committee’s recommendation and allocate the investment needed to match the promises made.

“It is important that general practice continues to evolve to meet the changing demands of patients, especially those who need more intensive, complex and flexible care in the community. Many GP practices are, with the BMA’s support and leadership, exploring new ways of working, including forming federations or networks to pool resources and plan care for their local populations. A “one size fits all” model won’t do this. General practice’s great strength is its flexibility, and smaller practices can work just as well as larger units in providing services that their patients want. The biggest threat to smaller practices is not their organisational form, but the pressure that all parts of the NHS are under from rising demand, unnecessary bureaucracy, stagnating budgets and staff shortages. It is this wider challenge that the government must urgently address.

We spend less on healthcare than other leading European economies and the NHS cannot continue to do more, with less. We need to end the chronic underfunding of our health service and address inadequate staffing and funding for the health and social care system as a whole.

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STPs are loose coalitions of agencies without statutory powers, so they cannot implement change, only encourage it. With little money left in the Transformation Fund, they have to “work around” their local NHS and social care organisations. At the launch of the King’s Fund report ‘Delivering sustainability and transformation plans: from ambitious proposals to credible plans’ (on 21st February) we heard that “with the right leadership” STPs could stabilise the NHS, that STPs mean that “politicians must be brave” (and not impede changes in the NHS in their constituencies), that NHSE and NHSI need to work as one (because they don’t), and that “there is no Plan B”.

STPs

Much of what was said at the launch was familiar. Plans to shift care into the community and integrate health and social care have surfaced several times in the last decades, leaving little trace. There is little new in the STPs, except perhaps the higher profile of local government.  The NHS is famous for its lack of memory, a point made gently by Chris Ham of the Kings Fund at the end of the launch event. The language used was standard NHS speak – “challenges”, “conversations”, “journeys”, “taking plans forward”, “meaningful engagement” – and the speaker who described how the STPs were “moving fast” surprised those who thought progress was painfully slow.

It was not clear from the discussion that there really are many parts of the NHS or social care where practitioners are straining at the leash to change, are constrained by present structures and rules, and are ready to innovate given permission and leadership. Perhaps the Vanguard sites are such places.

The impression I left with is that transforming social care and health services that are struggling to survive is a David versus Goliath battle, in which STP advocates are hoping for a lucky shot. The Kings Fund launch did say that in a way, suggesting that STP footprints should prioritise two or three changes, in effect abandoning transformation as an objective. The NHS Confederation has since urged ‘patience’ in developing STPs, not the current unrealistic timetable. This may be an opening for Labour to gain some traction within the NHS, and avoid being marginalised into “Slash, Trash and Privatise” rejectionism. We need to look at provision over the whole health and social care system and sort out a governance framework for a single health and social care service. STPs are an attempt to bring together relevant players at a higher organisational level than Joint Planning Boards, so could offer the overview and design the governance. If the STPs were led by local government, with a topped-up Transformation Fund and a ten year remit to bring about change, we might just make haste slowly.

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