tag:blogger.com,1999:blog-74626525460513004792024-03-18T03:04:06.039+00:00NHS VaultAnalysis of NHS and social policiesrichard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.comBlogger466125tag:blogger.com,1999:blog-7462652546051300479.post-84580722007621683882019-11-18T15:18:00.000+00:002019-11-18T15:18:38.408+00:00What the Computer Says<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-M4F8PO9hezA/XdKu5KZMZvI/AAAAAAAAAkM/UX-Z7GkLwx8e-vzzMGHeIZJ_ff-rGZDsgCLcBGAsYHQ/s1600/Fishlake.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="628" data-original-width="938" height="214" src="https://1.bp.blogspot.com/-M4F8PO9hezA/XdKu5KZMZvI/AAAAAAAAAkM/UX-Z7GkLwx8e-vzzMGHeIZJ_ff-rGZDsgCLcBGAsYHQ/s320/Fishlake.jpg" width="320" /></a></div>
<br />
<br />
This is not a Luddite attack on computers, in fact it is the opposite. This post is not telling you that computers are <i>bad</i>, but to tell you that they are just tools and that we have to avoid using them <i>badly</i>.<br />
<br />
Last week there were floods. So I looked at the <a href="https://flood-warning-information.service.gov.uk/warnings">Environment Agency website</a> to see if there were floods nearby. There were some 'red' areas and a lot of 'orange' areas. There was no key as to what red and orange meant, but there was a lot of orange areas. The reason is that there are several rivers nearby. Nothing more than nearby rivers and heavy rain. My wife travelled home through one of the red areas and she was not affected by flooding. That evening we had dinner with my son, and we had to drive through one of the red areas to his house in one of the orange areas. No sign of flooding, no sign of people evacuating from an orange area.<br />
<br />And yet there are flooded roads in the area. I was at a meeting on Thursday morning and most of the people were late because traffic was slow through flooded roads and some villages were cut off. My house is nowhere near a water course, but the end of my garden floods to 30 or 40 cm several times a year, and it was flooded last week. My garden is not marked on the Environment Agency as being at risk of flooding.<br />
<br />
So what is happening?<br />
<br />
It appears that the flood warning maps are based on what a computer has indicated using fairly basic information: <i>the computer says flood!</i> If the river level is higher than normal it is clear there is a danger of flooding and hence the lowest land near to the river is more likely to flood. The Environment Agency has contour maps and an algorithm has simply highlighted the land near the level of a water course. The maps come from satellite imagery and appear to be detailed - the red and orange areas appear to have jagged edges, as if being one side or other of the line is important. However, this is a very broad measure, and will not predict the most of the immediate flooding and will not necessarily give the extent of existing flooding.<br />
<br />
The people who were late to the meeting on Thursday drove along the dual carriageway which is <i>above</i> the fields it goes through. The flooding was caused by poor drainage, a blocked culvert, and heavy rain had accumulated on the road. My garden floods partly because it is lower than the gardens of my two immediate neighbours. But also because local planning guidelines are that rainwater from roofs should be channelled into a 'soakaway' rather than the main drains, and as an area of heavy clay with a high water table in the winter, a soakaway turns into a pond that overflows and flows into my garden.<br />
<br />
The Environment Agency maps highlight the <i>catastrophic</i> danger of flooding - <i>if</i> the river overflows <i>then</i> these are the areas most likely to be flooded. It does not reflect the blocked culverts on major roads or inadequate planning decisions. These are details you do not expect the Environment Agency to collate. Even so, it is not clear if the maps are accurate unless they also reflect the local flood avoidance actions being taken, including water management schemes like purposely flooding farmland. In other words these these maps appear to be detailed, but the actually <i>lack</i> the most important details.<br />
<br />
The reason why I mention this here is because it does highlight an issue of <i>big data</i>. This is a problem that often happens with healthcare commissioning where commissioners focus on the broader trends and pay no attention to the fine details of the data. The problem is that <i>the fine details</i> are actual people, and it is no comfort to a patient to learn that the service is designed for the <i>majority</i> of people if they are the minority that has been masked by commissioners looking at the broad trends.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com2tag:blogger.com,1999:blog-7462652546051300479.post-20396674021179300882017-01-04T12:52:00.002+00:002017-01-04T12:52:57.172+00:00This Tiredness Is ExhaustingI wrote this title three years ago, but I didn't get any further than the first paragraph, for reasons that will become apparent as you read this blog.<br />
<br />
For five years, from the beginning of 2010 to the end of 2014 I suffered from Chronic Fatigue. The fatigue was debilitating and, for someone who always made sure he was reliable, it made me thoroughly unreliable. I could not work because my fatigue meant I could rarely manage a full working day and often I had whole days when I could do no more than lie on my bed.<br />
<br />
For the record, I have had type 1 diabetes for 40 years. I was also diagnosed with an underactive thyroid more than a decade ago and have been taking thyroxine. The diagnosis of my thyroid condition came about when I mentioned to my diabetic specialist that I was feeling depressed and when he talked me through the symptoms he told me that it sounded like an underactive thyroid and ordered the tests that confirmed it. (Ironically, I have been told by other people with thyroid problems that their GP had misdiagnosed them as depressed and only received the thyroid tests when the antidepressants didn't alleviate the symptoms.) Both diabetes and thyroid problems can cause fatigue, but the fatigue is different to what I experienced during my five years of CF.<br />
<br />
As far as I remember the CF came on slowly, there was no trigger event after which I started to feel fatigued. However, I do remember events when I was far more tired than I should have been. For example on the <a href="http://nhsvault.blogspot.co.uk/2010/04/look-after-our-nhs.html">10th April 2010</a> there was a march in London to support public services. It was not a long march, it started at the park on the Embankment, along the embankment, went past the Houses of Parliament, along Whitehall and ended in Trafalgar Square. A short walk, but halfway round I had to sit down. I could not proceed until I had rested for 20 minutes. This was not me. I am the fidgety purposeful sort of person that does not rest until a task is completed. Yet here was I stopping halfway and resting. I don't do that, or at least, I didn't until then.<br />
<br />
<b>Misdiagnosis</b><br />
<br />
The fatigue got worse and so eventually I went to my GP. The first suspicion was that I was not taking the right thyroxine dose. This involved changing the dose and having blood tests six weeks later to see the effect of the medicine. An overdose of thyroxine (T4) is not good for your heart so one of the tests is for a hormone - thyroid stimulating hormone (TSH). If your T4 levels are low, you produce TSH, so high levels of TSH show that you need more thyroxine. Conversely, low levels of TSH indicate that you may be taking too much thyroxine. (Such a feedback loop appeals to my physicist training: you raise or lower the thyroxine does until you achieve 'normal' levels of TSH and T4. The problem, of course, is determining what 'normal' is.)<br />
<br />
In my case my values of T4 and TSH showed that the existing dose was right, but the GP I saw at that time clearly wanted to pursue it further and suggested that I may need triiodothyonine (T3) therapy. He told me that although the medicine could be prescribed by the NHS, the endocrine consultant at the hospital (who was my diabetes consultant) was not convinced about its use and so if I wanted to use it I would have to see another consultant. Since this was after the 2010 election, and we were in the new world of Lansley's NHS, the GP suggested I could see the other consultant privately. I was a patient too fatigued to work, and earn, so I did not have the money to spend money on healthcare that I thought was not necessary. This, however, was the new NHS. I decided not to see that GP again: he thought he knew more about endocrinology than the endocrine consultant and wanted to promote private healthcare over the NHS.<br />
<br />
I tried another GP at the same practice. This time my diabetes was the barrier to diagnosis. The GP looked at my notes, saw that I had type 1 diabetes, looked at my HbA1c and told me: "Your blood sugar is a bit high, did you know that high blood sugar can make you tired? Try to get it lower." When I tried to explain that the blood sugar was not high (want to see high? try taking bovine insulin for ten years with only a urine chemistry set to monitor the treatment) he would not listen to me. When I tried to explain that my blood sugar was high because I was not taking exercise, so it was the fatigue that was making my blood sugar high. I was not fatigued because of the blood sugar, the fatigue was making my blood sugar high: he just dismissed the idea. Another GP I will not see again.<br />
<br />
My HvA1C at that time was in the mid-50s. The NICE recommendation for a Type 1 diabetic is to have a value less than 48 mmol/mol. My diabetes consultant was not worried with the figure, and just gently encouraged me to try and get it lower. The GP, however, did not understand Type 1 diabetes and thought that a few points over the NICE level was 'clearly' a source for my fatigue. I have a letter when I was 22 that the diabetes consultant I was seeing then wrote to my GP. I was going through what the consultant called "a holiday from diabetes", (he told me that it often happens to young people). At 186cm my weight dropped to 64Kg (BMI 18.5). The blood tests (in modern units) were: my spot blood sugar was 30 mmol/l (it should be about 6) and my HbA1C was 180 mmol/mol (it should be less than 50). Was I tired then? No. I was buzzing. I was studying for a PhD in semiconductor physics, doing long hours in the lab and library and travelling a lot. Clearly when I was first diagnosed (at 11) with T1D I had a much higher HbA1c, because I certainly felt fatigue then.<br />
<br />
