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    This commentary is from the officers of SHA Cymru. It does not necessarily reflect the views of the SHA as a whole or other SHA members.

    During earlier phases of the Covid 19 pandemic it was expected that the “new normal” for health and social care would be be triggered once the pandemic had come to an end.  But this was an unduly optimist view. We now have to look at a resetting of health and social care while the pandemic lingers on. This will add to the complexity of the challenge. 


    The Welsh Government recognises this in its plans to modernise planned care and reduce waiting lists in Wales. Though it has allocated £170 million to the task it envisages that it could take up to 2026 to get our service back to an acceptable normal. In the interim there will be a series of phased targets to monitor progress. There are almost 700,000 people waiting in the system and that there were as many 500,000 referrals  deferred over the last two years. This reduction seems to be particularly high in the cancer field where referrals and investigation are significantly lower than expected.


    This massive backlog will require critical changes to the way health and social care is delivered. The focus will be on prioritising children, those with the most urgent need and who have waited the longest. There is a very welcome acknowledgement that service capacity will have to increase in many key areas. Sixty per cent of the patients who are waiting have to receive their first appointment so diagnosis needs to be made more quickly through the development of new more streamlined diagnostic pathways. 


    How outpatients departments operate is crucial to this. The efficiency of this gateway must be improved through fewer  visits delivering more optimal outcomes. Over 100,000 people are currently waiting for diagnostic tests. Diagnostics and assessments must dovetail more smoothly and where appropriate alternate pathways to diagnostics and care will be provided, including beyond conventional office hours and in new “Community Diagnostic Hubs”.


    And while patients wait more support will be provided both in terms of managing clinical care and keeping patient informed about what is happening. This should help to prevent patients being unable to avail of treatment because of a preventable deterioration in their health while they wait.


    There will be fewer routine, knee-jerk outpatient follow-ups. Instead more patients will be managed in a home setting with more ready access to advice and support through community and primary care services. Patients however will be empowered to self-initiate review or follow-up in line with protocols that are suited to their needs. The innovative use of IT means that these reviews will not always be at a physical out-patient clinic. However there will need to be greatly improved communication interfaces that work when needed if this is to be a real innovative asset rather than just another obstacle to care. In developing these new ways of working, priority will be given to the to the ten highest demand conditions.


    Steps will be taken to protect elective and planned capacity. This is a particular issue with the ongoing pandemic due to the risks of infection spread in clinical setting affecting both patients who  become unfit for their treatment and staff who are unable to work. Wherever possible there will be dedicated and segregated care pathways to protect elective capacity. There will be more regional elective centres with regional waiting lists to increase throughput, streamlined bespoke treatments and to provide segregated care.


    But there will also have to be greater flexible capacity  in responding to varying levels of emergency pressures. The present practice of running all in-patient services at close to maximum capacity must change. There should be headroom to allow for unexpected demand. The NHS needs to move more towards EU norms for hospital bed and medical staff numbers. There is a welcome recognition that it will no longer be acceptable to routinely curtail elective capacity in the face of predictable variability in  “winter” bed pressures.


    The Welsh Government says that the private sector will have to be mobilised to help clear the backlog. The Socialist Health Association Cymru supports  the requestion of all private sector capacity for the common good .This needs to be done in a way that does not interfere with the re- building of NHS capacity so that service will be in a position to again be able to meet its own needs in a timely way.  Wales had more or less achieved this position prior to start of the austerity cuts in 2010. But over the last decade  annual spending increased by about 1.5% while out-patient demand alone increased by 4% so it clear that there is is a serious mismatch between capacity and need. 


    Much of what the Welsh Government is planning makes sense and can be achieved with proper investment to tackle capacity bottlenecks and through re-designed care pathways. These pathways need to be regularly monitored and remedial action taken where problems are identified. As the NHS  internal market has been abolished in Wales, proper planning and leadership is needed at all stages to make it happen. And while programme has a particular focus on modernising planned care and reducing waiting lists in Wales it will not happen without strong joint working between primary and secondary health care and social services. And this is where the plan is weakest.


    The plan is dependent patients achieving a smooth transition from home to hospital and back again. This will also require increased capacity and innovation within primary  and social care. Investment in social care in Wales has continued to outstrip the position in England but the service remain very fragile. Services that prevent unnecessary admission or facilitate early discharge need to be enhanced. The decision of the Welsh Government to explore the creation of a National Care Service in Wales is therefore very welcome and well overdue.


    In launching the Plan in the Welsh Senedd the Health Minister, Eluned Morgan MS, highlighted that though staff numbers in the Welsh NHS increased by over 50% in the last two decades more needed to be done.  This is especially true in primary care where the numbers of GPs  principals  have remained static throughout all of this time at just under 2,000.  Considering the role that being assigned to primary care in the plan, this continuing failure to recruit more GP and reduce list sizes over such a long period of time is simply unsustainable.


    This failure to recruit GPs not only places this overall Plan in jeopardy but it also places the Welsh Government’s commitment to tackling growing health inequalities and the Inverse Care Law at risk. While the programme acknowledges that Covid has exacerbated growing health inequalities,  there is little  in it to indicate how the declared priorities of tacking health inequalities  are to be addressed. There is the usual exhortation to people to live healthier life-styles and for a greater involvement in the self-management of their care. Achieving any of this is however highly problematic in the face of the cost of living crisis, the loss of health promoting public facilities in our poorest areas and the lack of an effective allocation of capacity in line with need.


    A key part of the Plan is greater engagement  in providing quality assurance on the service that is being provided. The public will be involved in service design and change so that they the more match user needs. In addition more work will be done to embed patient outcomes and patient’s experience in the pathway. Effectively using this information is crucial to providing reassurance about care quality or to indicate where service improvement is needed.


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    The continuation of the Covid-19 pandemic requires a holistic response from the global to the personal. However in many instances this is not happening.

    The following letter had been sent by Doctors in Unite to a number of the medical Royal Colleges in England calling for a more focused response to the airborne nature of this infection.


    Dear President / Chair

    After almost two years of constant high level alert due to the Covid pandemic, as a medical trade union, Doctors in Unite share the profession’s concerns about the continuing implications of this ongoing situation for patients, society, the wide clinical team and the profession itself.

    In the last two years much attention has been given to keeping safe our patients and those who care for them, including your members, with particular attention being given to PPE, social distancing and vaccination. However, as medical trade union, Doctors in Unite is very concerned at the poor response to addressing what is a substantially an airborne disease. The importance of a clean air environment for patients, clinicians and the wider public has been at the very best an afterthought.

    It is quite clear that current protections against the virus for both health care workers (HCW) and patients, are inadequate and failing to keep them safe. One only has to look at the alarming increase in staff absence due to Omicron (at a time of rising hospital admissions) and the high numbers of hospital acquired infections to see this. This comes on top of over 1,500 HCW deaths 1 and 11,600 patient deaths 2 from nosocomial infections. It has been heart breaking to see so many of our colleagues in the front line die from this preventable disease. HCWs from black and Asian communities have paid a particularly heavy price, accounting for over 60% of HCW deaths while making up only 20% of the NHS workforce.3 Unless we recognise the centrality of airborne transmission going forwards, and respond rapidly by implementing airborne protections in our hospitals and clinics, we fear that further unnecessary illness and death will be the consequence for our colleagues in hospital and for patients.

    When we apply the standard health and safety “hierarchy of controls” to Covid-19, it is clear that airborne protections are literally central to that response. Vaccines, while essential, are not on their own going to get us out of this crisis. Assessing ventilation with CO2 monitors, improving ventilation where it is inadequate, installing air filters where this is not possible in the short term, and the wearing of respiratory protective equipment (RPE) will help ensure that HCWs and patients breathe clean air and will not get infected.

    Providing proper ventilation and clean air cannot be done at an individual level. It demands a collective and corporate strategic response from a wide range of agencies to make public spaces, including work and clinical spaces, safe. Employers, i.e. NHS Trusts have a critical role here. The WHO has now formally recognised airborne transmission of Covid-19 and recently stated, “Respirators, which includes masks known as N95, FFP2 and others, should especially be worn in care settings where ventilation is known to be poor.” 4

    As a Royal College, you have a very important role in setting standards, educating and promoting professional well-being. We hope you will be able to use your good offices to support growing demands on NHS employers to recognise airborne transmission and provide safe, clean air working environments for patients and staff throughout their estates. The distribution of RPE to all HCWs could be done within a matter of days, while other measures are being assessed, and would have a significant impact on transmission as this recent study at Addenbrooks Hospital showed. 5

    We look forward to hearing from you and would be happy to discuss things further if that would be helpful.

