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It is truly shocking that life expectancy has stalled in England, and for poorest women it has fallen.  The Marmot Review: 10 years on[1] published this week, shows us in detail how we have failed to improve on most of the indicators that were highlighted in the original review[2] 10 years ago. It points out that this can be clearly linked to the lack of implementation of those evidence-based recommendations.

The report looks at five of the six domains that were used in the 2010 report:

  1. Give every child the best start in life
  2. Enable all children, young people and adults to maximise their  capabilities  and  have  control  of  their lives
  3. Create fair employment and good work for all
  4. Ensure a healthy standard of living for all
  5. Create and develop healthy and sustainable places and communities
  6. Strengthen the role and impact of ill health prevention

It is interesting that they chose not to look at the sixth domain, on the grounds that plenty has been written on this area since 2010, and review was not necessary. This will ensure that there is no opportunity for Government to respond with messages about what it done in this domain, while evidence shows this to be the least cost-effective approach, and hence should have been lowest priority for policy and action.

We know that the top priority should be our children and young people. It is very worrying that infant mortality has increased in the poorest families, that child poverty has increased and now stands at over 4 million. It shows how tax and benefits changes have been deeply regressive, pushing many families into the poverty trap. Knife crime is more common in those areas where youth services have been cut the most. A positive finding is that poor children appear to thrive better in poorer areas than in richer ones: either they are more socially excluded and stressed in affluent areas or that children and education services are doing something right in more deprived areas.

Income is a massively important determinant of health. This report highlights how work is good for health only if it is good quality work. So, although employment has increased, this isn’t enough for people to feel the benefits. The report notes that the average weekly earnings at 2015 prices were £502 in September 2019, only £5 higher than in 2008. The UK is one of only five of the 35 OECD countries where the purchasing power of the average wage has fallen since 2008. Since 2008 there has been a large reduction in benefits available for working age people and children. This, together with the rise in housing costs, has been the driver for huge increases in food bank use. The most deprived households would now have to use over 70% of their disposable income on food if they wanted to follow the Eatwell guide for healthy nutrition.

The report highlights social cohesion throughout, and describes forgotten communities:

“there are   more   areas   of   intense   deprivation   in   the   North, Midlands   and in southern coastal towns than in the rest of England, whilst other parts of England have thrived in the last ten years, these areas have been left ignored. Since 2010 government spending has decreased most in the most deprived places and cuts in services outside health and social care have hit more deprived communities the hardest”

We welcome this report. It confirms the SHA conviction that austerity kills and that the policies of the Conservative-led governments since 2010 have directly led to a heavy burden of increased mortality, ill health and misery that is largely carried by the poor. The most effective actions should have been to address the wider determinants of heath rather than individual behaviour change. Polices have in fact done the opposite of this, including the Government Prevention Green Paper a year ago. This report shows how investment for most things that affect the wider determinants of health has instead been reduced in more deprived communities.

It would be of interest to compare the data collected here with similar analyses in the other devolved nations which have attempted to mitigate the impact of UK wide austerity policies from Westminster.

Prof Sir Marmot says:

‘If health has stopped improving, it’s a sign that society has stopped improving. When a society is flourishing, health tends to flourish’

The SHA realises that there is a very powerful lobby that will undermine this report and all the other emerging evidence, for political reasons.  We know that this report will be challenged by those who support right wing policies, and its conclusions ignored by those with an agenda that doesn’t believe in equity.

We must do all we can to reach agreement again on what a flourishing society looks like. We must change and strengthen our democracy to be more accountable to the multiple views in our communities. The report says

“Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

And as socialists, we believe that the state does have a crucial in protecting and improving the health of its people. For the last 10 years, our Government has been actively undermining the wellbeing of all but the most affluent.

[1] The Marmot Review; 10 years on, Institute of Health Equity http://www.instituteofhealthequity.org/the-marmot-review-10-years-on

[2] Fair Society, Healthy Lives, 2010 Institute of Health Equity http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

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A Healthier Wales (June 2018) is the Welsh Government’s response to the  Parliamentary Review of the future of Health and Social Care in Wales. It promises a programme of transformative whole system change with a move to a service that focused on health, well-being and prevention – a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality.

A key part of the this transformation will be delivered through local primary and community care clusters working with both Local Health and Regional Partnership Boards. There will be a shift in services from general hospitals to regional and local centres with primary and community care delivering a expanded range of professionally led services. In October 2019 the Wales Audit Office (WAO) published Primary Care Services in Wales which evaluated progress with a particular focus. on strategic planning, investment, workforce, oversight and leadership, and performance.

The WAO report acknowledges the work that the Welsh Government and NHS Cymru is doing to achieve the level of transformation that is needed. A National Primary Care Board and a National Director has been appointed to provide a focus and impetus to drive this agenda forward. A Primary and Community Care Development and Innovation Hub has been formed with the support of Public Health Wales which is also providing guidance to improve clinical network governance. And at health board level designated directors or senior operating officers provide a lead for primary care with work being undertaken to develop a national evaluation framework which can be used to measure progress at a local level.