So a GP refusing to listen to me because my HbA1C was a few points over the 48 recommended says a lot about his ignorance of diabetes and his disdain for patients. Neither of these GPs looked at my notes, and neither saw that (at that point) I had had Type 1 diabetes for 35 years and hence <i>must</i> have had a period of high blood sugar and the fatigue, and then asked me if the fatigue I was suffering was like that? No. As far as they were concerned, there was only one diabetes 'expert' in the room and it wasn't me.<br />
<br />
Indeed, during a following appointment with the diabetes specialist I described the fatigue and he said my blood sugar - while not desirable - was not high enough to cause the fatigue. The GPs were blinded by my existing conditions. Over several months the diabetes specialist ordered various tests - adrenal, testosterone and even a sleep study - but none came up with a conclusive explanation for the fatigue. Finally he told me that he thought it was Chronic Fatigue Syndrome, and then he retired. The locum specialist was not particularly interested in the fatigue, and so I never really did have any help for the condition.<br />
<br />
<b>The Fatigue</b><br />
<br />
It's easiest to describe the fatigue with a typical 'good' day. I would wake, as normal, at 8 not feeling particularly tired (I usually felt that I had benefitted from the sleep). I would do light work in the morning, mostly reading. By lunchtime I would start to feel physically tired and so in the afternoon I could not do any reading and - trying to make sure I kept active - I would do something in the garden, potter in the greenhouse, or do some weeding. By four the physical tiredness would get unbearable. I would have a headache and all my muscles ached, and I would barely be able to stay stood up. My brain would have slowed so much that any decision making was impossible. So I would take some ibuprofen and go to bed for a couple of hours. This happened every day, for five years.<br />
<br />
During the time I had Chronic Fatigue I found that I was cold. I took to wearing tracksuit trousers in bed because I was so cold, and I wore two pairs of socks (one over the other) every day, even in the summer. I had extra blankets over the duvet. <i>I was just so cold</i>. Now I am recovered I am no longer cold and I wear just one pair of socks at a time!<br />
<br />
I found that the main problem was not the physical tiredness, it was the mental tiredness. This was why it was so different to the fatigue from high blood sugar or lack of thyroxine. The CF slowed down my brain considerably. It got so bad that my wife said she was worried that I was developing dementia (in my 40s). I could not hold a conversation with my (sharp witted and intelligent) adult children, I was typically minutes behind the discourse.<br />
<br />
Before the fatigue I was a technical book writer and speaker. Over a period of 10 years I had written 6 books each over 500 pages, 150 articles (I had two monthly columns) and spoke at four or five conferences a year. I went from writing 500 page books to struggling to write 500 words. When you write a book - even a technical book - you have to tell a story, so each chapter has to lead the reader through that story. Although I would have an outline to write to, the chapter would be in my head until I had committed it to the computer. I would know where I was coming from and where I was going, and have a rough idea how I was going to get there. While writing the 'journey' would change and I would make adjustments to how I would get to the final point.<br />
<br />
In my job I would read many books, and I used to review technical books for publishers. If needed, I sometimes would speed read technical books, and I could read a 500 page book in a couple of days (I only did this occasionally - I found that I took in the book sufficiently well to be able to know the content of the book and where to find passages, but I really didn't get an understanding of the subject which I would have done if I read the book thoroughly).<br />
<br />
With Chronic Fatigue I lost that ability entirely. If I wrote more than a few hundred words I would lose sight of the purpose of what I was writing. I have many abandoned articles on my hard disk where I clearly had an idea, but after working on it for a few hours I had lost the impetus and the inspiration and often I just forgot what the article was about. Reading was no better. I could not read for more than a hour at a time at best. If I was reading a complex subject I would often have to read sections several times. If the article involved several concepts I would be completely lost, I could barely hold one concept in my mind at any one time.<br />
<br />
<b>Managing The Fatigue</b><br />
<br />
One of the main problems with Chronic Fatigue is that if you do any exertion - mental or physical - then it makes you overwhelmingly tired for days after. You cannot avoid those situations, so you have to learn how to manage them. I would avoid anything more than a half day meeting if I could. If the meeting was in the morning I would rest the day before and then when I got home after the meeting I would go to bed for the entire afternoon. If the meeting was in the afternoon, I would rest the morning before and then when I got home after the meeting I would go to bed. If the meeting was for an entire day then I would rest the day before but I would know that the day after I would be incapable of doing anything other than lie down.<br />
<br />
You may think that the "treatment" for Chronic Fatigue is sleep, and so all I needed to do was to sleep more: go to bed earlier, wake up later. Unfortunately, it's not that easy. Going to bed earlier just results in sleepless hours, and if anything it makes you more tired. The reason why I would do some light physical exercise when I started to feel tired is that if I tried to sleep, I would not be able to. Although the Chronic Fatigue makes you feel tired, your body has other criteria it uses to determine if you can sleep. I spent many hours just staring at the bedroom ceiling, unable to listen to the radio (because I was too fatigued to follow the programme) but unable to sleep. I can tell you that the tiredness from Chronic Fatigue is exhausting. I learned that taking some exercise is important, it helps you sleep.<br />
<br />
Rather than taking exercise (or working) until I was tired, as I do now, I had to do as much exercise (mental or physical) as I knew I could do and half a day's mental activity was my limit. This takes discipline but you soon learn that you have to do this because if you don't, you will pay with days of excessive fatigue. Conversely, you also know that you have to do <i>something</i> otherwise you cannot sleep when you need to.<br />
<br />
Since I could not work I decided that I would volunteer the time when I was not tired to the local NHS. I was already an elected FT governor and I volunteered to be part of the local CCG's patient group. This involved meetings, maybe, half a day a week. Although I tried hard to be reliable, volunteering means that there is some leeway in your expected reliability. It also helped me because I had regular commitments. The temptation with Chronic Fatigue is to simply 'take to your bed' and hope the condition goes away one day. Although the regular meetings tired me out, they made sure that I did do <i>something</i>.<br />
<br />
<b>Going Forward</b><br />
<br />
My Chronic Fatigue stopped fairly suddenly: one day I found that I did not need the afternoon nap. The first day that it happened it was a bit of a surprise, but when I found I didn't need the nap the next day, it was clear that something had changed. Over the following year I had a few 'relapses', which I think was me being careful and reacting to normal over exertion by immediately going to bed. I no longer get the 'post exercise malaise' the exhaustion that could last for days after doing some exertion more than you are used to. I have not had the flu-like symptoms of headache and muscle ache since then.<br />
<br />
Now when I go to my FT or CCG meetings I cycle the 10 mile round trip: as I explained to one of my colleagues, 'if you can do it, you should'. And I am writing a technical book, its quite a grueling schedule: 400 pages, ten chapters, one chapter every two weeks. It is such a brilliant feeling to be able to think again, to be able to exercise again.<br />
<br />
And my HbA1c. Its still in the mid 50s, my diabetes consultant is still gently encouraging me to get it lower, but is not worried about the figure.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com1tag:blogger.com,1999:blog-7462652546051300479.post-35037757160871945482016-12-15T21:12:00.006+00:002016-12-15T21:12:52.470+00:00Enough is Enough - Burnham's Speech on Social CareThis is worth reading, as well as Dan Poulter's useful intervention and Jeremy Hunts disgraceful attempt at political point scoring where he fell flat. Burnham spoke during the Opposition debate on Social Care on the <a href="https://hansard.parliament.uk/commons/2016-11-16/debates/DFB284D3-A7C7-477E-A7E3-95E8C0244A82/SocialCare#contribution-0755B593-05CA-4CAF-9117-BBCEE3A055E3">16 Nov</a> and its likely this will be the most important speech he will do in the House, with the Mayoral vote in Manchester next year. He really should have been the Secretary of State for Health longer.<br />
<br />
<b>Andy Burnham (Leigh) (Lab) </b><br />
<br />
I congratulate my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley)—my good friend—on an excellent speech. She has no equal in this House as a champion for older people and their carers. Her speech, unlike the speech by the Secretary of State, was firmly rooted in the real world.
<br />
<br />
This is the century of the ageing society. Caring for people as they live longer lives is the greatest public policy challenge of our times, but for years Parliament has shown itself to be unequal to that challenge. I want to speak today to tell the story of the efforts to reform social care over the last decade, because I want the facts to be on the record, so that people can understand what happened and vow to do better. The story explains the mess we are in today. To be honest, it is quite a shocking story of partisan point-scoring and, worse, political cowardice, which have seriously failed millions of older and disabled people.
<br />
<br />
The story started nine years ago at the spending review in 2007. I was Chief Secretary to the Treasury at the time, and at the insistence of the Treasury I gave the Department of Health the condition on its spending review settlement that it would conduct a root and branch review of the funding of social care. There was a recognition, even in the Treasury, that if we allowed the situation to continue, it could, in the end, damage the national health service. Quite clearly, the funding was not sustainable, and if social care was left to collapse, it would drag down the NHS with it.