    With kind regards,

    Jackie Applebee.

    DiU Chair



    Comments Off on Covid 19 Call to Royal Colleges.

    The White Paper says social care must give people ‘choice, control, and support to live independent lives’ through ‘outstanding quality and tailored care and support’ which they must find ‘fair and accessible’. No one will argue with any of that. If achieved, most will agree that the Prime Minister’s promise to ‘fix social care’ had been delivered.
    But there is a problem. This vision is no different from the vision set out when the personalisation strategy was launched in 2007. Nor is the vision any different from a re-launch in 2011 by Think Local Act Personal (TLAP), the body entrusted by Government to progress the personalisation strategy. TLAP gave it the title ‘Making It Real’ – the ‘it’, we may believe, being personalisation – making the implicit assumption clear that personalisation had not happened. And when the first iteration of ‘Making It Real’ failed to make it real, the strategy was re-launched in 2018.

    So the White Paper represents, incredibly, the fourth launch of a strategy with a 14 year history of repeated failure.
    Government shows no curiosity as to why the personalisation strategy has failed. There are three key elements of the strategy – direct payments and personal budgets, empowerment of people with information to navigate the system and exhortations to councils and their staff to change their behaviour. Each has proven problematic.

    Direct payments and personal budgets

    The White Paper sees these two mechanisms as a ‘vital way in which people can have more choice and control over their care and wellbeing’. However, meaningful personal budgets do not and cannot actually exist while it has been known for twenty years that direct payments work only for the small minority evidenced to be able to manage their own support systems in a harsh environment.

    The original idea of personal budgets was as an entitlement to a ‘fair allocation’ of money ‘up-front’, sufficient for the person to purchase the supports that would give them ‘full citizenship’. The New Labour government was enthusiastic, but before implementation, dealt it two blows that were fatal.

    The first blow was in changing the idea of a ‘fair allocation’ to be just a fair allocation of whatever budget the local council happened to have.

    The second and final blow was to declare that the ‘up-front’ allocation was not an entitlement, just an ‘indicative’ amount. What people actually got would be known once the council had decided what needs it would meet and with what resources.

    These two blows killed personal budgets at birth. The Care Act of 2014 introduced the term ‘personal budget’. But it could not be clearer that it was nothing more than an administrative costing exercise taking place at the very end of the process. A ‘personal budget’ under the Care Act is not a budget in any meaningful sense of the word. It is in reality a completely pointless exercise.

    It is an extraordinary act of manipulation of the public’s mind that personal budgets are even seen to exist, let alone have a transformative impact. A key part of that achievement was to conflate personal budgets with direct payments as if they were the same. But they are completely different. When direct payments were introduced in the 1990’s they allowed disabled people to step outside the mainstream provision to employ their own Personal Assistants and so control their support. It worked then and it still does. Up-front allocations, however, played no part then and play no part now. But by showcasing the successes of the small number of people self managing with a direct payment – about 8% of all long term service users – and parading them under the banner of being a form of ‘personal budgets’ TLAP has been able to keep the personal budget mythology alive.

    Empowering people to navigate the system

    The White Paper says people ‘struggle to understand the system’. This state of affairs is fundamentally disempowering. Yet provision of information as a means to empowerment was a key part of the personalisation strategy from the very beginning. Why have councils failed over so many years in what is surely a very simple task?This invites further hard questions. Do councils actually want to empower service users? Will empowering service users actually impede their operations? Or is the system so complex and obscure that it is not even navigable?
    So far Government has not shown sufficient curiosity to investigate the issue. Instead it has committed a modest £5M to ‘pilot and evaluate new ways to provide personalised advice to help people navigate local adult social care systems’. What point is there in such work without first answering the obvious unresolved questions?

    Exhortations to change

    The White Paper is packed with promises to change the behaviour of councils and their staff – to be person centred, to be empowering. They are the same promises made in each of the previous three launches of the personalisation strategy. Indeed, with only minor changes to the wording, the exact same promises can be traced back even further to the Community Care reforms of the early 1990’s.
    Yet, again, Government shows absolutely no curiosity as to why these positive behaviours, which councils readily sign up to, have not happened. The hard question neither central nor local government seem to ask is whether there is something about the system that is conditioning the disempowering, resource-led behaviour of councils and their staff? If there is, unless it is addressed, the promises are not worth the breath required to speak them.

    The Care Act

    The White Paper is, however, surely right when it says the 2014 Care Act ‘particularly its focus on wellbeing, provides a strong foundation for our vision’. The problem is that it then picks out five features of the Act but completely misses out the two most critical to delivery of the Act’s vision. The Act places specific duties on councils to;
    1. identify all needs a person has for their wellbeing, which can have no regard to resource availability
    2. have regard to the need to ensure that sufficient services are available for meeting the needs for care and support in their areas

    Neither of these requirements are being delivered. The second, indeed, cannot be delivered without the first. And the first is not delivered because Government policy is to maintain the traditional system whereby a need is a need only if there is resource to meet it.

    This is the effect of the ‘eligibility’ system. Councils calibrate what they deem to be a ‘need’ calling for council resources to that for which they have resource. Anything else is simply a non-need, a mere want or wish, but not a need. This circular, resource-led way of defining ‘need’ explains why there is a 60% disparity in how much support different councils give their service users. It also explains why councils never have any information about unmet need.

    Eligibility operates covertly. Councils tell their public that they follow the national criteria. These say that all needs that are ‘important to the person’ due to having a ‘significant impact on their wellbeing’ are treated as ‘eligible’. This is, of course, hopelessly undeliverable. No council could afford it. The real eligibility decisions are made behind closed doors.

    And, of course, it requires a process that destroys any prospect of being person centred or empowering. People have to be fitted into whatever types of needs their council will consider ‘eligible’, cutting across the uniqueness of need upon which the notion of being person-centred rests. And only the professionals are allowed to work out if there is a ‘need’, cutting across any notion of people having any control over the way their needs are defined.

    Two systems of social care

    There are two version of social care in this country – the official, glossy brochure version and the real one. They are worlds apart. Most people only find out when they have to seek help. The glossy brochures dupe the public into believing all needs important to each person’s wellbeing will be met, that personal budgets give people control and empower them, that national eligibility criteria ensure equity and fairness, that decisions are made in an open and transparent way. In the real world there is gross inequity, decisions are made behind closed doors, budgets, not importance to the person, determine priority and many hundreds of thousands of people with support needs go unhelped. Of course people find the system unnavigable. It is a complex web of false leads, mixed messages and downright untruths. It has to be that way if central and local government are to maintain that their glossy brochures tell the truth.

    Prospects for change

    The White Paper introduces some changes that will be broadly welcomed. The reduced severity of the means test, some attention to the workforce and a kick start to more housing options. But these are peripheral to the core challenge the White Paper itself identifies – the need for a system that empowers the individual to create personalised support. Yes, there are pockets of excellent practice dotted around the country. But that is no different from how it was in 1986 when the Audit Commission found, in a sea of mediocrity, ‘champions of change’. With exceptional drive and imagination, they were people and organisations that performed well despite the system or by by-passing the system. But their work has never been scaled up, and when the ‘champions’ went, their work usually went with them.

    It is either a great irony, or an act of great hypocrisy, that the Government is promising visionary change whilst clinging to the system that guarantees it can never be realised. The Government shows zero appetite for real change. Why should it? It’s a system that allows them to spend as much or as little on social care as they choose, and the system will deliver. The system is constitutionally built not to overspend whilst always meeting its statutory responsibilities. There is never the inconvenience of unmet need. It has allies in Think Local Act Personal who supply a steady stream of material for the glossy brochures. It is politically low risk.

    The White Paper is right in saying the legislation is in place. However, we await political leadership that has the strength and integrity to implement it in full. It will not actually cost a penny more to do so. But it will require political leaders to not only talk big but who act big. Political leaders must allow the professionals to work in authentic partnership with service users to identify and cost all the needs for wellbeing of every individual in need of care and support. They should set a standard for wellbeing. The United Nations* definition of Independent Living has international credibility and is an obvious candidate. They must then be big enough to hear how much money they must find if all are to have the level of wellbeing political leaders have said they want for them. And they must have the integrity to accept with good grace that their commitment to the wellbeing of people in need of care and support will be transparently tested. It will be measured by the action they take and at what pace to close the gap that will have been exposed between needs and resources.


    Following the Lost Decade of Austerity the NHS is undertaking a process of readjustment and reconfiguration to prevent the service falling over. In primary care the most prominent outward signs are “new models of care” and “Digital First”.