These initiatives have been supported by a number of funding streams that operate at all levels in Wales from the National Transformation Fund and the Integrated Care Fund to a National Primary Care Fund. These resources are allocated in a variety of ways including to clinical networks and practices to promote change and innovation including “pathfinder” and “pacesetter” projects operating at a grass roots level.
But despite all of this the WAO concludes that change has not happened as quickly or as widely as intended and has outlined a number of reasons why this has not happened. This is acknowledged in the Welsh Government’s own National Integrated Medium Term Plan (2020-23)

A key component of the Healthier Wales approach is The Strategic Programme for Primary Care was launched in November 2018. It is based on the new “Primary Care Model for Wales”. This outlines what it  regards as the main components of a good primary care system. These key components include informed and empowered citizens, self-care, stronger community services, new first points of contact for patients including triage to ensure they are seen by the appropriate healthcare professional, better urgent care arrangements and stronger multi-disciplinary working.

There is much to commend in this New Model but the WAO points out that it has emerged with little public consultation. This lack of debate and discussion means that in many respects there is a lack of clarity as to the purpose and direction of the New Model.

In the “old model” GPs were the initial point of contact and gatekeepers for virtually all other health services. In the New Model the GP will continue to provide the first port of call for some patients but many patients will also be able to directly access many alternative community based professionals, thus freeing up GP time to see the sickest patients and those with complex chronic conditions. These alternative practitioners will include pharmacists, physiotherapists, opticians, dentists and members of mental health teams.

The emergence of this New Model seems to be driven by necessity and is a pragmatic response to the sustainability challenges facing general practice rather than an evidence based evaluation of the key elements that a holistic general practice and primary care service would require . This sustainability challenge is caused by the combination of the growing workload in general practice, changing work and contractual patterns as well as signficant recruitment difficulties.

This New Model is intended to provide improved access “to services”. This is bound to be seen as preferable to having no access at all but of itself it may not be the most optimal configuration or care pathway. This range of “front doors” into the health service will inevitably lead to discontinuity of care, fragmentation and a lack of co-ordination.

Continuity of care is a key characteristic of quality primary care. It has two mail elements, horizontal continuity as a patient / service user utilises a range of services as part of a holistic response to their needs and longitudinal continuity based on ongoing personal care is delivered over time. Both are important but the former seems to have primacy in the current articulation of the New Model.

Delivering horizontal continuity depends on having good team work supported by an infrastructure that goes with the grain of seamless care across professional and organisational boundaries. This will require health and regional partnership boards as well as local clinical networks working more effectively together supported by shared personal care records and a robust IT system.

Longitudinal continuity and quality care is built on long term personal relationships. But these relationships will struggle to develop and mature if patients and service users face a variety of diverse professionals whenever they attempt to use the service. “Time” is at the heart of these relationships both in terms of having the time to listen and work with patients in line with their needs and also it is only over time that a continuing personal,professional relationships can be built.

General practice is under continuing and unsustainable pressure but despite this the workforce is not increasing in line with need and list sizes are static. This, in part, explains the pressure to promote the New Model of primary care but that will never be an adequate solution without a substantial increase in crucial front line workers particularly GPs. The Welsh Government has launched a number of initiatives to increase GP numbers including a welcome increase in training posts  but neither it or the WAO seem to be willing to move much beyond the traditional parameters of the solutions being offered by the medical “establishment” such as GPC Wales or the RCGP.

There are between two to three dozen health board managed practices in Wales as well as 778 sessional / “locum” GPs working alongside 1,964 GPs principles. But despite this large salaried GP workforce there is no overall strategic policy in place to promote their professional development or retain them in clinical practice. Initiatives such as the establishment of a GP Locum Register are a step forward but much more needs to be done in the face of the evidence that the independent contractor option is no longer the preferred model of work by very many GPs.

Already the Auditor General for Wales pointed out that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years has not being achieved. If the changes that the Welsh Government and NHS Cymru have put in place do not achieve a  rebalance in resource allocation then little new will happen. In addition the WAO also expressed concern at the lack of transparency in the way that primary and community care is funded. This makes it very difficult to monitor any real shifts in resources is taking place with is a precondition to achieving transformational change.

Apart from the reasons outlined in the WAO report there are additional problems in monitoring where NHS resources are actually allocated. The creation of larger health boards in Wales in 2009 has meant that a certain level of sensitivity has been lost allocating resources. The Welsh Government’s commitment to clinical networks, which cover about 50,000 people, is an opportunity to address this loss of sensitivity as well as providing a more meaningful population size to monitor health inputs and outcomes.

Over recent recent years health and social care spending has has increased between 4.5 – 6% which is generous compared to the pressures on the overall Welsh Government budgets. These increases must be used to provide the headroom for a meaningful transfer of resources towards primary and community care. As the WAO suggests a transparent framework is needed to monitor this transfer.

This framework should include a rapid move towards a 10% allocation of NHS resources to primary care services. This should be linked to the creation of at least an additional 200 GPs in post in Wales as a matter of urgency so that average list sizes will be reduced to Scottish levels with more easily accessible time being available for patients.

Health boards and clinical networks, working with Public Health Wales, must monitor where these resources go locally to ensure that there is a clear focus on addressing health inequalities and the Inverse Care Law.