<br />
<br />
The urgency of such action had been recognised almost a decade earlier, in 1999, when a report by a royal commission on the matter recommended free personal care, paid for by general taxation. It did so for the reason that if we pay for free preventive care in people’s homes, those people do not end up in hospital and costing us all more. Nothing was done, and by 2007 the need for reform was urgent. So between 2007 and 2009, a huge amount of detailed modelling work was done and options were looked at.
<br />
<br />
When I arrived in the post of Health Secretary in 2009, the work had come to a head. The analysis supported a clear conclusion that radical reform, rather than patching up, was needed. Department of Health officials supported the Treasury analysis that there would be risks to the NHS if social care was allowed to decline. A Green Paper was published in July 2009, and the idea of a national care service was first put forward. The thinking was that only by bringing the systems together, with a system of clear national entitlement, would we be able properly to move towards integration. The maintenance of two entirely differently funded systems—one free at the point of use and the other means-tested and charged for—would mean that they would never be able to speak the same language and there would always be barriers to integration.
<br />
<br />
I was ready to grasp the nettle, because it was clear to me that the NHS was facing a decade of lower funding from 2010 and 2020, and that one of the ways it could cope with that was with the efficiencies we could unlock through properly and fully integrating health and social care and by moving from a hospital-based medical model to a person-centred social model of care starting in the home.
<br />
<br />
This is where things went wrong. Picking up that I was ready to up the momentum for reform, the then shadow Health Secretary, Andrew Lansley, approached me in Portcullis House just before Christmas 2009 and asked me for cross-party talks. I thought about it, but I agreed. I thought, as my hon. Friend the Member for Barrow and Furness (John Woodcock) has suggested, that we should take the issue out of party politics, which would be better for everybody. We had a couple of meetings, in which we went round the issues. I favoured the more ambitious, comprehensive reform of paying for social care on the NHS principle—that everybody contributes, but everybody is covered for their care needs and has peace of mind in later life. Andrew Lansley wanted a more voluntary system, in which the insurance market would come up with solutions. That was where we left it.
<br />
<br />
Then a bombshell was dropped in February 2010: the poster saying, “Now Gordon wants £20,000 when you die.” I very vividly remember the day when it landed. I was told that Andy Coulson had put pressure on Andrew Lansley to do it, and that he did not really want to, but felt he could not say no. I do not know whether that is true, but I know that the Conservatives, who asked me for cross-party talks, betrayed the confidence that I gave, and they have never seen fit to apologise for that. The point is not about the personal political damage that that did, but about the chilling effect the poster had on the social care debate. It instantly killed any talk of radical reform, and it actually had a deadening effect for the rest of the following Parliament—the last Parliament—during which no real progress was made.
<br />
<br />
That brings me to what happened after the election, when, as shadow Health Secretary, I challenged the Government from the Opposition Front Bench about the poster that they had put out during the election saying that they would cut the deficit, not the NHS. I made the point that if they did so, they would in effect cut social care: if they prioritised NHS spending within the reduced envelope, that would have devastating consequences for social care and would in the end come back to affect the NHS.
<br />
<br />
From the Dispatch Box at every Prime Minister’s Question Time, the then Prime Minister used to quote me as claiming that it would be irresponsible to give the NHS real-terms increases, but he never commented on the second part of what I had said, which was that it was irresponsible to do so if we were cutting social care. I did say that, and it was irresponsible to social care in the way they did to pay for their commitment to the NHS. Social care was cut by 9% during the last Parliament, with 400,000 vulnerable people losing support in their homes. Those people ended up in A&E or trapped in hospital beds, piling pressure on the hospital system.
<br />
<br />
<b>Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)
</b><br />
<br />
I pay tribute to the right hon. Gentleman—this may be my last chance to do so—for the work he has done as a Member and wish him well in his future career if he is successful in his election. Does he agree that the chilling effect of the outcome of those conversations before the election and perhaps the betrayal of his confidence, as he puts it, is that there could no longer be a rational conversation about properly funding the health and care system through any form of taxation? That is the problem that has emerged, and perhaps the best way to fix it is through general taxation.
<br />
<br />
<b>Andy Burnham
</b><br />
<br />
I am very grateful to the hon. Gentleman for his intervention and the spirit in which he made it. He is absolutely right: that set everything back and meant that there was no possibility of a cross-party approach. There will have to be such an approach if we are to fix social care and, indeed, to give the NHS what it needs, because they will both need more funding during this Parliament. That is the real shame. I did not make my point about Andrew Lansley for political reasons; I just want people to understand what happened, so that the current generations of politicians might do something different.
<br />
<br />
The answers we have since had from the Government are wholly inadequate. We have heard today that the precept does not raise enough money, particularly for poorer councils. It is no answer; in fact, it just cynically devolves the responsibility for the whole issue to local government, even though councils did not create the problem. I still favour an all-in system. I will say it: I favour a system in which we ask older people to pay a set contribution, so that they have peace of mind in later life, with all their care costs covered.
<br />
<br />
<b>Mr Jeremy Hunt
</b><br />
<br />
I am listening very carefully to the right hon. Gentleman. In the spirit of wanting to rise above party politics, will he agree that it was totally wrong of him to suggest at any stage in the last Parliament that the Government wanted to privatise the NHS, when we have never had the intention to do so? It was wholly irresponsible to scare the public about that.
<br />
<br />
<b>Andy Burnham
</b><br />
<br />
In a week when Virgin Care is taking on a huge community care contract, I do not think the Secretary of State should be making that point—particularly the Secretary of State who privatised ambulance services in Greater Manchester. I honestly do not think we need to go there.
<br />
<br />
The point that I am making is about funding social care. The Conservatives claimed that we were introducing a new inheritance tax. Do people not understand that just 3.4% of estates in this country attract inheritance tax? Why is that? Because the vast majority of estates are whittled down by the costs of care—tens of thousands of pounds, or hundreds of thousands of pounds for some people. That is not fair and it is not sustainable. We must be able to do better.
<br />
<br />
I feel so strongly about this because I saw my grandmother go through the care system in England 20 years ago and, frankly, it was nowhere near good enough. I arrived here saying that I would do something about it. I tried to do something about it, but we have not got anywhere near a solution to the scale of the challenge. People will need to put party politics aside and find common ground. The point scoring and failure to grasp big issues have led to a situation where people have low regard for this place.
<br />
<br />
We are left with a malnourished, privatised care system in England that is sinking lower as we speak. A culture of slap-dash 15-minute visits is entrenched, in which staff do not get properly treated, trained or respected. Standards in care homes have slipped even further, and stories of neglect and abuse abound—we hear them all the time. Countless vulnerable people and their families still have to pay these cruel dementia taxes, which have risen under this Government, losing everything they have worked for and going into later life with everything on the roulette table: home, pension, savings—the lot. That is not the care system we should have in 2016 in this country. At what point are we going to say, “Enough is enough,” and actually do something about it?
richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-90602907705396995852016-08-29T22:17:00.001+01:002016-08-29T22:47:19.423+01:00Abbott should stop acting like a Tory and be more like BlairOn Friday, 26th August, Diane Abbott was interviewed by Shaun Lay on the Radio 4 news programme the <a href="http://www.bbc.co.uk/programmes/b07pd4z6">World at One</a>. (The podcast can be downloaded <a href="http://open.live.bbc.co.uk/mediaselector/5/redir/version/2.0/mediaset/audio-nondrm-download/proto/http/vpid/p045yl73.mp3">here</a>.) The most interesting thing was that she didn't promise any extra money for the NHS. In fact she flatly ruled it out. The interviewer, Shaun Ley, pressed her on this:<br />
<blockquote class="tr_bq">
“is your only option to say that we actually need to spend more on the NHS as a proportion of GDP, is that fair?” </blockquote>
to which Abbott replied<br />
<blockquote class="tr_bq">
“we certainly aspire to maintain what we spend on the NHS in a proportion of GDP”</blockquote>
So Ley pressed her again:<br />
<blockquote class="tr_bq">
“you say that you do not want any increase in co-payment, you say that you do not want to change the system of funding, then you’ve got to spend more?”</blockquote>
And Abbott refused to promise more funding<br />
<blockquote class="tr_bq">
“you’ve also got to save money, as I’ve explained to you”.</blockquote>
Abbot refuses to increase spending on the NHS in spite of the fact that the NHS is clearly underfunded. The government says that the NHS “overspends” whereas it's clear the NHS is not funded sufficiently to cover the demand. Labour under Corbyn are now agreeing with the government on the level of NHS funding. This is probably not surprising since John McDonnell agreed with Osborne’s ludicrous Fiscal Responsibility Act. Abbott, who is possible the least informed of any shadow minister ever, trotted out unevidenced tripe. She gave three ways that the NHS reorganised under Corbyn would “save” money.<br />
<br />
First, PFI. Abbott said:<br />
<blockquote class="tr_bq">
“Every year for the coming decade we going to be spending nearly £2bn on PFI and I’ve spoken to CEOs of big London teaching hospitals who are talking about buying out their private finance initiative arrangements because it would be much cheaper at current levels of interest.” </blockquote>
Ley challenged this:<br />
<blockquote class="tr_bq">
“to do that will they have to be able to borrow from elsewhere, or will the Treasury have to pay for it?” </blockquote>
Abbott replied that<br />
<blockquote class="tr_bq">
“the CEOs I have been speaking to are talking about borrowing money as an institution”.</blockquote>
I won’t defend PFI, it is an expensive mechanism for many
reasons, but Abbott is clearly out of her depth on PFI. There are several issues
here. Let’s start with her claim that getting rid of PFI would “save” £2bn. The
only source for this figure appears to be an article in <a href="http://www.telegraph.co.uk/news/nhs/11748960/The-PFI-hospitals-costing-NHS-2bn-every-year.html">The Daily Telegraph</a> in July 2015 – a year ago.<br />
<br />
The Telegraph says<br />
<blockquote class="tr_bq">
“The scale of the PFI charges is contained in official figures compiled by the Department of Health and obtained by The Telegraph.” </blockquote>
Unfortunately the Telegraph do not provide a link to these “official figures” and searches on the Department of Health website does not yield any results. Abbott is quoting figures a year out of date that clearly she has not checked.<br />
<br />
Up until April 2016, there were two financial regulators: Monitor for Foundation Trusts and the NHS Trust Development Agency (TDA) for NHS Trusts. In April 2016 these were amalgamated into one regulator called NHS Improvement. Two thirds of trusts are Foundation Trusts. Monitor provides annually consolidated accounts for all Foundation Trusts. The <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/544144/Consolidated_NHS_FT_accounts_2015-16_corrected.pdf">consolidated accounts for 2015/16</a> says that the capital repayment payments for PFI were £185m and the interest paid was £363m. So the total PFI finance costs for Foundation Trusts was £548m. This is in comparison to the total PDC dividend payments of £544m for Foundation Trusts (PDC is an alternative, government-backed, finance scheme).<br />
<br />
The Trust Development Agency did not issue consolidated accounts, but there is no reason to think that NHS Trusts have larger amounts of PFI per trust than Foundation Trusts. NHS Improvement has released the <a href="https://improvement.nhs.uk/uploads/documents/BM1653_Q4_sector_performance_report.pdf">2015/16 fourth quarter performance report</a> which includes both the aggregated figures for Foundation Trusts and NHS Trusts. This report says that in the 12 months to the end of March 2016 PFI costs (capital repayment and interest) were £898m (compared to £839m for PDC).