    The new models of care vary depending on locations but at their core is an attempt to divert what might be classed as routine and less serious illnesses from general practitioners so that they can concentrate on more serious specialist work. The focus shifts from the individual GP to a multi-disciplinary teams in its broadest, an often disconnected, sense. The GP is not longer the obvious and uncontested access point to the NHS.

    In the first instance patients are encouraged to take greater responsibility for their own health and its management rather than “bothering” the NHS. This has always gone on but now there are the additional opportunities and pathways for on-line advice and guidance.

    If that fails then consideration should be give to using alternative non-medical practitioners such as “blue light services if deemed an emergency, specialist nurses, physician’s assistants, pharmacists, self-referral physiotherapy, opticians, health visitors etc. And while use is made of these alternative practitioners by very many, a substantial number of patients who feel unwell vote with their feet and take themselves to an already over-pressed Accident & Emergency service.

    For those who cross this initial threshold, access to general practice is increasingly via a triage / “Digital First” portal. From here, it is claimed, patients access the advice, support and treatment they need using telephone, digital and online tools. In practical terms, this means patients should use these tools to access all primary care services, such as receiving advice, getting repeat prescriptions, booking and cancelling appointments, having a consultation with a healthcare professional, receiving a referral and obtaining a prescription. And any patient who wishes to consult their GP must digitally provide an initial description of their problem to a third party and will then wait for electronic triage via a phone or video call. It is only at this stage a face to face consultation may be offered if felt appropriate.

    Much of this has commendable elements if it was part of a strategy where primary care was evolving to meet to meet ever growing and complex needs. Many patients will find the use of “digital consultations” both convenient, time saving and satisfactory. Indeed there is some evidence to suggest that patients may be more satisfied with a digital consultation than the clinician.

    However overwhelmingly that transition to “digital first” is being hastily introduced as a dominant new paradigm of care and as a pressure valve for a service that is already in serious danger of imploding. Most of these changes have been introduced with bullish optimism and little consultation or debate with either patients or the professions involved. The speed of this uncritical implementation has been greatly accelerated by the Covid pandemic – for understandable reasons.

    An increasingly obvious outcome of these changes is a public perception that general practice is no longer a accessible first port of call for either new problems or the management of chronic long-term conditions. And fanned by some Tory politicians and elements in the right-wing press, general practitioners are having to shoulder the blame for this state of affairs in an increasingly hostile atmosphere.

    Some GPs have been dragged into a confrontation with patients on these issues in a way that seeks to minimise legitimate public concern. Such a response may be understandable but it is ill conceived. Both they and their patients must seek to make common cause to address the real underlying problems they jointly face.

    At the core of this problem has been the failure to expand medical capacity in primary care. In contrast to many other primary care professionals or their hospital colleagues, the numbers of GPs in general practice has been static for decades. This failure to increase numbers, linked to the changes in contract preferences of new GPs, has meant that more and more service is being expected from fewer and fewer practitioners. This is not sustainable.

    Jeremy Hunt MP, a former Tory Health Minister ( 2012-1218), has stated that his efforts to increase GP numbers failed, not because extra GPs were not trained but because more experienced GPs were retiring or going part time faster than new trainees arrived. This is a crucial lesson for the current Health Minister Sajid Javid MP.

    Javid’s recent proposals to provide an additional £250m to improve GP access provides some long over-due remediation for years of under-investment. But very worrying there are a range of conditions attached to the payments which most GPs will see as toxic strings. This could drive even more GPs out of the service when the need for them is greater than ever.

    Collectively all of these changes pose a risk to the essence of British general practice. As a gateway to the NHS, general practice had a key role in sorting undifferentiated presenting problems and to make decisions accordingly. GPs become a crucial signpost and the patient’s advocate in an every complex care service.

    The consultation has also been where opportunist preventive and anticipatory care took beyond the presenting problem. And this was the basis for the building of a continuing personal relationship between the patient and their practitioner. Time was of the essence in building this relationship – but time is one thing the present system does not have.

    Instead much of primary care provision is being fragmented into disconnected episodic incidents where continuity and personalisation is sacrificed for a transactional, call centre style of medicine. In this model patients move through the system as quickly as possible with a focus of narrowing  care down to just “today’s problem”.

    This approach will inevitably undermine the personal, generalist and holistic nature of general practice. The initial contact with primary care becomes the lottery of the taxi rank. Remote access will deprive the clinician of many important non-verbal cues and time pressures will mitigate against pursuing broader concerns that are not immediately relevant — though they may have longer term implications for patients’ health and well-being. Instead of being a holistic generalist , the GP is at risk of becoming a “specaloid in episodic care”.

    As the rivets pop throughout health and social care, rising such issues of quality may seem to be an indulgence. To some with immediate and pressing medical problems these concerns could look like worrying about the icing on a cake when there is no bread on the table. But these issues are fundamental way that British general underpins the whole of NHS. If we discard them, particularly in a trivial or cavalier way, the very fabric of the service will be placed at risk.


    Up to a third of UK social class differences in health was probably caused by work 50 years ago. Since then, many hazardous jobs have been exported but new types of unhealthy work have emerged.
    Work can be bad for health but so is unemployment. The most disadvantaged suffer unemployment in recessions and poor-quality work during economic growth. Work in a safe and supportive environment benefits health.
    Chronic illness and disability often prevent obtaining such work, or lead to its loss. People with impairments should be employed for their abilities. Punitive ‘welfare to work’ policies damage health, cause stress and diminish self-respect.
    Profit-driven economic activity can damage health through pollution, environmental harm, unhealthy products and unhealthy lifestyles.
    Comprehensive occupational health services provide biological monitoring, employment rehabilitation, workplace clinical services and health promotion. They support workplace health and safety systems, identifying hazards, assessing risk, preventing occupational disease and supportively managing disability and sickness. They should also work with trade union health and safety representatives in the workplace.
    About a third of the workforce had a comprehensive occupational health service in the 1980s, a third had a partial service and a third had no service. 
    Most of the workforce today have no direct access to occupational health services.
    Occupational health services in the UK have never been statutory, but mostly employer-provided services. There have been campaigns to incorporate occupational health into the NHS, but by 1980 this was seen as medicalising the issue.
    But with no statutory duty on employers, occupational health services declined and were commercialised. Public ownership is essential to ensure accountability to workers’ health rather than to corporate interests.
    DiU (MPU) has often provided medical support to trade unions. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Network. We also liaise with the H&S representatives of other unions and the TUC.

    Doctors in UNITE (the Medical Practitioners’ Union) believes there should be National Occupational Health Services (NOHS) for England and devolved nations, including the following criteria:

    NOHS  should cover all workers, paid or unpaid.
    NOHS  should address occupational, environmental and commercial determinants of health.
    NOHS  would provide biological monitoring, employment rehabilitation, and health promotion, and support safety management. We will discuss later whether it should also provide clinical services at the workplace.
    NOHS  should normally be publicly provided, although where a satisfactory comprehensive occupational health service already exists in a particular workplace, and has the confidence of the trade unions, it could be publicly licensed and its role extended.
    NOHS  should be accountable to Parliament through a Minister for Industrial Health shared between DHSC, DWP and DBEIS.
    They should also be accountable to devolved Assemblies
    The existing national organisations for health and safety, employment of sick and disabled people, or control of pollution should be redesignated as part of the statutory comprehensive health service and should review ways to work together and fill gaps. This does not imply any major reorganisation.
    Locally NOHS should be controlled by workers (preferably through their trade unions), the appropriate regulatory agency (be that HSE or the local authority), consumer representatives and local communities. In a previous policy statement some years ago, we advocated joint control by employers, expert regulators and trade unions/ communities/ consumers, as that fitted with the tripartite model of health and safety current at the time. However, that model has not proved robust so we now feel NOHS must be controlled by those it serves.
    Professional independence is central.
    The issue of funding will be raised. In a previous statement we said this needs to come from employers, but funding from general taxation would enhance independence so increases in corporate tax would be better. As health services have a Keynesian multiplier in excess of the figure at which they become self-funding, it may actually not be an issue. At a Keynesian multiplier of 2.5, £1 spent generates £2.50 of growth which generates £1 of tax. Keynesian multipliers for health, education, welfare, recreation and cultural services, care, and social protection are significantly in excess of that – about 4.32 for health – implying that spending reduces the Government deficit.
    In smaller and medium sized workplaces, NOHS would be provided on a group basis. For the smallest workplaces (such as a corner shop) it might be provided by the kind of neighbourhood public health system which we have advocated in our paper “Public Health and Primary Care”.
    In creating safe and healthy systems of work and in biological monitoring NOHS would feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supported a supportive management of disability and sickness. This system must extend to contractors and volunteers as well as employees.
    NOHS and the workplace health and safety system must address stress at work not by victim-blaming “stress management” terms but through the factors in the workplace environment which we described earlier such as autonomy, social networking, training and resourcing of responsibilities, pleasant environments and work/life balance.
    There has been much debate about whether occupational health should also provide clinical services at the workplace. This must not dominate and take occupational health staff away from other roles. Many services described as “partial” in 1980 consisted of a factory nurse providing mainly clinical care. This led to doubts about the appropriateness of a clinical role. However, the workplace is a convenient place to provide certain types of health care, including screening, blood pressure measurement, stress counselling and treatment of minor injuries or minor illnesses manifesting at work. There needs to be a system for providing the simple front-line healthcare that in many countries would be provided by a “barefoot doctor” or “community health worker”. This should be planned on a universal basis, so as not to exclude retired or unemployed people, but for those who spend time at a workplace, either as an employee, a contractor or a voluntary worker, clinical care at the workplace could sensibly be a part. In providing such clinical services at the workplace NOHS would be linked to the NHS.
    In employment rehabilitation, NOHS would be linked to a Work and Health Service which would take over the disability functions of the DWP, would be part of the NHS (New Zealand is an interesting model here) and would offer employment-focused rehabilitation. Such services were previously operated by EMAS, by Employment Rehabilitation Centres and by Remploy but were inadequately resourced and only operated for the most severely disabled people – at the time we described it as “an excellent icing on a mouldy cake”. Government then shifted the function into a “welfare to work” model which operated too late in the process, missing the opportunity to retain people in work. Both of these systems were separate from the NHS clinical care of the patient, in which work needs to be a central factor.
    In addressing the environmental and commercial determinants of health NOHS would be linked to the public health system
    NOHS would have access to all levels of management and of regulation.
    NOHS needs specialist support from the NHS, laboratory services, environmental services, HSE, public health and academic institutions.
    NOHS should be part of the statutory health service. The 1948-74 terminology in which the statutory health service was called “the NHS” should be restored. Even with current terminology there are services NOHS should provide for the NHS, especially front-line health advice, health promotion and employment rehabilitation. NHS bodies may act as local providers of NOHS in some areas.


    Updated to include a tribute from the Friends of Le Monde Diplomatique (link at the end of the article)

    To his friend, the warm and wise novelist, poet and activist, Susanna Mitchell, both members of SHA.
    Reprinted from Camden New Journal 22nd July 2021.

    The sad news came from Susanna Mitchell’s family on the afternoon of July 7th – “Susanna has passed away peacefully at the Marie Curie Hospice,” after a long illness.
    Susanna was born and educated in Ireland. She was a novelist and poet, an activist and teacher with a background in political philosophy. Her novels include The Token, shortlisted for the Yorkshire Post Prize, and The Colour of His Hair, which addresses the problems of her native Northern Ireland.
    She taught politics and political thought in the Social and Political Science Faculty at Cambridge University, and later was a Fellow of the New Economics Foundation. There she worked with the Global New Economics team on international debt and immigration, the power relations between these issues and the political arena, and their impact on health care systems in the so-called developing world.
    In retirement she was active in local politics, with a focus on campaigning against the privatisation of the NHS. She was a member of KONP (Keep Our NHS public) and the Socialist Health Association, and an SHA delegate to Holborn and St Pancras Constituency Labour Party General Committee.
    Susanna had gone into the Marie Curie Hospice towards the end of 2020. But she recovered sufficiently to move back to her family and home in Highgate.
    In the spring of this year she was well enough to meet up on Parliament Hill Fields. It was a warm sunny morning. She and I walked into the park, and Susanna directed us to a wooden bench that was sheltered from the wind by high bushes. The bench gave a spectacular view over London.
    We chatted – and laughed – about all sorts if things, both personal and political. For example, friends and comrades were very concerned about the Centene Corporation taking over some of the general practices in Camden. Susanna and I had previously collaborated on a number of articles about this sneaking privatisation of the NHS for the CNJ. But friends’ concerns about Centene were surprising.
    “They have seen the articles, but this is a new outrage to them.” Susanna said of her friends, “and they work so hard, and they’re all so good…”
    Feeling like Cassandra, Susanna confirmed: “It’s not that they don’t believe these things about the NHS, they just seem to forget them. It’s like a kind of amnesia. This means that each new revelation about privatisation feels fresh to them: it’s a new outrage.”
    We stopped talking and turned to look over the fields that sloped away in front of us. Although it was a warm and brilliantly sunny day, there were just a few people walking on the fields. We watched as a lone cyclist walked to find a good spot for sunbathing. He took off his shirt, laid down and basked in the sun.

    Susanna was a poet as well as an academic and activist. Without discussing the poem we silently acknowledged WH Auden’s poem about the fall of Icarus, caused by flying too close to the sun. Down on earth, this poem says, we go about our daily lives with an indifference to disaster.
    This day’s disasters were personal and political. The young man sunbathing could be unaware of concerns about the coronavirus pandemic, and how healthcare systems around the world – including our NHS – were being overwhelmed. And, although the day was idyllic, Susanna knew that meeting friends like this on the Heath would not last. We turned back to look at each other. We were suitably spaced apart at either end of the bench.
    “You look well,” I said.
    “Yes, people say this, but I’m in some pain,” she replied.
    Her eyes sparkled as she smiled. She was wearing some fine and delicate jewellery, and her handsome face was framed by them as well as the fine shirt and jumper.
    We carried on talking and smiling about so many different things.
    And then it was time to part. We walked back to Highgate Road and said goodbye.
    “Lots of love,” called Susanna as she walked towards her home. I carried on down to Kentish Town.
    As I walked, I remembered a phone conversation I’d had with Susanna. Perhaps it was her elegant outfit that reminded me, and I smiled as I recalled the day the phone rang.
    Susanna laughed as we said hello.
    “What’s happened?” I asked.
    “Oh goodness”, she said, “you’ll never guess. I was going to have a busy day and I was just getting myself ready when the doorbell rang, but I was only half way into my jumper.”
    She said she hadn’t quite got the jumper over her head because of the arthritis – she laughed again.
    Who could be ringing the bell? – she wondered – it might be important. No one else was at home so she had to answer it herself. She struggled down the hall and opened the door.
    She couldn’t quite see through the jumper – she told me – and only then realised how funny this looked. The callers must have been shocked and amazed to be confronted by someone answering the door with a face completely covered and an arm stuck but desperately trying to get into a position to find the sleeve.

    Knowing Susanna, she probably said – through the material – and in a sweet but serious voice: “How can I help?”
    Susanna was always helping. She was loving and kind to everyone. And she was supportive of all the people she knew. She worked hard to make a difference for the better.
    Whether for family and friends or in politics and society in general, she always made a difference for the better – even with her head stuck in her jumper!

    1 Comment

    The Local Government Association has released a statement that 91% of 600 councillors support a campaign for reform of social care launched by a partnership called Social Care Futures. As part of re-building society post-pandemic, their campaign calls for social care to serve the purpose of enabling people in need of care and support to: ‘live in the place we call home, be with the people and things that we love, in communities where we care about and support each other, doing the things that matter to us’.
    This is a warming vision whose worthiness few will dispute. But before committing to it political leaders are likely to want to know the cost. The Chancellor will certainly want to know the cost before his colleagues commit. However, with this vision so different from the current realities of social care, testified by the 500 people who responded to a survey by Social Care Futures, the cost is simply not known. All that Social Care Futures can say is;‘Government resources must be increased to the level that allows people the funding they need to live a life like other people’.

    Social care has not lacked for a vision similar to this for a long time. The most recent is a vision based on wellbeing in the Care Act of 2014. Before that the ‘personalisation’ agenda of the noughties. Neither have happened, with sector leaders claiming lack of funding.
    But there is a chicken and egg situation. While social care leaders say they cannot deliver a visionary service without more money, in the absence of the vision being costed, political leaders will not give sector leaders more money. It is an impasse.

    Breaking the impasse – a parallel campaign
    Coincidentally there is another campaign to reform social care concurrently being launched. It has been developed by a national collaboration of disabled peoples’ organisations. Included in its proposals is a route to break the impasse. It comes in the form of endorsement of the principle of ‘progressive realisation’ of the resources required through ‘concrete action’. This is a concept taken from the United Nations vision of Independent Living, which is a vision almost identical to Social Care Futures’ vision. The UN recognises that the resources required for people to lead the lives right for them is a political matter, not a legal right. Much as we may like the world to stop still while social care gets the funding it requires first, it is most unlikely political leaders will be so moved by the Social Care Futures vision that that will happen. The concrete action that must be taken is the key.