Primary health and community care teams must be strengthened both address current health and care needs both at the individual and wider community level. And where traditional models of delivery, such as the independent GP contract, are failing to deliver, health boards must take direct responsibility. Progress cannot be held back by the speed of the slowest.

The latest NHS Planning Framework (2019-22) specifically asks that health boards should place a particular emphasis on prevention, reducing health inequalities, the new Primary Care Model for Wales, timely access to care and mental health. However it does so at a fairly high level and only give very broad indications as to what it expects it health boards to deliver. In this context, the WAO report’s recommendation of a more explicit accountability framework should provide for greater focus and accountability.

In a Healthier Wales the Welsh Government expected to demonstrate early impacts over three years. We are already half way though this time frame and, as the WAO report shows, much more now needs to be done to deliver against that ambition.

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The result of the historic ballot was 3,229 votes (92.4%) in favour of the trade union, with only 266 votes (7.6%) supporting the senior management proposal.  This also meant that 47.5% of those eligible to vote supported the union, which surpassed the 40% threshold required for the union to succeed.

On the question of the ballot and what happens next at Boots, the union will now reach a recognition agreement with the company under the guidance of the Central Arbitration Committee.

The PDA Union believe that the strength of feeling from pharmacists about the need to improve their employment is so strong at Boots that it was always inevitable that the union would win this ballot.  This overwhelming result simply demonstrates just how detached senior management  have become from the views of Boots pharmacists, over the last 8 years.

Mark Pitt, Assistant General Secretary said: “We mustn’t forget that every single day over the last 8 years the company have had the ability to voluntarily recognise the PDAU, but every single day they decided to keep fighting their own employees.  As a result of this behaviour Boots will now be forced to recognise their employees’ choice of union.

Despite the clear message from pharmacists in the 2018 ballot, where 87% voted in favour of removing the BPA to allow PDAU recognition, the company continued to use everything it could to stop pharmacists securing an independent voice at work until now. 

Three senior managers became the faces of the 2019 management anti-union strategy; they risked their personal and professional credibility by running a negative campaign.  They not only lost, but this result shows support for the PDA Union has grown as this process has continued.”

The PDAU hope that the company will now finally agree to put the past behind them and work positively together with the Union so that we can improve things at Boots for pharmacists, pre-registration pharmacists, patients and the company. John Murphy, General Secretary of the PDA Union has written to Boots head Seb James, inviting him to create a new, positive chapter in employee relations at the company.  Read more here,

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A tribute to the much-loved Mags Portman on the sad news of her death

First published by HIV i-Base in HIV Treatment Bulletin (HTB) on 20 February 2019

It is with great sadness that we have to report the death of the much-loved sexual health pioneer and community activist Dr Mags Portman.

Mags had immense energy and enthusiasm for everything that she became involved with. Most recently this included linking with community activists to demand and enable access to PrEP.

Mags initially trained as a GP in Glasgow, qualifying in 2003, where she also worked at the Steve Retson Project that specialised in services for gay and bisexual men. After working briefly as a GP in Leeds, Mags retrained to become a specialist in sexual health, while continuing to support community projects including Leeds Skyline and Yorkshire MESMAC.

By 2014, Mags was working as a consultant at both the Royal London and Homerton Hospitals in East London, where involvement in the PROUD study started a new focus as a PrEP activist. Later, as a consultant at the Mortimer Market Centre, she expanded services to be one of the first NHS clinics to provide monitoring for people accessing PrEP online.

It was for her many diverse activities related to PrEP, that in April 2018, at the Joint BHIVA/BASHH conference in Edinburgh, Mags was awarded the BASHH Outstanding Achievement Award, where hundreds of delegates showed their appreciation with a standing ovation at the ceremony awards.

Her generosity as a friend also included the decision to write openly about her two-year struggle after being diagnosed with an aggressive form of mesothelioma. This documented the painstaking experiences of a doctor accessing NHS care as a patient, always with insights into the importance of her family and friends.

Mags died on 6 February 2019, in her hometown of Leeds. Our thoughts are with her husband Martin and their two children. She was 44.

Mags made such a lasting impression on everyone who was lucky enough to know her that she will always be remembered as an inspirational example of how to lead life to the best. Tributes from her friends and colleagues remembered Mags as an exceptional, talented, passionate and committed doctor who touched everyone with her compassion and kindness.

Simon Collins, HIV i-Base

Messages of farewell or in celebration of Mags’ life are being collected by friend and colleague, PrEP activist Greg Owen.

References

  1. Saving Lives. Dr Mags Portman.
    https://www.savinglivesuk.com/about-us/patrons/dr-mags-portman
  2. Strudwick P. A trailblazing HIV doctor who helped thousands access PrEP has died at 44. Buzzfeed. (12 February 2019).https://www.buzzfeed.com/patrickstrudwick/a-pioneering-doctor-who-helped-revolutionise-hiv-prevention
  3. Mags Portman Blog. NotDoingThingsByHalf.https://notdoingthingsbyhalf.wordpress.com
  4. Remembering Dr Mags Portman – an exceptional, talented, passionate, committed sexual health physician. (12 February 2019).https://www.cnwl.nhs.uk/news/remembering-dr-mags-portman-exceptional-talented-passionate-committed-sexual-health-physician
  5. Greg Owen blog. (6 February 2019).https://gregowenblog.wordpress.com
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Obesophobia

Posted: 16 Aug 2018 11:27 PM PDT

In 1976, we ate more than we do today. So why are we fatter?