<br />
<br />
Thus we can assume that the finance cost of PFI to the NHS is around £900m a year.<br />
<br />
So where does the Telegraph get a figure of £2bn from? The PFI arrangement is usually that a private company builds, and then operates the building on behalf of the NHS. The trust owns the building on effectively a lease mechanism. The “operates” comes in several forms, it could be just the maintenance of the building, but it could include services like cleaning, catering and car parking. These are all services that must be provided, and without the PFI contract, a trust would either have to provide these services themselves, or contract a private provider. (Under a law passed by John Major, there are VAT benefits for a trust to outsource such services to a private contractor.)<br />
<br />
The important point is that there will still be a cost, even if a trust provides the services itself. The extra billion that the Telegraph quotes is presumably the service charges. For services the vast majority of the costs will be staff, so it is unlikely that there will be much scope for savings, unless there are staff losses or pay cuts. If there is a saving, it will be in the region of millions over the country rather than billions.<br />
<br />
The finance part of PFI involves borrowing money, which can be done cheaply now by the government. However, note that Abbott did not pledge government funding to “buy out” PFI she specifically said that the trusts would have to borrow the money themselves, and this will be at a higher rate than the government would pay.<br />
<br />
One English trust, Northumbria Healthcare Foundation Trust, has "bought out" its PFI, however, they didn’t go to the open market to borrow the money. Instead, Northumbria obtained a loan of £114m from Northumberland County Council and the council borrowed this money from the Treasury’s Public Works Loan Board. In effect this is a government loan in a roundabout route. Abbott has ruled out a Labour government financing such “buy outs” of PFI, so Northumbria is not the model she will use. Even so, the loan of £114m would yield a saving of just £3.5m a year to the trust, and if this is scaled up to all PFI schemes, such savings are unlikely to provide savings of “billions”.<br />
<br />
Abbott's policy that trusts should make their own arrangements to "buy out" PFI schemes is at odds with many of Corbyn's ardent supporters, who demand that the government should either buy out the schemes or even cancel them altogether. Since Abbott is saying that trusts should borrow to buy out PFI schemes raises the question of whether anything has changed at all since a trust may borrow from a bank, who may be part of a consortium providing PFI services.<br />
<br />
Morally, one has to question “buying out” PFI loans. If the PFI companies have been “swindling” the NHS for decades there is no moral case to simply reward them by buying the loan off them. Morally, a radical government would seek redress for such “swindling”. Abbott is not suggesting this, which implies that she really does not regard PFI as being as bad as she is saying in public. What is clear is that there are unlikely to be savings of billions in buying out PFI schemes.<br />
<div>
<br /></div>
Abbott’s second point was agency staff. She told Ley<br />
<blockquote class="tr_bq">
“we are spending £3.6bn on agency staff, there is no need for the health service to spending that on agency staff.” </blockquote>
Here, she is marching in lock step with Jeremy Hunt, and like Hunt she will fail. There are numerous cases around the country where trusts have breached Hunt’s agency cap because trust boards have recognised that care would be unsafe with their staff level without agency staff. Removing agency staff does not solve the workforce problem. The staff shortage problem was caused by the Coalition. Osborne froze NHS pay rises and Lansley abolished the Strategic Health Authorities which were responsible for training. Although Lansley created new organisations to manage the funding of training of staff (Health Education England and Local Education and Training Boards) there was a hiatus in workforce planning. Further, Osborne made this even worse by announcing the abolition of the nurse bursary to pay for nurse training.<br />
<br />
Abbott could have used the interview as an opportunity to attack the bursary policy and the woeful workforce policy of the Conservatives, but she didn’t. Instead, she just echoed what Hunt has already said.<br />
<br />
The third area that Abbott claimed she would save money was on medicines and in particular Abbott chose to stigmatise diabetics. Abbott told Ley:<br />
<blockquote class="tr_bq">
“And then there is the question of drugs, some of these proprietary brand drugs there is a mark up of times seventy three, so we think that there is money to be saved. And I think in the long term we do need to look at public health, we do need to look at prevention. Ten percent of NHS drugs bill goes on drugs for diabetes. We think public health issues like diabetes, like obesity, exercise and alcohol could in the long run bring down costs of the NHS as a whole.”</blockquote>
On the question of drug prices, this presumably comes from a report by The Times earlier this year that claimed that there was a “loophole” that allowed branded drugs to make such large mark-ups (accompanied, of course, by cherry picked examples). Abbott mentions “proprietary brand drugs” and presumably she means branded drugs that are dispensed when a chemically identical generic drug can be dispensed instead. (Some drugs are still under patent, so a generic is not available.)<br />
<br />
While it is possible to improve the prescribing of generics, the NHS has actually done very well so far. <a href="http://www.kingsfund.org.uk/blog/2015/07/how-much-has-generic-prescribing-and-dispensing-saved-nhs">Prof Appleby</a> (then) at the Kings Fund estimated that the proportion of proprietary drugs has fallen by a third since 1976. If this change had not happened then the cost of prescriptions (taking into account that the volume of prescriptions has increased four times) would be twice what they are now. Of course, savings can always be made, but the likelihood is that the easiest savings have already been made, and the next lot of savings will be a lot harder.
<br />
<br />
I do not think that Abbott has any coherent plan as to make more savings from switching from branded to generics, I think she is making this point because it is part of Corbyn’s campaign against Owen Smith because of his former employment by Pfizer. Note that Abbott does not attack the politically created, but non-evidenced Cancer Drug Fund. She does not supply any new innovative ideas, like NICE. No, she attacks branded drugs because Smith once worked for Pfizer.
<br />
<br />
After attacking the price of branded drugs, Abbott then goes on the offensive against “diabetics”. She says:<br />
<blockquote class="tr_bq">
“ten percent of NHS drugs bill goes on drugs for diabetes. We think public health issues like diabetes, like obesity, exercise and alcohol could in the long run bring down costs of the NHS as a whole”. </blockquote>
While Abbott is right that “diabetes” does cost the NHS a large amount of money she makes the typical second rate politician error of not stating the type of diabetes. There are two: type 1, which is an autoimmune disease and cannot be prevented or cured, and type 2 that has some association with obesity, but is not entirely caused by obesity. Nine tenths of diabetics are type 2, and the NHS is keen on trying, where it is possible, to prevent people developing type 2 diabetes. However, blaming type 2 diabetics for the financial state of the NHS is something that <a href="http://www.mirror.co.uk/news/uk-news/dr-phillip-lee-conservative-mp-1458840">right wing politicians</a> do, now Abbott is joining in.