    Concrete action

    The action required to make progressive realisation a reality relates back to the very reason why social care leaders do not know how much it would cost to give people the lives they should have. In the NHS, clinicians diagnose and recommend treatments based on what they see before them. Waiting lists act as the financial safety valve if clinical need outstrips resources at the operational level, and as the weather vane and information source for funding requirements at the strategic level.
    This is not so in social care. Resources determine what is recognised as ‘need’. Managers determine ‘eligibility’ thresholds in order to ensure demand matches the local budget. It is the reason why sector leaders have no idea how much it would cost to resource the Social Care Futures vision or any other vision.

    The action required is to abolish the resource led definition of need – the eligibility process. Councils must require their front line practitioners to identify and cost all the needs each individual has to live the life described by whatever vision is adopted. On a case by case basis, councils must decide what can be afforded and what cannot. The needs unmet must be aggregated and put in the public domain. In this way, unmet needs in social care can sit alongside waiting lists in the NHS to inform future budgets. This is an approach that has recently been adopted by the Equality and Human Rights Commission (please see link below). It recommends the Secretary of State should periodically set out plans to close the gap between needs and funding.

    Delivering change – problems for Social Care Futures
    At the core of the action required is the axis between needs on the one hand and resources on the other. A founding principle of the NHS was that need must precede resources. In social care, from the outset, the opposite applied. The concrete action required is to reverse the polarity putting social care on the same basis as the NHS. Whilst simple in concept, it will require a change in the both the culture and modus operandi of the way councils deliver their part of the social care system that will shake the system to its roots. But this creates a problem for Social Care Futures. It is a partnership involving the key leaders of the sector – the LGA, the Association of Directors of Social Services, Skills for Care, Social Care Institute of Excellence. But the sector consistently and collectively denies the need for change in the way councils operate, citing only lack of funding as preventing them from delivering the personalisation vision.

    But the evidence not only undermines this position, it points to a seriously dysfunctional system;
    • In 2009/10 (at 2019/20 prices) £21.4BN was spent on social care, which included £1.3BN of NHS money. In 2019/20, £22.4BN was spent, which included £2.3BN of NHS money. Spending in real terms has thus actually increased by about 5%.
    • Whilst sector leaders point to increased demand from increased demography thus suggesting an effectively cut, they are silent on levels to which demand has – or should have been – reduced.
    • One of the selling points of the personalisation agenda was that it would reduce demand. By matching resources to the personalised needs of individuals, better outcomes at lower cost would follow.
    • Over the past decade the sector has proclaimed great success in delivering a range of demand reduction strategies. Chief amongst them has been what is called ‘strengths based practice’, designed to eliminate the dependency on services. However, while all councils have adopted the practice, sector leaders offer no information as to how much this may have saved.
    • In 2009/10, 1.7 million people were served. In 2019/20 that had reduced to 1.1 million. Spend per service user has therefore increased by some 35%. Why does the Social Care Futures survey find people seriously under-supported?
    • According to the LGA’s own figures, shared confidentially with councils but not released to the public, the highest centile of councils spent 60% more than the lowest in 2018/19. However, there is no suggestion that the highest spending councils have broken the mould any more or any less than the lowest.

    These figures point to a dysfunctional system. Until and unless sector leaders acknowledge as much and the parts they have played in its design and delivery, they will remain a central part of the problem, not the solution.

    The immediate needs for increased funding within the existing system are beyond dispute. In particular the low level of pay for the care workforce and the unfairness of the charging regime and pricing that risks market collapse should be addressed without delay. However, hopes for funding levels beyond the immediate that rest on the belief that government will be so moved by a new vision that it will commit regardless of cost is at best naïve. Worse, how can government have the confidence required to entrust new funds to a sector so dysfunctional and incapable of making best use of the resource it already has.
    It is easy to sign up to Social Care Futures’ vision. Who wouldn’t? But if we want a system of social care driven by that vision, or any variation of it, it will only happen if government listens more to the call for the fundamental systemic change that the disabled peoples’ movement includes in its agenda for change.


    Colin Slasberg is a social care consultant

    This post makes an important contribution to the debate on the provision of social care in England and is not a reflection of the SHA’s policy.


    Many readers may be aware that this is a major issue, but I am going to do my utmost to condense its main aspects into this blog. Obviously different people will have a varying spectrum of knowledge on this subject, but I am writing here from the perspective that many might be unaware or have limited knowledge of the issues involved.

    What is a PEEP?

    PEEP stands for a Personal Emergency Evacuation Plan. Its purpose is to provide people who are unable to self evacuate unaided from a building, or to a place of safety, with a plan to help ensure that they can.

    Not everyone identifies as disabled or with a health condition, and whether they do or not, some people may not realise that PEEPs exist, or that they could benefit from one. I know I didn’t.

    Some might need a PEEP for a temporary period, e.g. while they have a broken leg, whilst others need them long-term, and the PEEP may need to be updated as needs change. I would argue it is in everyone’s interests for PEEPs to be readily available, not only as a principle, but also because nobody has any idea if they might need one, either on a short-term basis or permanently. I have not been disabled for most of my life, for instance.

    Brief Background

    It is utterly shameful, to put it politely, to think that 42% of those who lost their lives in Grenfell were disabled. None had PEEPs, and it seems to me there has been no will by Government or those who make such decisions, to even try and increase access to PEEPs.

    Four years on, and only now has the Government recently opened a consultation. This has been due to what has (and continues to) come out of the Grenfell Inquiry. It isn’t an easy listen or read. More poignantly, bereaved families, survivors and others have fought the injustice throughout, including going to court over this major issue. That should never be forgotten. We would not be having this consultation otherwise, even though it has taken far too long.
    It should also be noted that PEEPs are nothing new: they have existed for decades. Although I think it is clear that current law legislates for them, arguably this has been and is being continuously contested by various parties. Due to the current situation, as described below, I will not focus on that here, for reasons that will hopefully become clear.

    My Experience

    When major fire safety issues were found in our building, our evacuation procedure changed from ‘stay put’ to simultaneous evacuation. It was assumed that all of us could self evacuate. Those who could not were not even considered, let alone acknowledged. Maybe it did not occur to those involved in making this decision? So installing a Gerda box (secure and fireproof for the storage of PEEPs) turned out to be pure tokenism. Initially it gave me hope, thinking that finally we were going to have PEEPs stored where the Fire and Rescue Service could easily access the necessary information. I had been refused a PEEP countless times and advised that I needed to ‘stay put.’ That because I am disabled I would have to wait to be rescued, while my neighbours, who can self evacuate, should do so. But I had to wait.

    Can you imagine being told that? Many disabled people will have been told this already. I know people who have. Sadly, more people have a similar experience than a positive one. Something else to have to fight for on top of everything else, when some of us are also at risk of losing our homes and having no choice but to declare bankruptcy, due to the huge fire safety remediation work that would be necessary, and other associated costs. The failure to include the cost of complying with a PEEP assessment in the service charge shared by everyone is discussed later.

    However, a company kindly undertook a PEEP assessment with me, without charging a fee. As a wheelchair user with complex needs, including support to leave their flat, the PEEP advised a specific model evac chair that I would need to safely evacuate with a ‘buddy.’ In my situation, my ‘buddies’ include: my partner, my Personal Assistants and neighbours. If nobody is with me and there is a fire, I can contact neighbours via text. I keep my phone near me at all times in case.

    This advice was not accepted by my managing agent, management company or the Fire and Rescue Service. There was not even a discussion, just people in offices or zoom meetings, making this decision without me. Not a trivial decision, but one that could, in the event of a fire, leave me injured or worse. This is about all the lives unnecessarily lost already, about my life and anyone’s who can’t self evacuate. It is about all those people who have lost loved ones and those who care about disabled peoples’ safety. It is yet another example of disabled people not being classed as equal. Classic ableism.

    If able bodied people were told that they had to be rescued and only disabled people could evacuate first, do you think that would be accepted? Do any of these people making such decisions wonder what it would be like for them or someone they care about to be in this situation? Physically trapped and in my case, as in many others, in a building that was built unsafe. This obviously increases the risk of a fire and therefore of injury and death.
    If the building had been built to higher safety standards, then I feel that the risk of living on the third floor is a reasonable one for me. Others may disagree with that, but then to ‘stay put,’ in my experience, either before I became disabled or after, was standard and I wasn’t aware of other options. Now the situation is very different and yet I, like so many others, are plainly refused.