By George Monbiot, published in the Guardian 15thAugust 2018

When I saw the photo, I could scarcely believe it was the same country. The picture of Brighton Beach in 1976  featured in the Guardian a few weeks ago appeared to show an alien race. Almost everyone was slim. I mentioned it on social media, then went on holiday.

When I returned, I found that people were still debating it. The heated discussion prompted me to read more. How have we changed so far, so fast? To my astonishment, almost every explanation proposed in the thread turned out to be untrue.

Unfortunately, there are no consistent obesity data in the United Kingdom before 1988, at which point the incidence was already rising sharply. But in the US, the figures go back further. They show that, by chance, the inflection point was more or less 1976. Suddenly, at around the time when the photograph was taken, people started becoming fatter, and the trend has continued ever since.

The obvious explanation, many of those debating the photo insisted, is that we’re eating more. Several pointed out, not without justice, that food was generally disgusting in the 1970s. It was also more expensive. There were fewer fast food outlets and the shops shut earlier, ensuring that if you missed your tea, you went hungry. So here’s the first big surprise: we ate more in 1976.

According to government figures, we currently consume an average of 2131 kcals per day, a figure that appears to include sweets and alcohol. But in 1976, we consumed 2280 kcal, excluding alcohol and sweets, or 2590 when they’re included. Can this really be true? I have found no reason to discredit the figures.

Others insisted that the cause is a decline in manual labour. Again, this seems to make sense, but again the data don’t support it. A paper in the International Journal of Surgery  states that “adults working in unskilled manual professions are over 4 times more likely to be classified as morbidly obese compared with those in professional employment”.

So how about voluntary exercise? Plenty of people argued that, as we drive rather than walk or cycle, are stuck to our screens and order our groceries online, we exercise far less than we did. It seems to make sense – so here comes the next surprise. According to a long-term study at Plymouth University, children’s physical activity is the same as it was 50 years ago. A paper in the International Journal of Epidemiologyfinds that, corrected for body size, there is no difference between the amount of calories burnt by people in rich countries and in poor ones, where subsistence agriculture remains the norm. It proposes that there is no relationship between physical activity and weight gain. Many other  studies suggest that exercise, while crucial to other aspects of good health, is far less important than diet in regulating our weight. Some suggest it plays no role at all, as the more we exercise, the hungrier we become.

Other people pointed to more obscure factors: adenovirus-36 infection, antibiotic use in childhood and endocrine-disrupting chemicals. While there is evidence suggesting they might all play a role, and while they could explain some of the variation in the weight gained by different people on similar diets, none appear powerful enough to explain the general trend.

So what has happened? The light begins to dawn when you look at the nutrition figures in more detail. Yes, we ate more in 1976, but differently. Today, we buy half as much fresh milk per person, but five times more yoghurt, three times more ice cream and – wait for it – 39 times as many dairy desserts. We buy half as many eggs as in 1976, but a third more breakfast cereals and twice the cereal snacks; half the total potatoes, but three times the crisps. While our direct purchases of sugar have sharply declined, the sugar we consume in drinks and confectionery is likely to have rocketed (there are purchase numbers only from 1992, at which point they were rising rapidly. Perhaps, as we consumed just 9kcal per day in the form of drinks in 1976, no one thought the numbers were worth collecting). In other words, the opportunities to load our food with sugar have boomed. As some experts have long proposed, this seems to be the issue.

The shift has not happened by accident. As Jacques Peretti argued in his film The Men Who Made Us Fat, we have been deliberately and systematically outgunned. Food companies have invested heavily in designing products that use sugar to bypass our appetite control mechanisms, and packaging and promoting them to break down what remains of our defences, including through the use of subliminal scents. They employ an army of food scientists and psychologists to trick us into eating more junk (and therefore less wholesome food) than we need, while their advertisers  use the latest findings in neuroscience to overcome our resistance.

They hire biddable scientists and thinktanks to confuse us about the causes of obesity. Above all, just as the tobacco companies did with smoking, they promote the idea that weight is a question of “personal responsibility”. After spending billions on overriding our willpower, they blame us for failing to exercise it.

To judge by the debate the photo triggered, it works. “There are no excuses. Take responsibility for your own lives, people!”. “No one force feeds you junk food, it’s personal choice. We’re not lemmings.” “Sometimes I think having free healthcare is a mistake. It’s everyone’s right to be lazy and fat because there is a sense of entitlement about getting fixed.” The thrill of disapproval chimes disastrously with industry propaganda. We delight in blaming the victims.

More alarmingly, according to a paper in the Lancet, over 90% of policymakers believe that “personal motivation” is “a strong or very strong influence on the rise of obesity.” Such people propose no mechanism by which the 61% of English people who are overweight or obese have lost their willpower. But this improbable explanation seems immune to evidence.

Perhaps this is because obesophobia is often a fatly-disguised form of snobbery. In most rich nations, obesity rates are much higher at the bottom of the socio-economic scale. They correlate strongly with inequality, which helps to explain why the UK’s incidence is greater than in most European and OECD nations. The scientific literature shows how the lower spending power, stress, anxiety and depression associated with low social status makes people more vulnerable to bad diets.