<br />
<br />
A tenth of diabetics are type 1, and there is little that can be done about reducing the cost of their treatment. Even if Abbott is claiming that she can save money on treating type 2 diabetics, she is being misleading. There is a growing obesity problem, and obesity may lead to type 2 diabetes. However, the age demographics of current type 2 diabetes is that it is a condition of the elderly. It is being old that is the cause of their condition. There are ways to make the treatment of type 2 diabetes in older people safer and more effective (and consequently, save money) but Abbott did not mention these ways and I am sure she does not know about them.<br />
<br />
Everything about the interview screamed: a clueless politician briefed by an ignorant researcher. Spouting nonsense loses the confidence of the public, and worse, it threatens Labour's rightful claim to be the party of the NHS.<br />
<br />
Abbott says that she will keep to the Tory NHS funding levels. This is appalling; the most effective way of destroying the NHS is to keep to the damaging flat funding policy of the Tories. Abbott needs to acknowledge that in 1997 Blair promised to raise the funding of the NHS every year in real terms. And on this Blair won a landslide. Then in 2000 Blair pledged to raise NHS funding as a proportion of GDP to European levels. And on this Blair maintained an enormous Commons majority in the 2001 election.<br />
<br />
These figures are clear: Abbot should stop acting like a Tory, and should be more like Blair.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com4tag:blogger.com,1999:blog-7462652546051300479.post-7597740982605573562016-06-28T17:09:00.002+01:002016-06-28T17:09:47.797+01:00Second Brexit Referendum: a Positive ResolutionIt is clear that the the <b>next</b> Prime Minister after Cameron will have a tough time deciding whether to recommend to Parliament that the UK should make an Article 50 notification (of the Lisbon Treaty) to the European Council. The current timetable is that the Conservatives intend a quick election campaign, appointing their leader (and hence the Prime Minister) by the beginning of September.<br /><br />If the UK goes into recession then there will be political pressure <b>not</b> to invoke the A50 notification which will be seen as an action that could make matters worse. (Technically the country cannot go into recessions because the definition is that there has to be two quarters of negative growth, and September is less than two quarters away, so I should say "if it looks like the country is heading into recession".)<br />
<br />
In the few optimistic moments I have had over the weekend I have come up with this scenario.<br />
<br />
The UK Parliament will have to approve the A50 notification, and Parliament is about to go into summer recess and does not meet again until September, then pauses for the party conferences, and real business starts in October. So the A50 notification cannot be done before October. At which point there will be:<br />
<br />
<ul>
<li>a new Prime Minister (which could be pro-Remain May or Osborne); </li>
<li>a summer of the civil service planning for how long, and how many resources, it would take to disentangle EU laws from UK law (most likely: a long time and a lot of people that they do not have); </li>
<li>a summer of MPs talking to businesses and communities and finding out the real effect of Brexit (a lot of scare stories will be gathered); and </li>
<li>the party conferences allowing MPs to get the opinion of party members. </li>
</ul>
<br />
After all of this, a good many of the <i>"the people have spoken"</i> MPs will think <i>"maybe if we can get a better deal then the people will think again"</i>.<br />
<br />
Since it was clear that immigration was the top line issue during the referendum, the "better deal" will have to be about immigration from the EU. We know that it is a red line for the EU: access to the single market, inside or outside the EU has to have an agreement on free movement of people. That won't change.<br />
<br />
In my opinion, immigration is good, but you have to have the infrastructure for the increase in population. So the "better deal" I suggest is that the EU will have to agree to pay for the building of this infrastructure: schools, health centres, hospitals, as well as social housing, in areas with a large influx of EU migrants. This policy would cover the entire EU, not just the UK, so it could get the approval of all countries. Such a policy would mean that EU migrants will no longer be seen as a drain on public services, but will be seen as the reason for the improvement of public services. A positive policy, and a second referendum will approve it, in my opinion.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-32009823030533686682015-11-08T18:34:00.001+00:002015-11-08T18:34:34.153+00:00Unbiased JournalismIt doesn't happen. It cannot. Journalism <i>always</i> contains some bias. I have written for a living since 1996 (books, journal columns, features, and more recently, training courses and presentations) and I can confidently say that, from my experience, journalism is never unbiased.<br />
<br />
We know that the national newspapers have their own overt biases. When we pick up a newspaper we know their political leanings (they <b>all</b> tell us who to vote for at the General Election, so of course they <b>all</b> have a political bias). We also know, in general, how a newspaper will react to a news story and we make allowances when we read the article and subconsciously strip out the opinion and bias to extract the news. (However, to be frank, the Daily Express support for Junior Doctors surprised me).<br />
<br />
Journalism always has a bias. Journalists on the Nationals usually excuse themselves by giving a quote from someone who is known to have an opinion contrary to the main opinion they are reporting. I find that lazy and inadequate. A formulaic quote from a Press Officer at a government department, or a public body, can never be regarded as a balanced response. For a start, a Press Officer is, by definition, detached from the issue, they are not responsible, nor are they necessarily knowledgeable of the subject. A Press Officer is simply another journalist, <i>poacher-turned-gamekeeper</i>: a journalist giving a quote to another journalist. Worse, a Press Officer is merely parroting the statements from the person who the article's journalist <b>should</b> have interviewed, so why haven't they?<br />
<br />
Some journalists have suggested that any subconscious bias in their copy is removed by editing. I find this hard to believe, particularly if an article is written by a "specialist journalist". As their title suggests, specialist journalists are unique at the publication. Other journalists editing the piece will not have adequate knowledge of the subject to be able to determine if there is "bias" in the article. At most publications, the editing that occurs is more about the publication's style guide, grammar, spelling and legal liabilities, than about the subject of the article.<br />
<br />
Most of my career has been writing for technical journals. I have never used the term "reporter" to describe what I do, and I rarely use "journalist". The reason is because I wrote columns and features and refused to report on the carefully created press releases, or press conferences, from the vendors of the products I wrote about. More recently, I have worked for those vendors and have written such press releases (or "white papers" as the vendor insists on calling them) and feel justified that I ignored them when I wrote for the journals. I always called myself a "writer" because I knew that everything I wrote was my - well researched - opinions, and I was employed because the journals' editors trusted my opinions.<br />
<br />
These journals always had a rather unhealthy relationship with the dominant vendor because although they were subscription publications, and had some income from their readers, a significant proportion of their advertising came from the dominant vendor. Thus, the articles were about the products of the provider of the journal's main income. That is a difficult situation to manage and can lead to a form of hagiography, or worse, simple churnalism where press releases are regurgitated. This is not how I worked.<br />
<br />
I always made sure that whenever I wrote an article I always went back to first principles: try the product myself and write about what I experienced, and not what the vendor said I <i>should</i> experience. Further, if I was critical - which I usually was - I would say why there was a problem with the product, but more importantly, how the reader could work around the issue. The vendor was generally happy because I was helping them to improve their product and provide ways to keep their customers using their product. I could not do this by merely reporting what the vendor said because the vendor rarely wanted to publicise flaws in their product.<br />
<br />
Sometimes (but not often) I would be contacted by people who worked for the vendor and they would indicate issues they were concerned about. Whistleblowing is an overused phrase, but I guess it's possible to say that such people were "whistleblowing" on the product. A journalist on a national newspaper would have reported such issues as "concerns from an unnamed source". I never did this, because I could see that there was nothing to be gained by reporting second hand concerns. If an issue was reported to me, I would replicate the issue, sometimes spending a large amount of time writing code to illustrate the issue and its cause. I would then publish my findings and how to replicate the issue. I would never jeopodise a source by quoting them as "an unnamed source" and I would never write an article based solely on the opinion of someone unwilling to be named: I would always do the research myself first,<br />
<br />
My opinion is that all written words are biased to some extent, and that it is impossible to remove all bias. Worse, any attempt to "remove" bias by so-called balancing opinions with bland statements from Press Officers is amateur and lazy. It is far more important that a journalist clearly states their biases so the reader can take them into account when reading the article, than to attempt to remove (in <b>their</b> opinion) any traces of bias from the report.<br />
<br />
<b>Postscript</b><br />
<br />
You may have detected the use of the past tense when I talk about writing for journals. The reason is that a few years back I wrote a critical piece about the most significant product of the dominant vendor. As always, I provided the results of my research and the tools for readers to replicate my findings. After the article was published, I was contacted by a senior manager at the company who asked me to retract my findings, and gave me an incentive, he offered contract work to help them improve the product. It turned out that the manager was not authorised to make the offer of work (and so it was a hollow promise), and anyway, I later learned that a manager several levels up in the company had declared that I was not welcome at any of the company's sites and my name was removed from the list of writers would got preview copies of their products. In effect, my career writing for journals was shut down.<br />