    Such a decision made me feel extremely upset, angry and as previously explained, that my life and disabled peoples’ lives aren’t viewed as equal. We know this already, but even in such serious situations, it is often the case. Surely being rescued should be a last resort, not your only option. For some people there might not be an alternative or one they feel comfortable with, and/or some may prefer to be rescued. For me and so many others, that is not the case.

    There should be financial support for aids and adaptations to enable evacuation. As a reasonable adjustment, disabled people should not legally have to pay and the cost should not be added to service charges. It should apply generally, let alone during the current building safety crisis. Having huge bills, or expecting them, is a recipe for disaster and can lead to hate crime. I have known it to happen: disabled people being targeted by those worried about their precarious financial situations. This can and does happen, whether people are impacted by the building safety crisis or not.

    This has not been my experience, although my management company made me aware that if my PEEP was accepted, that it would be added onto the service charge. The recommended equipment tends to not be viewed in the same way as installing a new door, a new light, or having car lifts repaired. Not everyone uses everything that is included in the service charge, but evacuation aids are seen differently from other things included. Up to a point, I understand, as it should be classed as a reasonable adjustment, but anger should not be directed at the disabled person. There should be a central fund that people can apply to, and PEEPs need to be offered as standard. In some places they are, in Oldham, for example: but this is not typical by any means. If the Government is really serious about reducing fire risk to a vulnerable group of people, then they need to provide adequate funding. Local councils cannot be squeezed even more.

    In addition, PEEPs should be made available to anyone who cannot self evacuate, regardless of building height. Currently the Government are focussing on buildings 18 metres and above. PEEPs should be person-centred and not building-centred. Fire does not discriminate in terms of height. If you need help to evacuate, then you need help, however high the building you live in.

    So after a lot of thought and in desperation, I decided to crowd-fund for the evac chair. Within 3 days, mainly people I didn’t know kindly donated enough to reach the target amount. A couple of days after, the evac chair was delivered and my buddies have been trained how to use it.

    I’m only one person impacted, but not everyone can crowd-fund for equipment – and nobody should have to, under any circumstances. It is shameful.

    My fear was that without a plan there was a risk of injury or death, either to myself or others trying to help me, who would not feel able to leave me behind. This is not just about me, but about people who care about me. Now I have a plan and appropriate equipment, that reduces the risk to all. Several months back we nearly had an electrical fire, which made the potential situation even more real to me. We did not have to evacuate, but it made me even more aware of the fact that I could not even if I needed to. This petrified me and the feeling has stayed with me. Hopefully there will not be a fire, but if there is, I am as prepared as I can be though my management agent still has not accepted my PEEP, or acknowledged that I need one.

    Who are Claddag?

    Claddag is a Direct Action Group for Disabled Leaseholders and those with health conditions, impacted by the building safety crisis/cladding scandal. I am one of the co-founders. I was painfully aware that disabled people were not being considered or included in any part of the response to the building safety crisis and not only wanted this to change, but believed it had to. Another disabled activist, Sarah Rennie, was trying to do the same and although we’ve never met in person, via social media we founded Claddag.

    Obviously PEEPs impact a much wider range of people than those at whom Claddag is primarily aimed. It affects people in different circumstances, across housing tenures, whether impacted by the building safety crisis or not. So part of our campaign is focusing on PEEPs and this consultation is extremely important. It will inform legislation that is vital to those who need evacuation plans.

    Further to our open letter, we are making progress!

    The Government has been forced to think again on whether disabled people have the right to an evacuation plan within blocks of flats. Here is a recent Channel 4 report highlighting the dangerous situation disabled people are in, and the refusals of landlords/agents to agree evacuation plans.

    Call to Action – How to Help?

    The consultation on evacuation plans (known as ‘PEEPs’) has a short window for response. We know there will be a lot of opposition and so it is vital that disabled individuals, allies, MPs, DDPOs and charities make their voices heard. We need as many responses as possible.

    We are simply asking for:
    • PEEPs for every disabled resident
    • PEEPs must be the responsibility of the Responsible Person
    • PEEPs must be clear and accessible
    • PEEPs must be secure and up-to-date

    We are happy to distribute our draft response to anyone who might find it useful. If so, please contact us. Our contact details are on our website (link included below). The deadline to respond is 19 July 2021. Examples of lived experience is invaluable, so please encourage the groups and individuals you know and/or meet to respond.

    Some disabled people are struggling to get the consultation in alternative formats, so please let us know if you hear anything concerning that, which we should raise with the Home Office.

    Any questions please let us know. It would be very, very helpful to know if you do submit a response.

    More materials/stories about the impact of the building safety crisis can be found on Claddag’s website (



    The consultation on evacuation plans (known as ‘PEEPs’) has a short window for response. We know there will be a lot of opposition and so it is vital that disabled individuals, allies, MPs, DDPOs and charities make their voices heard. We need as many responses as possible.

    We are simply asking for:
    • PEEPs for every disabled resident
    • PEEPs must be the responsibility of the Responsible Person
    • PEEPs must be clear and accessible
    • PEEPs must be secure and up-to-date

    We are happy to distribute our draft response to anyone who might find it useful. If so, please contact us. Our contact details are on our website (link included below). The deadline to respond is 19 July 2021. Examples of lived experience is invaluable, so please encourage the groups and individuals you know and/or meet to respond.

    Some disabled people are struggling to get the consultation in alternative formats, so please let us know if you hear anything concerning that, which we should raise with the Home Office.

    Any questions please let us know. It would be very, very helpful to know if you do submit a response.

    More materials/stories about the impact of the building safety crisis can be found on Claddag’s website (



    The Welsh Government Social Care Minister, Julie Morgan MS, had just published the Welsh Labour Cabinet’s immediate priorities in progressing social care in Wales. A key element is the step to recognise the important role of the social care workforce, both paid and unpaid, in service delivery.

    In addition the Welsh Government has announced that it will be appointing a Chief Social Care Officer who will work with the Chief Medical Officer and the Chief Nursing Officers for Wales. This is a very important step which should provide an important strategic boost to the development of social care.

    Following the recent publication of the Programme for Government this week, Ms Morgan was pleased to provide Senedd Members with an early update about on the Welsh Government plans and priorities for social care.

    The challenges the pandemic continues to bring to the social care sector and of the need to support it to recover. A social care recovery framework before summer recess, which will set out the Welsh Government priorities for recovery. The framework will build on Improving Health and Social Care (Covid 19 Looking Forward), which was published in March.

    The recovery framework is being developed in collaboration with partners across the social care sector.

    The Welsh Government ( WG ) will:

    Ensure the core of our recovery planning is focused on rebuilding wellbeing, reducing inequalities, widening participation and creating an inclusive society;
    Support people with Long-Covid, including in terms of increased demand for social care provision;
    Continue to ensure the risk of Covid-19 entering care homes is minimised and visiting is maintained safely;
    Address the adverse impact Covid 19 has on unpaid carers;
    Work with the Social Care Fair Work Forum to improve terms and conditions for the social care workforce and ensure there is a continued focus on supporting wellbeing and mental health;
    Work with partners to shape a future funding approach to enable commissioners to respond to changing population needs to secure care and support for the future;
    Harness and build on the improved collaborative working across health and social care we have seen during the pandemic to drive improvement.
    It is critically important that we use this recovery period to lay the right foundations for the future of social care in Wales, in line with our longer-term ambitions, which are set out in the Rebalancing Care and Support white paper.

    Minister Morgan will be providing Senedd Members with an update on this work in the next two months.

    A key commitment for this new government is to introduce the Real Living Wage for social care workers. The WG wants to create a stronger and better paid workforce, which will be the bedrock for delivering better services.

    This can only be delivered in social partnership, through the Social Care Fair Work Forum – with the WG wanting  to ensure additional funding for social care to implement the Real Living Wage reaches the pockets of social care workers. This is a priority area of work.

    As an early sign of the Welsh Government’s intent, it has established the post of chief social care officer for Wales. It will be a strong voice for everyone working in the sector, supporting the wellbeing and development of the workforce, promoting improvement and reform, and providing national leadership and promoting esteem for all those in social care roles.

    A former social worker with a career spanning 33 years in social care in Wales, Albert Heaney has taken on this role and responsibilities alongside his current Welsh Government policy lead for Social Services. In parallel with the similar roles of Chief Medical Officer and Chief Nursing Officer, in this new role, Albert will provide leadership for the sector within and outside Welsh Government, providing impartial and informed advice to Welsh Ministers on priorities for change.