Just as jobless people are blamed for structural unemployment and indebted people are blamed for impossible housing costs, fat people are blamed for a societal problem. Yes, willpower needs to be exercised – by governments. Yes, we need personal responsibility – on the part of policymakers. Yes, control needs to be exerted – over those who have discovered our weaknesses and ruthlessly exploit them.

www.monbiot.com

www.guardian.co.uk
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Posted by Jean Smith on behalf of author Zsuzsa Ferge.

The Orbán regime introduced legislation to shut down accredited gender studies programs offered by universities in Hungary. Academics now have 24 hours to respond to the government’s plan. The ban will primarily impact students at Eötvös Loránd University in Budapest (ELTE)–the only institution in Hungary, other than Central European University, to offer gender studies at the graduate level, and the only one to provide this program in Hungarian.

The number of students impacted by the ban is small–only 11 applicants were admitted this year at ELTE and two at CEU. The maximum number of students that ELTE can admit any given year is 18 and those enrolled this coming academic year will be the last to take this program in Hungary. The decision to give those impacted 24 hours, in the middle of the summer vacation, to respond to this plan is a prime example of the spectacular arrogance that this regime has displayed for the past eight years. Gender studies in Hungary hardly pose a risk to the social narratives espoused by Fidesz and the Christian Democrats, but this regime is best known for kicking people and sectors of the society when they are down.

Although the government is not formally citing ideological reasons for its decision to cancel gender studies (the official reason is that this program is not “economically rational”), circles within Fidesz, most notably its Christian Democrat (KDNP) wing, have been calling for this for some time. In 2017, Lőrinc Nacsa, the leader of KDNP’s youth wing, labelled gender studies at ELTE as a wasteful luxury and also as destructive. “We must raise awareness to the fact that these programs are doing nothing to lift up our nation. In fact, they are destroying the values-centered mode of thinking that is still present in the countries of Central Europe,” wrote Mr. Nacsa in his letter to the rector of ELTE.

As well, HVG reminds its readers today that State Secretary Bence Rétvári (KDNP) in the Ministry of Human Capacities questioned whether gender studies even qualifies as a legitimate academic field, adding that this field of research is at odds with everything that the Fidesz government espouses.

I could feign shock at this news or recite the obscene mantra of how Fidesz has now truly crossed a red line–a line that up until now nobody would have thought that they would pass. Yet this would be insincere. It’s too late to be horrified that this can happen in Hungary–it’s about eight years too late. Most sectors and demographics of Hungarian society, from journalists to shop owners to NGOs, have already felt the scourge of the party state in profound ways. Academics are next in line.

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BMA: No deal Brexit could be catastrophic for health

The British Medical Association (BMA) is today warning that a no deal Brexit could have could have potentially catastrophic consequences for patients, the health workforce, services and the nation’s health.

In a new briefing paper published today, the BMA outlines what is at stake for health services if the UK and the EU fail to reach a deal on the Withdrawal Agreement by March 2019. The paper warns that, in a worst-case scenario, a no deal Brexit could:

  • Cause real disruption for almost a million patients receiving treatment for rare diseases as the UK would be excluded from the European Rare Disease Network;
  • Cause delays in diagnosis and treatment for cancer patients because the UK would have to source important radioisotopes from outside of EURATOM;
  • End reciprocal healthcare agreements which could disrupt patient care and increase insurance costs. If 190,000 UK state pensioners currently signed up to the S1 scheme and living within the EU return to the UK it could cost the health services between £500 million and £1 billion per year;
  • Weaken the UK’s response to pandemics and increase the chances of diseases spreading as we lose partnerships with key EU bodies, such as the European Centre for Disease Prevention and Control;
  • Risk the return of a hard border between Northern Ireland and the Republic of Ireland which could see doctors leaving the profession and patients having to travel miles to receive care;
  • See fewer doctors and other medical staff, at a time when there are already huge shortages of these roles, due to uncertainty over future immigration status and confusion around the mutual recognition of medical qualifications across the EU.

At the BMA’s Annual Representative Meeting in June, doctors made it clear that they believe Brexit poses a major threat to the NHS and the nation’s health. With less than eight months to go until the UK leaves the EU, there is still far too much uncertainty and confusion around the implications of Brexit for patients, doctors and wider health services.

The BMA supports the idea of the public having a final say on the Brexit deal, now that more is known regarding the potential impact of Brexit on the NHS and the nation’s health.

Commenting on the briefing paper, Dr Chaand Nagpaul, BMA council chair, said:

“The consequences of ‘no deal’ could have potentially catastrophic consequences for patients, the health workforce, services and the nation’s health.

“The UK Government has finally started planning to ensure the health sector and industry are prepared in the short term for a no deal Brexit, but this is too little, too late and quite frankly, proof that the impact on the NHS has not received the attention it deserves in the Brexit negotiations.

“Some will say we are scaremongering by warning of the dangers of a ‘no deal’ Brexit, but this is not the case. We aren’t shying away from being honest about what is at stake for health services if the UK and the EU fail to reach a deal. As experts in delivering health services and providing care for our patients, we have a duty to set out the consequences of leaving the EU with no future deal in place.”