<br />
Ironically, after that I worked for a publishing company where I wrote conference presentations and "white papers", for the vendor who had "banished" me. My name never appeared on these items, so the manager who had declared me <i>persona non grata</i> was none the wiser, and was likely to have given one of my presentations.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com1tag:blogger.com,1999:blog-7462652546051300479.post-2931535222894897772015-07-25T14:35:00.002+01:002015-07-25T14:35:27.966+01:00PrivatisationIt is worth listening to Peter Hennessy's Reflections interview with Nigel Lawson, the Listen Again link is <a href="http://www.bbc.co.uk/programmes/b062jsmv">here</a>. What is immediately apparent is how arrogant Lawson is. Here is a man who's policies caused the so-called Lawson Boom that pushed up inflation and hence interest rates (to 15%! a level that seems incredulous now) and which lead to a catastrophic bust, and yet he never had a single regret and blamed everything on everyone else because in his mind he could do no wrong. In the interview Lawson said:<br />
<blockquote class="tr_bq">
<i>the idea that you go from state ownership to private ownership that had had never been tried anywhere in the world and we were the pioneers in this country and it was subsequently followed all over the world, first in the western world and subsequently in the countries that had escaped from the Soviet Union - the Soviet empire rather - and they went in for privatisation and indeed it was not only this country that gave the policy to the rest of the world but gave the word <b>privatisation</b> which is used in every language under the sun </i></blockquote>
Well, thank you Nigel, we now know that not only have you screwed up this country, but the entire world! Such arrogance.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-86589183123871468862015-07-13T11:50:00.000+01:002015-07-13T22:02:29.562+01:00NHS Funding InquiryLord Patel, a Crossbench peer and Obstetrician, on the 9th of July moved a <a href="http://www.publications.parliament.uk/pa/ld201516/ldhansrd/text/150709-0001.htm#15070961000762">debate</a> in the House of Lords over the "sustainability" of the NHS. In effect, this was the House of Lords debating whether taxpayer funding of the NHS was a good idea. Predictably, the debate was mostly filled with anecdotes from people who appear not to realise that their one anecdote is just one treatment out of the 18 million that are performed every year and is thus not representative. Also predictable was that the Tory peers who spoke acknowledged the need for taxpayer funding but expressed their favour of having an inquiry to bring in insurance or user charges.<br />
<br />
At no point during the General Election was there any suggestion that any political party would change how the NHS was funded, the "sustainability" of NHS funding was not, and still isn't in doubt. The service is funded by general taxation and if it needs more money, more money is found from taxation. At the budget the Chancellor promised an extra £8bn - not enough, but it shows that taxpayers can afford to pay more if there is the political will. So why the debate?<br />
<br />
I suspect it is more to do with the Junior Minister who represented the Government in the debate than with Lord Patel. The minister, Lord David Prior, is a former Tory MP and deputy Chair of the party, and was the previous chair of the Care Quality Commission. Prior is a loose cannon, who is well known for wanting to <a href="http://www.telegraph.co.uk/news/nhs/10612450/NHS-care-watchdog-warns-of-alarming-culture.html">extend private provision in the NHS</a>:<br />
<blockquote class="tr_bq">
<i>"We need more competition to drive up standards of care; <b>more entrants
into the market from private-sector companies</b>, the voluntary sector and
other care providers"</i></blockquote>
This makes him useful to the Government because he can be expected to initiate the sort of debates that no one has voted for, and where better than in the House of Lords, which no one has voted for? Lord Patel is a Crossbencher and so is not restrained by party political strictures. This meant that he was able to ask a question that party politicians cannot ask - can we fund the NHS in ways other than taxation? The right-wing Prior saw Lord Patel's debate as an opportunity.<br />
<br />
The NHS principles that have (mostly) stood firm since 1946 are summed up in clauses 4 of Command Paper 6761:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://2.bp.blogspot.com/-QQpFJMhuZX0/VaD8tufLu_I/AAAAAAAAAcA/WVWUffX7rHw/s1600/clause_04.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="63" src="http://2.bp.blogspot.com/-QQpFJMhuZX0/VaD8tufLu_I/AAAAAAAAAcA/WVWUffX7rHw/s400/clause_04.jpg" width="400" /></a></div>
<br />
That is, the NHS is available to everyone, whether or not they can afford to pay user charges, or whether they are insurable. This says quite clearly, that the NHS cannot be funded by co-pay or health insurance. The question about whether the NHS could be funded through user charges or insurance is answered here: <i>No it shouldn't</i>.<br />
<br />
The Conservatives, as can be expected, were far more in favour of moving away from tax funding. For example, Lord Cormack, while acknowledging that the NHS would need more money, would not even countenance a tax rise:<br />
<blockquote class="tr_bq">
<i>"All forms of funding must be looked at. We have to have a plurality of
funding if we are to have a sustainable NHS. <b>Whether the extra funding comes from compulsory insurances or certain charges matters not</b>,
but it has to come—we have to have a quality service that does not
lurch from crisis to crisis, from one application of sticking plaster to
the next. It is crucial that we attain that."</i></blockquote>
<i>Matters not!?</i> As a true Tory, he says that the funding should not come from taxing the rich, but instead from taxing the sick.<br />
<br />
More disappointing were the contributions from Labour peers. Lord Warner is well known for being in favour of the private sector and even suggested in his speech that "failing" providers should be privatised. On the issue of NHS funding he said:<br />
<blockquote class="tr_bq">
<i>"Our tax-funded, largely free at the point of clinical need NHS is
rapidly approaching an existential moment. The voices of dissent and
outrage will no doubt be deafening but a wise Government should <b>begin
now the process of helping the public</b> engage in a discourse about future
funding of the NHS."</i></blockquote>
This is hardly an endorsement of the tax-funded system, indeed, he appears to suggest that the government should "help" the public to think of other ways to pay for healthcare. Another Labour peer, Lord Desai, even made the bizarre suggestion that people should be issued with an "Oyster card" which is deducted whenever a patient uses healthcare, and patients should receive a "bill" at the end of the year:<br />
<blockquote class="tr_bq">
<i>"Another suggestion that I have made before in your Lordships’ House is
that, although we do not want anyone to feel that they are being charged
for using the health service, we ought to make clear to people the cost
of providing it. People think that because it is free, it is
costless—but it is not. We often worry about people missing GP
appointments, so I propose a sort of health Oyster card for every
citizen. <b>Every time they used the National Health Service, they would
have to swipe their Oyster card and a certain number of points would be
deducted.</b> The Oyster cards could be recharged. <b>At the end of the year,
people would get a bill showing how many points had been used and on
which health service facilities</b>. If people missed a GP appointment, 15
points would be deducted rather than two—things like that. Perhaps
something like that could be done to make it clear to people that a free
National Health Service is not a costless one. If we can somehow get
people involved as patients and potential patients so that they modify
their behaviour in demanding healthcare, it may solve some of the
problems of the National Health Service."</i></blockquote>
This is another version of Jeremy Hunt's daft suggestion to put the price on prescription medicines, a policy <a href="http://campaign.r20.constantcontact.com/render?ca=1aa95caf-6349-41ec-80b1-d938991f3076&c=72ada140-b428-11e3-be5a-d4ae52986b44&ch=73dc8450-b428-11e3-be71-d4ae52986b44">expertly dismissed by Roy Lilley recently</a>. The problem with the NHS is not unnecessary demands, it is the sheer magnitude of people who <i>need</i> healthcare. An "NHS Oyster card" will not reduce the number of elderly people with acute co-morbidities. And if "consumer demand" is a problem, the solution is to turn patients back into patients rather than healthcare consumers, and remove the market.<br />
<br />
Prior, summed up the debate by saying that he was personally in favour of a taxpayer funded system:<br />
<blockquote class="tr_bq">
<i>"However, I have listened to the debate and the strength of feeling
about whether we should take a longer-term view that goes way beyond
this Parliament. The sustainability of the health service is an issue
that extends out 20 years, probably, but it is one that every developed
country faces. I would like to meet the noble Lord, Lord Patel, and
maybe two or three others, to discuss this in more detail to see whether
we can frame some kind of independent inquiry—I do not think that it
needs to be a royal commission. We are not short of people who could
look at this issue for us; there are health foundations, such as the
Nuffield Trust and the King’s Fund. The issue is: what will the
long-term demand for healthcare be in this country in 10 or 20 years’
time? Will we have the economic growth to fund it?</i> </blockquote>
<blockquote class="tr_bq">
<i>At
heart, our ability to have a world-class health system will depend on
our ability to create the wealth in this country to fund it.<b> I am
personally convinced</b>, having looked at many other funding systems around
the world, <b>that a tax-funded system is the right one</b>. However, if
demand for healthcare outstrips growth in the economy for a prolonged
period, of course that premise has to be questioned."</i></blockquote>
<a class="anchor noCont" href="https://www.blogger.com/null" name="150709-0002.htm_para14"></a><a class="anchor" href="https://www.blogger.com/null" name="stpa_144"></a><br />
The statement at the end is a curious one, suggesting that he is not wholly convinced because he would support other funding mechanisms if the state of the economy demanded it. (An odd statement to make because it implies that if the country goes into recession, and people lose their jobs and have to spend less, he would be in favour of taxing the sick through health insurance and user charges.)<br />
<br />
However, Prior goes way above his station by declaring an inquiry on an issue as fundamental as how the NHS should be funded. If Jeremy Hunt, George Osborne or David Cameron had suggested such an inquiry I would express my opposition, but at least those politicians hold significant positions in the government and have the power to order such inquiries.<br />
<br />