    After leading policy on the transformative Social Services and Wellbeing (Wales) Act and the Regulation and Inspection of Social Care (Wales) Act, Albert will build on this experience and expertise, bringing together contributions from social care voices and social services providers, working in meaningful partnership, to co-produce results for the future.

    Minister Morgan paid tribute to everyone working in social care – who have gone above and beyond to maintain a professional, high quality service during the pandemic. It is essential that these  voices are heard as we put in place recovery plans and move forward with our ambitious plans for health and social care this term.

    The new chief social care officer for Wales is a valuable contribution to this agenda and will make a real difference to all who work in, as well as those who benefit from, social care in Wales.


    The Equalities and Human Rights Commission has published a document setting out how independent living, as defined by the United Nations’ Convention on the Rights of Persons with Disabilities, can and should be written into domestic law. The document addresses the breadth of issues relevant to independent living, including recommendations relevant to such as transport and housing. As far as social care is concerned its recommendations describe a route to a newly envisioned but financially sustainable future built to deliver independent living.

    What is independent living?
    It is first important to understand what the UN means by independent living. It is firstly about living in the place of one’s own choosing, whether in one’s own home or communally, and secondly being able to make all the day to day choices that non disabled people take for granted. It applies to people of whatever age and whatever their impairment of body or mind. It applies as much to an older person wanting to choose the time they go to bed as to a younger person wanting to make their full contribution to society. In other words, it applies to every person in need of care and support.
    This is a different understanding from its original meaning created by the disabled people’s movement in the 1980’s. In relation to care and support, independent living was an alternative service model whereby the person managed their own support staff in their own home. Made possible by the 1996 Direct Payments Act, it has been a very successful model in the 25 years since for people with the skills, energy and time to make it work.

    Independent living and wellbeing

    The Commission notes the close relationship between the wellbeing principle of the Care Act and independent living. If a person can tick all nine of the wellbeing boxes of the Care Act – including as they do control over the person’s life and services, dignity and living in a home of their choosing – they will have independent living.
    How can it realistically happen?
    Resources are, of course, key. How can you reconcile such an ambitious vision with having to work within budgets settled in the hurly burly context of competing interests for limited public funds?
    The key is to acknowledge the simple and self evident truth that the adoption of any person centred ambition, whatever it might be, cannot be guaranteed to be affordable within existing resources. There will be a measure of unmet need. The test of society’s commitment to the vision will be the scale of unmet need.
    The UN approach to the resource challenge is straightforward. It does not expect states to make the resources required for independent living a legal right or in any other way guarantee all the funding required. What it does expect is that states adopt a strategy of progressively realising the resources that are required.
    The Equalities Commission accordingly reflects this approach. It believes the Secretary of State should periodically set out plans for how the resources required will be progressively realised.
    The start point for these plans must be knowing the true scale of unmet need.

    Making the plan a reality
    The first inescapable requirement must be real time information about the scale of unmet need at any point in time. That will require the wholesale transformation of the way needs are assessed, support planned and resources allocated.
    Whilst the law does not require it, policy in England, as in other parts of the UK, prohibits exposure of unmet need.
    An entirely new system of assessing need and allocating resources will be required. Assessments must start from the vision of what each person needs for independent living. Practitioners must identify and cost all such needs for every older and disabled person in need of care and support. Budget holders must control spending not by controlling the local eligibility threshold, but by making decisions about what they can afford. They must learn to secure the greatest degree of independent living for the greatest number of people their budgets allow. IT systems must capture information about needs met and unmet for strategic reporting.

    Political benefits
    Political leaders may not like being put on the spot in the way the Commission’s recommendation might suggest. However, it would be hard to mount an argument against its reasonableness. It does nothing more than expose political leaders to their responsibilities.
    But they can look forward to a silver lining – the banishment of the fear of social care as a bottomless pit of demand. The vision of independent living would create a positive, aspirational context for understanding ‘need’. Research has long shown that support plans built on the best that life can be for the persona and on their strengths, no matter how dire their circumstances, require less public resource than plans built on how bad life is and on their deficits which, it is widely acknowledged, is the hallmark of the current system. The need for, and existence, of stand alone ‘strengths based’ strategies testifies to as much. Swimming against a powerful tide, ‘strength based’ strategies are doomed to fail. The tide must be turned so that ‘need’ is routinely understood in the context of making life as good as it can be for the person. Support plans will be built on the person’s strengths as a matter of routine.

    Interestingly, as Peter Beresford and I previously pointed out, Scotland is ahead on this agenda. It is on the cusp of contemplating such a transformation. Its review of social care has recommended a new paradigm, one that will deliver on human rights with independent living at its core. Whether or not the Scottish government makes the leap is a matter of international as well as domestic interest.

    This change can be achieved without legislation and instead through moral compulsion and pragmatic good sense. It can happen now. It will not require a single penny more for new services. The only ‘price’ is political courage and integrity.
    At the heart of the change is reversal of the dynamic between needs and resources. A founding principle of the NHS in 1948 was that need must always precede resource. If not always working perfectly, by and large it has survived. We expect clinicians to say what is wrong with us and what modern treatments can do to the best of their knowledge. Waiting times provide a safety valve if need exceeds resources.
    In social care, the reverse was applied. In passing responsibility for the care of older and disabled people from Poor Law Boards to local authorities, when pressed in Parliament on what local authorities would do, Nye Bevan as Minister for Health said they would do ‘as much as resources allow’. No doubt the best answer at the time, the surely unintended consequences were to put social care at the back of the queue for public resources and set it on the path of a resource led definition of need resulting in the tyranny of ‘eligibility criteria’.
    The Commission’s recommendation would require social care to be placed on the same footing as the NHS in how needs and resources are reconciled. It amounts to nothing less than the ‘1948 moment’ increasingly being heard by the likes of Nicola Sturgeon as being what social care requires.

    Colin Slasberg is a social care consultant

    This post makes an important contribution to the debate on the provision of social care in England and is not a reflection of the SHA’s policy.


    The news that Sir Simon Stevens was standing down from his post as NHS England Chief Executive in July prompted some remarkable tributes from the Health Service Journal (HSJ), even by own standards. The editorial said that Stevens had managed to save the health service on no less than three occasions and has been the most important figure in NHS history since Aneurin Bevan. It also said that Stevens was “the greatest strategic health policy thinker of his generation”, and in this point at least the journal is accurate.

    Back in May 2004 the Guardian’s John Carvel asked with regard to Stevens: “Why does a bright young man who has probably had more influence on NHS policy over the past seven years than anyone else in Britain decide to quit the public service to work for a $28bn US healthcare corporation intent on aggressive expansion into a new NHS market”? Indeed, Carvel thought that “If he had gone back into NHS management, he could have been running the whole shooting match after two or three more moves”.

    At the time Steven’s move did appear odd as UnitedHealth’s – his new employer and the largest health insurer in the world – anticipated role within the NHS was thought to be marginal at best. It only ran two GP practices in Derbyshire and a case management programme for elderly people. But by 2007 Stevens’ former colleagues had given the green light to 14 companies, including United and other US insurers, to bid for potentially much bigger contracts from primary care trusts providing data analysis and research, giving PCTs a clearer idea of how to manage patients with chronic condition.

    However, as the Guardian pointed out, “their role may be bigger than that. Companies may also be invited in to act as middlemen, negotiating with hospitals on the trusts’ behalf to reduce costs, ushering in the prospect that some patients may find their care plan managed not by a doctor but by an American insurance company”.

    While this programme – the FESC – proved a little premature, it offers much of the key to Stevens’ strategy. Transnational capital was in the early stages of creating a global market in healthcare and adopting standardized organizational formats from which the greatest profit could be extracted. As this process was US-led, it was inevitable that its dominant and most profitable format, that of Managed Care, would be adopted as the guiding template, and Stevens’ move to Minneapolis was in part to familiarize himself more fully with the working of this system and with its leading participants.

    It was also, as became evident, to locate himself as a major player within this wider market creation, and to bring English healthcare into its framework.

    The focus of Stevens’ early work in the US was Managed Care’s applicability within public programmes, and in 2007 he became chief executive of Ovations, United’s division providing insurance packages for older patients, and which accounted for over 1/3 of its revenue. It also included Medicare Advantage, the private sector management of the state-funded programme for the over-sixties; a programme which had been heavily criticised for excessive administration costs, its evolution into a multibillion-dollar subsidy for private companies, as well as the insurer’s monopoly within certain states.

    Indeed, the scale of profiteering within Medicare Advantage, and within the US system in general, produced considerable clamour for reform. In 2007, Stevens told the Guardian, “For all its problems, there is often an ability in the States to innovate faster and really test new models of care. This is an exciting time in health reform in the US – there’s a real sense that there will be meaningful change here in the next few years”.