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Principles for a National Health Service

One of the Centre’s friends, Jack Czauderna, recently shared this with us:

Dr Julian Tudor Hart, who has recently died, was a pioneering GP who inspired generations of health workers. He coined the term Inverse Care Law in 1971 which asserts:

“The availability of good medical care tends to vary inversely with the need of the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”

Here are his 9 distinctive and essential characteristics of a National Health Service:

  1. A united national service devoted directly and indirectly to care, fully available to all citizens.
  2. A gift economy including everyone, funded by general taxation, of which the largest component is income tax.
  3. Its most important inputs and processes are personal interactions between lay and professional people.
  4. Its products are potentially measurable as health gains for the whole population.Its staff and component units are not expected to compete for market share but to co-operate to maximise useful service.
  5. Continuity of care is central to its efficiency and effectiveness.
  6. Its local staff and local populations believe they have moral ownership of and loyalty to neighbourhood NHS units.
  7. None of its decisions and few of its procedures can be fully standardised. All of its decisions entail some uncertainty and doubt. They are therefore unsuited to commodity form, either for personal sale or for long term contracts.
  8. The NHS is a labour-intensive economy. Every new diagnostic or therapeutic machine generates new needs for more skilled staff able to control and interpret the work of the machines and translate them into human terms.

We believe that this is from Tudor Hart’s The Political Economy of Health Care: A Clinical Perspective, published in 2006.

You can also read Tudor Hart’s Feasible Socialism online at the Socialist Health Association.


Principles for a National Health Service © Julian Tudor Hart

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By 999callfornhs, Aug 9 2018 12:35PM (PERMISSIONS  GRANTED)

Steve Carne keeps getting dragged into the pit…

The image of vicious piranhas fighting for flesh, (made in desire for a dramatic context I confess in yesterday’s blog about Babylon), seems to be ever more relevant and continues to grow as more corporate quibbling and quarrelling now truly “disrupts” every layer of the once public service NHS.

Including the basics of supplies and logistical planning that supports the once joined-up network of hospitals and healthcare NHS units (clinics etc.) All under the guise of greater integration of course and using the Carter Review 2015 which called for something called the Procurement Transformation Programme (PTP) which has led to the Future Operating Model (FOM!) and its new rather confusing logistical planning landscape.

NHS Supply Chain Logistics is now being revamped (not a top-down reorganisation you understand nobody likes them do they?) at the end of September it seems – after DHL have run it since 2006.

And even though Health Care Supplies Association (HCSA) in 2016 thought that the commercial procurement arrangements with the outsourced service NHS Supply Chain were working well and should be extended NHS and they warned that “New NHS Procurement structures may be disastrous” – NHS Procurement, NHS Improvement and Uncle Tom Cobblybollox and all have decided that it’s best if NHS Supply Chain is revamped into something called the Future Operating Model (FOM) and ‘has been designed to realise £615m of savings in real terms over the next 3 years (2018-21).’

ELEVEN TOWERS

Yes apparently the new structure is all about Towers. Category Towers. Stick with me as I attempt to climb the dark staircase…

So NHS resources – things to buy, sorry PROCURE – are now divided up into these Eleven Category Towers (which Lord of the Rings numpty thought that one up I wonder?) So below, courtesy of Dept of Health info pdf  is a simple chart of these Eleven Categories.

Bottom Right is interesting…

The Health Care Supplies Association (HCSA) says “the eleven tower system is hard to understand” – but they shouldn’t be alarmed because apparently there are 200 very intelligent people employed to become the Intelligent Client Coordinator… fingers crossed.

Still with me?

Blimey so… what this is supposed to do (apparently) is save money through making more resources flow through less broken up chains of command – we assume. Sort of what it must have been like before the tendering competitive market moved in – back in the 90’s – and festered until getting the boost it needed in 2012 with the Health & Social Care Act that did all the damage. The Dept of Health kindly offer a nice graphic to help us get the picture.

Trouble is …

this is where the piranha-profit fish now get really pissed off cos they are missing a meal and they see other corporate piranhas munching into their prey. And DHL are pissed off enough to take the Dept of Health to court claiming that the tendering process is faulty because they haven’t been given a big enough slice of the dish.

You see to make it fair the Dept of Health thought best if procurement companies were only allowed to take hold of THREE TOWERS at a time (joined-up thinking see?). DHL already have three towers – the procurement of large diagnostic capital devices, ward-based consumables, and infection control /wound care.

But what they are really pissed off about is the fact that after 13years of being the logistical handler of the NHS Supply Chain they have now lost out to UNIPART.

And it’s a fairly big contract… look. Estimated £730million over 5 years…

So Unipart are happy no doubt trolling about twixt towers. And they do have good experience in the “Unipart Way” – oh yes that old Toyota Car Factory chestnut the Lean Management System is something they are enormously proud of. I expect NHS Managers up and down the country will be clapping their little hands because they understand that after their three-day “how can we show Compassion whilst burning the workforce” training course.

Well Unipart can keep their hands well away from my bottom thank you very much.