But why is a junior minister, the "Under Secretary of State for NHS Productivity", announcing an inquiry in an area that is outside of his remit? I suggest the reaction of the Press is the reason: this inquiry has not been reported in the mainstream media. If the Health Secretary, the Chancellor, or the Prime Minister had announced such an inquiry it would have been on the 10 o'clock News, the front pages of the national newspapers and there would have been a whole Newsnight devoted to what the inquiry will be looking at. Because a little known minister announces such an inquiry, the media are not interested, and so something as fundamental as the funding of the NHS will go ahead without any public scrutiny.<br />
<br />
There is one final point to be made. Prior says:<br />
<blockquote class="tr_bq">
<i>"We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund."</i></blockquote>
Indeed. The Kings Fund has already carried out such an inquiry, it was called the <a href="http://www.kingsfund.org.uk/publications/new-settlement-health-and-social-care">Barker Review</a>. Barker says:<br />
<blockquote class="tr_bq">
<i>"We looked hard at the question of introducing new charges into the NHS. However, most </i><i>options for charges seem likely to raise administrative problems and the risk of adverse </i><i>impacts, <b>which make them unattractive</b>."</i></blockquote>
Barker rejects any idea of user charges, did any of the Lords in Lord Patel's debate mention this? Further, Barker suggests that the gap in health funding should be met by more taxes, not fewer:<br />
<blockquote class="tr_bq">
<i>"We make two </i><i>suggestions to close this gap, although clearly there are others. The first is <b>a review of </b></i><i><b>wealth taxation</b>, including inheritance tax, which is too frequently avoided. The second </i><i>is a package of <b>increases in National Insurance</b>, affecting those over 40 (who will be </i><i>considerable beneficiaries from the new settlement) and the higher paid."</i></blockquote>
It is interesting that the Chancellor has removed the ability to raise taxes through inheritance tax by raising the tax threshold in the Budget, and he has cut some National Insurance contributions. In other words the very things that Barker says should happen, Osborne does the opposite. On can conclude Osborne is likely react similarly to Barker's opinion on user charges.<br />
<br />
The government already has a detailed report into NHS and social care funding, one which recommends raising taxes. Rather than acting on this report, Prior (taking an action which few people would regard him as authorised to do) orders another inquiry, this time using people he has chosen and presumably people who will produce the desired result.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com5tag:blogger.com,1999:blog-7462652546051300479.post-58523203278754554212015-06-07T16:45:00.001+01:002015-06-07T16:45:05.194+01:00Prisoner debt<i>If I were ever to become a Special Advisor to the Conservative Party not only would I lose all credibility and respect of all of my friends and family, but I would also lose any credibility and respect I have for myself. So take this as a declaration that the following is not what I think <b>should</b> happen, but, considering that we have one of the most right wing governments ever elected to this country, this is </i><i>what <b>may</b> happen</i><i>.</i><br />
<br />
<b>Comfort Allowance</b><br />
<br />
In March 1943 my grandfather, grandmother and father (then 10) were interned in the Civilian Internment camp at Lunghua in Shanghai. (Yes, the same camp as JG Ballard, and no, <i>Empire of the Sun</i> is not autobiographical; the camp was not like that and Ballard has even written saying that the book was a novel and the event did not happen.)<br />
<br />
In August 1945 the camp was liberated and in September 1945 my grandmother and father (who was seriously ill) were repatriated (first via plane to Hong Kong, and then a three month journey via a military hospital ship back to Liverpool). My grandfather stayed on in Shanghai and returned to the job he had before the war. I have the letters that my grandfather wrote back to England (he returned back to the UK in July 1946, it was not his intention to return, but that is another story...).<br />
<br />
The letters are mostly about his failing health, and about money: he expresses great regret that he could not provide more money for my grandmother. Bear in mind that my father needed many operations and this was before the NHS, so my grandmother would have to pay the medical bills.<br />
<br />
In one of the letters is a passage that says:<br />
<blockquote class="tr_bq">
<i>"Our firm promised to pay for comfort allowance but whether they will pay for our wives + families remains to be seen."</i></blockquote>
This needs a bit of explanation.<br />
<br />
The camp provided little food to the internees. Part of the reason was that there was little food in Shanghai during the war. The camp had a small farm with chickens, and my grandfather had to pay for eggs and milk (I have records of how much he paid, and even in the camp there was rampant inflation). My father was a young boy so it was important that he had milk and eggs. (By "eggs" I mean not only the gooey stuff inside that could be boiled, poached or fried, but also the shell. Egg shell was ground up and children had to eat this as a source of calcium.)<br />
<br />
In addition, the internees could receive Red Cross Parcels. These were not charity, the name comes from the fact that the Red Cross delivered the parcels and ensured that they were checked and did not contain forbidden items. Before they were interned, people gave some money to a trusted friend who would not be interned, and this friend would purchase allowed items and package up for the Red Cross to deliver. My grandfather worked with a Rumanian Jew, Bernard, who had escaped Nazi East Europe. In some of his letters Bernard gave his nationality as "Rumanian" in others he described himself as "stateless", but since he was not from an Allied country, he was not interned by the Japanese. My grandfather gave Bernard money to provide Red Cross parcels, but since no one knew how long internment would last, and the money soon ran out.<br />
<br />
Internees could borrow "comfort allowance". Since this money would be used to pay for essentials, the word "comfort" was certainly a euphemism. The money came through the Swiss Consulate who handled British affairs in occupied Shanghai. The British government reimbursed the Swiss government for this money. At the end of the war, the civilian internees were expected to reimburse the UK government for this debt.<br />
<br />
That's right, people were interned for two and a half years in appalling conditions, with inadequate food, and the UK government treated it as if they were staying in a holiday camp, running up a bill that had to be paid.<br />
<br />
The comment in my grandfather's letter referred to an offer from the company he worked for to pay for the cost of his internment "comfort allowance", although he was unsure as to whether they would also pay for my grandmother and father. I have no other references to these payments, so as far as I know my grandfather paid for the food my grandmother and father had while interned. Since my father was seriously ill during the last 6 months of internment, there were also his hospital bills and medical for that time. (On two occasions my father was allowed out of the camp to go to a hospital in Shanghai for x-rays.)<br />
<br />
<b>Ludicrous and Unbelievable Election Pledges</b><br />
<br />
The Cameron government were elected with an unexpected majority. It surprised Conservatives as much as it surprised everyone else. They did not expect to get a majority, and so, in the last few weeks of the election campaign, to give them some chance of forming a minority government, or be the biggest party in a coalition, the Tories went on a rampage of throwing money around in a series of election pledges they did not intend to honour. The problem is that they <i>did</i> get a majority and they <i>do</i> have to deliver the election pledges.<br />
<br />
Such pledges include: cuts in inheritance tax, rise in the tax threshold, an extra £8bn for the NHS and (the expensive pledge of) seven day working, right to buy of Housing Association houses underwritten by the public purse and increases in the state pension. Big expensive pledges. All of these come at the same time as a ludicrous law that says that income tax, VAT and National Insurance will not be raised during the Parliament, and an unbelievable pledge that the government will generate a surplus in 2018-19. These expensive pledges have to be paid for and the government have said they will do this with cuts including £12bn to welfare.<br />
<br />
Cutting their way to a surplus will be very difficult, so I reckon the government will find ways of raising revenue, and this means they will look towards user charges.<br />
<br />
<b>"Prisoner Debt"</b><br />
<br />
The Ministry of Justice estimates that the cost per prisoner is £34k per year (2013-14 <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/367551/cost-per-place-and-prisoner-2013-14-summary.pdf">pdf</a>). Compare this to higher education students who leave university with (on average) a <a href="http://www.bbc.co.uk/news/education-26954901">£44k debt</a>. Assuming that the student debt was generated over a 3 year period, this means an average debt of £14,600 per year per student. Basically - using these contrived figures - prisoners are twice as expensive as students.<br />
<br />
The cost of higher education has been "solved", or at least the Conservative government thinks so since they do not intend any significant reforms in the student loan system, except, perhaps, the sale of the Student Loan Company as a asset to pay for their reckless election pledges.<br />
<br />
The government has squeezed the provision of prisons, with many prisons privatised, and services like probation moved to privately provided "payment by results". However, these reforms have been more ideological than a sure way to make sustainable savings. It could be argued that there is little scope to make prison provision cheaper, so the only way to reduce the government's contribution will be to find another source of income.<br />
<br />
This is why I said above that I think the government will look to user charges. Prisoners cost the state £34k a year, the government could regard this as an "obligation" of the prisoner, just as they regard the cost of higher education tuition to be an "obligation" of the student. Every year the prisoner remains in prison, their "debt" will go up. If the prisoner shows good behaviour and receives a cut in their sentence, their "prisoner debt" will be curtailed. Right wingers like financial incentives and this will fit into their ideology: the prospect of curtailing their "prisoner debt" will make prisoners reform! Of course, giving a prisoner a bill when they are released could be counter productive since most prisoners will not want to be released, so steps will have to be taken to avoid this.<br />
<br />