    But this was nonsense. Any sense of global market creation would be fatally undermined if Managed Care was to be replaced by single payer – a national system that would eradicate the need for insurers – on its home ground, and every effort was made to make sure this didn’t happen. Indeed, United, and Stevens himself, played significant roles not only in destroying single payer but ensuring that the position of the giant insurers was strengthened; in large achieved by taking greater control of Medicare, Medicaid and the new market exchanges, to the extent that within a few years these programmes had become the main artery of profits.

    With the home territory secured, United, and Stevens, began to apply themselves more fully to global market formation.

    In 2009 Stevens was also charged with managing United’s international operations, growth and M&A in 123 countries, including North America, Europe, and the Middle East. One of his first tasks was helping set up, in 2011, a high-level trade lobby group, the Alliance for Healthcare Competitiveness (AHC), which wanted “the Office of the US Trade Representative, acting through the World Trade Organisation, to force other nations to open up their national health systems to US for-profit insurers, hospitals, professionals, medical device makers, pharmaceutical firms, IT companies and other investor-owned firms”.

    However, it makes little sense to open up national systems unless these conform to standardized templates. A year later, Stevens was helping to pursue this aim, by acting as Project Steward within the World Economic Forum’s (WEF) year-long project on Sustainable Health Systems. Co-organized with the leading US consultancy, McKinsey, workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London were, according to the WEF, “remarkable in their consistency of vision”, advocating new care models with delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”.

    In ‘Health Incorporated’, undoubtedly the WEF’s scenario of choice, the boundaries of the health industry would be redefined. “Corporations provide new products and services as markets liberalize, governments cut back on public services and a new sense of conditional solidarity emerges”. Further, “Health schemes and insurance markets boom as people seek to cover their health costs. Governments, meanwhile, focus on regulating large integrated health providers in a complex expanding global marketplace”.

    The final part of the jigsaw was applying these structures within the English NHS, and Stevens’ policy formation over the following years – the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 regional-scale Integrated Care Systems – must be seen entirely within this context. With, for example, UnitedHealth “sitting within the ICS in Somerset and acting as the engine room” of transformation, and with Centene playing the same role in Nottingham, such relationships will be pursued in as many ICSs as possible. The bulk of the English policy community is firmly behind this and as yet the process only requires legal ratification.

    This is Stevens’ legacy: that of helping to create a global regime of accumulation, and situating English healthcare within that. In this, and here we must agree with the HSJ, he has proved remarkably successful. Rather than viewing Stevens as unique, however, he should instead be seen as an exemplar of a widespread phenomenon, as throughout his tenure with NHSE, for example, he continued to work with the World Economic Forum on its Executive Board of the Value in Healthcare Coalition, alongside CEO’s from Humana, Kaiser Permanente, Takeda, and several others, to further the aims of transnational capitalism. But in terms of developing and promoting the central tenets of the NHS – those of universality, equity, and indeed ‘freedom from fear’ – he is as far removed from Aneurin Bevan as you can get.


  • The Framework for Procuring External Support for Commissioning. This was set up by Mark Britnell, then the Department of Health’s director general of commissioning and system management, and now short-listed to be Stevens’ successor as NHSE CEO. The policy community clearly
    expects some form of continuity.
  • See for example:
  • Hellander, I. ‘Health firms’ proposal: Use trade rules to force other nations to import our failed “health ecosystem”’. Physicians For a National Health Program, 4 October 2011.
  • Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.


    The recent buyout of a chain of London GP practices by the giant US insurer, Centene, prompted considerable media coverage last month with many Labour MPs and campaigning groups claiming the deal represented ‘privatization by stealth’. However, while this description may have been apt in 2005 it is now entirely outmoded as there is nothing covert nor slow about the process anymore. Instead, what is taking place – and has been for many years – is a full-blown, US-led takeover, by the same corporate interests, adopting the same instruments and organizational structures and effected by the deployment of key personnel within public office.

    In fact, primary care services are only a branch-line within Centene’s English ambitions; as in the US its core business will be managing as many of the regional-scale Integrated Care Systems (ICSs) as it can. And, as in the US, making huge profits from the role.

    Anyone doubting the speed and transparency of this takeover need only consider two recent headlines. On the 24th March the Health Service Journal (HSJ) reported that Timothy Ferris, the CEO of a leading US healthcare organization had been hired as NHS England’s new Director of Transformation and even, according to the journals’ editorial, a strong candidate to replace Sir Simon Stevens as head of the NHS in England. While undoubtedly the Director role is extremely important, it was thought that Ferris was unlikely to take such a pay loss unless something even bigger was in the offing. Even more tellingly, it was announced a week later that Boris Johnson’s new health ‘supremo’ was Centene’s UK Chief Executive Officer, Samantha Jones, and that she was entering government as expert adviser for NHS transformation and social care delivery.

    Having its UK CEO within the corridors of Number 10 is the culmination of several years of engagement with the NHS transformation agenda, and Centene’s business model also reveals a great deal about the nature of this agenda and its intended outcome.

    The corporation is unusual in that, unlike its main US competitors, UnitedHealth, Aetna, Anthem and Cigna, its revenues have been built almost entirely from public health programmes. While Centene’s annual accounts highlight its diversified portfolio of, among others, behavioral health management, correctional healthcare services, home-based primary care services, and telehealth, its core business is that of managing services for the poor and disabled, under what is known as Medicaid Managed Care (MMC).

    Collecting money from the state on a per-patient basis, the corporation promises to negotiate with healthcare providers for patient care. As it is allowed to keep any cost difference that may accrue, the incentive is to reduce such care to a minimum. While MMC existed before 2010, it was greatly expanded by the US Affordable Care Act – or Obamacare – in that year, and since then Centene has become the largest Medicaid insurer in the nation. Following its buyout of a major competitor, WellCare, in January 2020, it now commands 21% of this market and is the dominant presence in such key states as California, New York, Florida and Texas. Given the above-mentioned incentive to cut care, the company has inevitably left a trail of scandals, financial penalties and public outcry in almost every state it entered. (See attached examples)

    On the back of its rapidly growing wealth, in 2014, the company sought opportunities overseas, and whilst its first entry point was a 50% share in the Spanish Public Private Partnership company Ribera Salud, this was largely a stepping stone to the English NHS, where Managed Care was being pursued at a systemic level. Centene’s entry to the NHS in fact followed an event in October 2015 co-organized by NHS England’s New Care Model programme, led by Samantha Jones, and the NHS Confederation.

    At least 20 of these New Care Model vanguards – prototypes of the Integrated Care Systems (ICSs) – were introduced to Centene though it is not known how many engaged its services. They did include Nottingham and West Essex, and in the case of the former, the corporation designed the entire ICS over a two-year period beginning in early 2016. This involved an actuarial analysis – necessary for an insurance system – and 32 workstreams including those on patient pathways, population health management, social care integration, IT services, provider payment models, together with governance and contract design.

    Nottingham leaders were happy to boast of their affiliation with Centene and Ribera, saying they were now “standing of the shoulders of giants”. In subsequent events organized by the leading think thanks, the Kings Fund and Nuffield Trust, the corporation was described as a ‘system integrator’ or ‘transformation partner’ but little clarity was offered in terms of its future role.

    However, one presentation revealed far more than the policy community intended – and has since been removed – which described the corporation as an “impartial ICS manager, accountable for all services, data reporting, contracts, and other functions to manage the financial risk effectively”. It would also provide investment via capital and loan guarantees and risk-sharing would be involved. In other words, it would act as a middleman between public funding bodies and provider networks, be able to financially profit from the management of risk, and effectively be a Medicaid Managed Care Organization.

    It is clear that the US Managed Care model lies at the heart of the ICS Programme and of the entire NHS transformation process and is a model which systematically profits from the denial of care to patients, particularly the most vulnerable sections of the population. This is what the headlines should be saying, and this is the role that Centene is primarily seeking to replicate throughout as many ICSs as it can and why with Jones once again at the centre of government such ambitions will be rapidly realized. GP services, while very useful, will be small change in comparison.


    2. >
    3. It should also be pointed out that Centene has a large presence in both Medicare Advantage – the over 65’s equivalent of MMC – and in the Obamacare market exchanges.
    4. The list also includes: Arizona, Alaska, Georgia, Illinois, Kentucky, Michigan, and Mississippi.
    9. Nottingham City Clinical Commissioning Group, ‘NHS Clinical Commissioners. Core Cities’, 6 December 2016.

    Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.