The whole point is…

What the hell are we doing letting all these multi-national businesses scramble our public services in search of ever-more profit? Just like piranhas the smell of blood money is overpowering and will dominate their motives and actions. How can they be allowed to hold to ransom the Department of Health? Or any of our government departments?

How this all fits into the other NHS restructures and redisorganisations is the next step to understand. Campaigners are often told by politicians on both sides of the House that the NHS can’t afford another Top-Down Reorganisation. Seriously we can’t afford not to once and for all take the big step and bring the NHS back into public control. The poor NHS has been and still is (frontline staff will tell you) being attacked and thrown into chaos by more and more corporate top-down changes usually requiring yet more top-down levels to provide muddy transparency.

The shrinking, cutting and slashing we have all seen over the last four years (more I know now) is nothing more than the government desired move to a reduced, poor-quality NHS based on the USA system with corporates like DHL and Unipart taking more control and more money out of the system with their in-fighting and board room battles.

And once companies learn they can use the courts to fight their commercial interests and “bugger the consequences” there is no stopping them. After all they can afford it. And the prize is probably worth it. Eventually local councils, public departments will have to give in just because they can’t keep on paying costs.

Meanwhile people die. Paramedics and many many NHS staff watch them die. And they know there is a better way. It’s not the Unipart Way. It’s the Reinstatement of the NHS Way. There has never been a more urgent time for campaigners and public alike to understand that we are about to hand over the NHS to a bunch of piranhas.

The only way now is renationalise the health system – bring back the values of a healthcare system based on equality and the improvement of people’s lives. In that there is hope of a better society and future.

The public service model NHS used to be a world leader in that.

By Steve Carne

 

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LATEST figures on A&E waiting times reveal the “astonishing” collapse in NHS standards under Theresa May, Labour said today.

Monthly statistics for July 2018 published by NHS England show that just 89.3 per cent of people attending A&E were seen within four hours, well below the 95 per cent target.

That dismal performance means NHS England has consistently failed to meet the 95 per cent four-hour target — lowered from 98 per cent by the coalition government — since July 2015.

The number of people attending A&E in July 2018 also hit a record 2.176 million people in July 2018, the highest figure since records began in 2010.

Shadow health minister Justin Madders said: “After two years of Theresa May’s premiership, patients are left with the worst-ever July A&E performance, thousands more people waiting too long for cancer treatment and waiting lists well above four million.”

“The sheer scale of the collapse in standards for patients since the Prime Minister took over is astonishing.”

Chris Hopson, chief executive of NHS Providers, said there had been “no respite” for NHS staff this summer.

“We have also seen exceptionally high numbers of patients then admitted to hospital beds,” he said. “This has led to more patients waiting longer to be seen in A&E with performance against the four hour standard slipping further.

“All of this is a symptom of an NHS running at boiling point all year round.”

Royal College of Emergency Medicine president Dr Taj Hassan said: “The recent heatwave will have had an impact, but this should not be used to excuse inappropriate resourcing.

“It should also not come as a surprise that whatever the weather conditions, working in a continually under-resourced and declining system has consequences — all of which are detrimental to our patients.”

NHS England also published the 2018 GP Patient Survey yesterday, which revealed that 24 per cent of patients had to wait a week or more for an appointment, up from 20 per cent in 2017.

Shadow minister for community care Julie Cooper said: “Today’s patient survey is yet more evidence of the Tories’ devastating failure to deliver for GPs and their patients as staffing shortages lead to cuts in services and reduced availability of treatments.”

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The Commonwealth Fund

The Issue

How medical practices are organized and structured keeps changing. But as more practices merge and more physicians sell their practices to hospitals, we don’t have a good understanding of whether, and how, these factors affect the quality and cost of health care.

Using 2012–2013 data from the National Study of Physician Organizations linked with Medicare claims, Commonwealth Fund–supported researchers writing in Health Services Research (July 5, 2018) examined how the size of a practice, along with other characteristics, relate to the total amount spent on a patient’s care and the quality of care provided. Quality was measured by two indicators: 30-day hospital readmissions and admissions for “ambulatory care–sensitive” conditions, which usually don’t require hospitalization when appropriate outpatient care is provided. The study focused on all Medicare beneficiaries with a special focus on those with high health care needs.

Large practices — with 100 or more physicians — spent

$1,870

more annually per high-need Medicare beneficiary than practices with one to two physicians.

What the Study Found

  • Annual risk-adjusted spending per high-need Medicare beneficiary was $1,870 (12.5%) higher in practices with 100 or more physicians than in practices with just one to two physicians. In practices with 50 to 99 physicians, the spending difference was similar — $1,824 higher.
  • Practices with a higher percentage of primary care physicians had lower total spending compared to practices with a lower percentage.
  • Relationships were similar for hospital readmission rates. Practices with 100 or more physicians had readmission rates 1.64 times higher than small practices with one to two physicians; for practices with 50 to 99 doctors, rates were 1.71 times higher.
  • There were no statistically significant associations between practice characteristics and ambulatory care–sensitive admissions.

The Big Picture

Though larger practices are often thought to provide better care, the results of this study do not support this assumption. Despite spending more per high-need patient and having more quality improvement processes, health information technology systems, and care management programs in place, larger practices in this study did not incur lower spending or achieve higher quality than smaller practices. It is possible that larger practices, which tend to have a higher percentage of specialist physicians, may attract more complex patients that may not be totally accounted for by the severity of illness risk-adjusted measures currently available for analysis. Or it is possible that they provide care that costs more than, but is not superior to, care provided by smaller practices.

The Bottom Line

Large physician practices spend more per person and their patients are readmitted to the hospital at a higher rate than the smallest practices.

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New BMA poll show nine out of ten doctors regard latest government pay award as “unacceptable”

A BMA poll of more than 12,000 doctors in England shows that nine out of ten regard the recent pay offer from the government as unacceptable, while a similar number believe that their morale has worsened in the wake of the announcement.

The BMA received responses from 12, 717 doctors to its survey asking for their opinion on the pay uplifts for doctors in England which were published in July 2018.

In making the award, the government ignored the recommendations of the independent review body, which many already regarded as insufficient, and announced what the BMA described as an “inadequate” pay settlement. The deal will see junior receive just a 2% increase, consultants 1.5%  and GPs 2%.

The findings from the BMA show:

  • When asked how acceptable the government’s offer was, three quarters (74%) said it was “highly unacceptable” while almost two out of ten (18%) said it was “somewhat unacceptable”.
  • Less than one per cent of respondents regarding the deal as “highly acceptable”.
  • As result of the pay announcement, almost six out of ten (58%) felt “significant reduced” value working as a doctor in the NHS, while a further three in ten (30%) felt a “reduced” value.
  • Less than 1% felt more valued because of the pay uplifts, of this only 0.1% felt their morale had “significantly improved”.
  • In total, more than four in ten (45%) felt their morale had “significantly worsened”, while a four out of ten (40%) felt it had “worsened”.

Dr Chaand Nagpaul, BMA Council Chair said

“Today’s survey findings of doctors in England should be a wake-up call for the Government. They have seriously misjudged the mood of the profession with what is another sub-inflationary pay award.

“The government’s decision to not implement the recommendations of the Doctors and Dentist’s Review Body (DDRB) has been compounded by its unjust decision to not back-date this pay award to April 2018 for hospital doctors. This is wholly contrary to the definition of an “annual” pay uplift.

“The government’s headline figures are inaccurate and misleading for doctors since this six month pay uplift commencing in October effectively halves its value for the year. Far from the government claiming to lift the pay cap for public sector workers, most doctors will continue to receive an uplift of 1% or less – and appear uniquely targeted in this unfair manner.

“For those thousands of our hard-working members and their families this is nothing more than an insult and the figures speak for themselves. More than 9 in 10 feel that the Government’s offer is unacceptable. Since 2008, doctors have experienced the largest drop in earnings of all professions subject to pay review bodies, with consultants seeing a 19 per cent fall in pay, junior doctors 21 per cent and GPs 20 per cent. The effective pay uplift this year for some doctors will be as little as 0.75 per cent as a result of the government’s interference form the pay body recommendations, which will be widely seen as derisory.

“After the Secretary of State’s recognition that NHS staff are feeling ‘under-valued’ what is most troubling is the devastating impact this has had on doctor morale. 84% say theirs has worsened in the wake of the Government’s offer, with 88% saying that the value they feel as a doctor working in the NHS has reduced over the past week.

“With the NHS facing severe shortages of doctors across all specialities, it is more important than ever that the Government recognises the contribution declining pay has had on the ability to recruit and detain doctors and takes steps to reverse this.

“These results give the Secretary of State compelling evidence to make tangible improvements to the morale and well-being of doctors. Back-dating the pay to April and increasing the offer would go a long way towards showing doctors that the Government does recognise their invaluable contribution and I look forward to meeting with the Secretary of State in person to discuss how this can be done.”

Ends

Notes to Editors

The BMA is a trade union representing and negotiating on behalf of all doctors in the UK. A leading voice advocating for outstanding health care and a healthy population. An association providing members with excellent individual services and support throughout their lives.

A full copy of the survey findings can be found here.

Key questions from the survey include:

Overall, how acceptable is the pay offer from the Government?

Highly unacceptable

 

74.5%
Somewhat unacceptable

 

17.6%
Neither acceptable nor unacceptable 3.3%
Somewhat acceptable

 

3.9%
Highly acceptable

 

0.7%

Overall, how acceptable is the pay recommendation from the DDRB?

Highly unacceptable

 

20.1%
Somewhat unacceptable

 

24.6%
Neither acceptable nor unacceptable 12.4%
Somewhat acceptable

 

34.7%
Highly acceptable

 

8.2%

As a result of the government’s offer, has there been any change in how valued you feel working as a doctor in the NHS?

Significantly reduced

 

57.8%
Reduced

 

30.3%
Neither increased nor reduced

 

11.1%
Increased

 

0.6%
Significantly increased

 

0.2%

As a result of the government’s offer, how would you describe your current level of morale?

Significantly worsened

 

44.6%
Worsened

 

40.2%
Neither improved nor worsened

 

14.5%
Improved

 

0.6%
Significantly improved

 

 

0.1%

 

Contact

Paul Gadsby

Senior BMA Media Officer

T: 07827 858 992

E: pgadsby@bma.org.uk

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