There is a model in student loans that can be used. When students leave higher education they are not presented with a bill and told to pay it immediately. Students do pay off their loans, but not in a lump sum. They pay off their loans gradually via automatic deductions from their pay packet. The infrastructure is there. It works, so why not use it as a mechanism for ex-cons to pay off their "prisoner debt"?<br />
<br />
<b>Government Charging Prisoners</b><br />
<br />
Of course, there will be objections to charging prisoners for their spell in prison, but as I have already shown above, the British government already have a precedent for doing this: they charged people who had committed no crime and were imprisoned by a foreign government! If they can charge citizens they know to be innocent, what moral objection will they have to charging people who have been convicted of committing a crime?<br />
<br />
You may balk at the idea of charging prisoners for their board and lodging while incarcerated, but bear in mind that many people are already being charged for services that the state should provide and it is likely that other user charges will appear in the next few years ("hotel charges" for staying in an NHS hospital is a likely charge). We have a right wing government, committed to reducing the state, so don't be surprised of the extremity of the schemes they will create to pay for the reckless pledges they made to get elected.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-17458037091796366102015-02-27T19:42:00.001+00:002015-02-27T21:14:46.371+00:00DevoManc: Huge Centralisation of NHS Commissioning<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-d2nWLR1zWPs/VPDHwQ-5HdI/AAAAAAAAAbM/IbjjCQmQ09E/s1600/DevoManc.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="One Health and Wellbeing Board to Rule Them All" border="0" src="http://4.bp.blogspot.com/-d2nWLR1zWPs/VPDHwQ-5HdI/AAAAAAAAAbM/IbjjCQmQ09E/s1600/DevoManc.jpg" height="320" title="One Health and Wellbeing Board to Rule Them All" width="320" /></a></div>
<br />
<br />
The proposals, that are known as DevoManc, are huge, they promise lots and yet there are very little detail about how they will work. Labour should be very cautious about them.<br />
<br />
The normal way to make huge changes to how we are governed is for a political party to put the proposals in their manifesto and ask the public to vote on it. Osborne has not done this, so it is legitimate to say it is not democratic and probably not constitutional. At the very least, since it will involve a lot of legislation, there should be a white paper on the DevoManc proposals so that there is a consultation process involving experts. This has not happened, which means that we have a huge change that has not been properly consulted upon. Worse, the negotiations about this policy has involved months of secret negotiations between the (mostly Labour) leaders of the ten Greater Manchester councils and the (Conservative) Chancellor. How can this be a proper way to decide the future of a region, <i>policy by secret meetings</i>?<br />
<br />
<b>To any Labour politician who is thinking about DevoManc, I suggest you get yourself a barge pole and keep it far away from this policy.</b><br />
<br />
The DevoManc Memorandum of Understanding (<a href="http://www.agma.gov.uk/cms_media/files/mou.pdf">pdf</a>) says under the agreement NHS commissioning will be devolved to the <i>Joint Commissioning Board</i> (GM JCB) this will include:<br />
<ul>
<li>Acute care (including specialised services); </li>
<li>Primary care (including management of GP contracts); </li>
<li>Community services;</li>
<li>Mental health services;</li>
</ul>
These services are either commissioned currently by the twelve Clinical Commissioning Groups, or will be soon, under NHS England's new plans for <i>co-commissioning.</i> (The only exception is "specialised services" which only makes up 10% of the NHS budget.)<br />
<br />
The other services that the GM JCB will commission are:<br />
<ul>
<li>Social care;</li>
<li>Public Health;</li>
<li>Health Education</li>
<li>Research and Development</li>
</ul>
The first two are currently commissioned by the ten local authorities and, along with the commissioning carried out by the NHS CCGs, are overseen by the local authorities' Health and Wellbeing Boards (HWB). (The last two services in the list will involve further consultations because neither CCGs nor Local Authorities are responsible for them, however, taking the responsibility for training and research out of national bodies is <b>very</b> worrying.)<br />
<br />
Think about this. This is not <b>devolution</b> this is <b>centralisation</b>! The only part of the NHS budget that is being devolved is the specialised services which is about 10% of all NHS money spent. That means that 90% of NHS money in the twelve CCGs and the ten local authorities that make up the Greater Manchester Combined Authority will be <b>centralised</b>, not <b>localised</b>.<br />
<br />
Also, note that CCGs are <i>membership</i> groups. Were the GPs, who are members of the CCGs, consulted about this, and did they approve it? (For the curious, the answer is no, the discussions were secret, remember.) Primary Care Trusts were criticised for being big and remote, <b>the GM JCB will be the granddaddy of big and remote</b>.<br />
<br />
Greater Manchester have already created the GM Health and Wellbeing Board. This is "one board to rule them all!" The very existence of this board means that it will override the subservient boards of the ten councils, localism of NHS and social care in the region will undoubtedly be controlled by Manchester City Hall.<br />
<br />
This is in no way like the careful plans that Andy Burnham created. Burnham said that under Labour existing NHS structures would be retained (in particular, CCGs and HWBs). He did this specifically because the very last thing the NHS needs right now is yet another re-organisation. Burnham's plans would be for <i>local</i> HWB to have more control over <i>local</i> CCGs, in particular, to ensure that the "NHS Preferred provider" policy is followed. Burnham is not suggesting a radical re-organisation.<br />
<br />
DevoManc is a huge, disruptive change and it cannot go ahead without a lot of legislation (not least, changing the behemoth that is the Health and Social Care Act 2012). It cannot be done before the election. Labour's approach should be to calm this down, point out how reckless it is to make policy by secret agreements and promise after the election to have a proper commission on devolution, and before any legislation is changed, have a white paper with proper public consultation.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-55738996971764117572015-01-19T14:06:00.002+00:002015-01-19T14:06:10.144+00:00Fill in the gaps<div class="tr_bq">
This is my response to Bill Morgan in a blog on the <a href="http://blogs.spectator.co.uk/coffeehouse/2015/01/the-government-are-not-blame-for-the-latest-nhs-crisis-but-all-parties-need-to-back-the-stevens-plan/">Spectator</a>. Bear in mind that Morgan was a Special Advisor to Lansley so there is a whiff of the <a href="http://en.wikiquote.org/wiki/Mandy_Rice-Davies">Mandy Rice-Davie</a>s about his post.</div>
<blockquote>
<i>You rightly start by saying that the 2010 winter was affected by a flu outbreak. However, you then go on to say that 2011, 2012 and 2013 were uneventful. This is not true. There was more flu and norovirus at this point last year compared with now. Last year the NHS could cope (just) with the flu, this year the NHS cannot cope even without flu. It is this problem we have to address. The run up to Xmas was mild - just like it was the year before - so why wasn't 2014 like 2013?</i><i><br /></i><i>It isn't a small dip in A&E performance. Every winter you will find that *some* trusts will fail to meet targets (the usual suspects), but what is characteristic about this winter is that *every* trust has been effected, even the best performers. Since the dip (you claim "small", well on the front line it isn't seen that way) is universal, so there must be a universal reason for it. You're right to say that Labour have jumped upon the Lansley "reforms" (well, fragmentation of the NHS) without explaining why it has affected A&E performance. The problem is that most trusts will say that they really don't know - the problem started in the summer when we had winter activity all year with no lull. As you rightly say, no trust, nor NHS England can explain why, but the facts are clear - there are large numbers of frail elderly people, who are sick with multiple conditions and these are the reason for the drop in performance. </i><i><br /></i><i>People from different parts of the health service and different political persuasions, will have their theories, but it is rather silly to blame it on the GP contract because the performance problems is not due to the people who would have otherwise gone to a GP. You dispute the cuts in social care, which I think is brave since many social services are close to collapse. (My theory, is that it is community health services, that has failed. I think we have got to the limit of treating people "in the community", at home or in nursing homes, certainly at the level of funding there is now. Nursing homes are a particular problem, there isn't enough NHS medical care in those homes (which is their right), so people are deteriorating unseen. You *can* blame GPs for that. Consequently people are being admitted from care homes in a poorly state. But I can be wrong, just like anyone else.)</i><i><br /></i><i>You say "the reforms – largely focussed on making doctors responsible for long-term NHS planning", which is a statement from a politician, not from someone with any experience in how CCGs run. Most GPs will tell you that they have no more control or say in how local services are planned. GPs are inherently independent and most of them want to remain so. A few GPs have got involved in CCGs, but this happened with PCTs too. GPs joined the PCT and became managers and those few GPs who have joined CCGs have now become managers too. Analysis I have carried out on CCGs show that less than a third of CCG boards have a GP majority (and mostly, that is the limit of GP involvement). Plus ca change, plus c'est la meme chose.</i><i><br /></i><i>In fact the fragmentation of commissioning has been a disaster, which is why things are changing now and with co-commissioning CCGs are starting to look just like PCTs. For my condition - type 1 diabetes - there was one commissioner of all the NHS services I use in 2010. Now there are three different commissioners, one for the GP services, one for the hospital services and (bizarrely) another one for the monitoring of my diabetic eyes. None of these commissioners talk to each other. Whenever I ask them why such-and-such service is not integrated with the other services (like it was in 2010) I am told "we don't commission that". It's a mess, and the mess was predicted when Lansley came up with his plans in 2010.</i><i><br /></i><i>You talk of the timing "why would a set of reforms cause short-term problems in our A&Es two-and-a-half years after most of them were in place". This is a valid question (except your calendar is wrong, the reforms came into place in April 2013, 20 months ago, not 30 months ago). However, I think you are saying "look over there". We know that social care has been viciously cut in the last four years (NAO says a 7% cut in spite of a £1bn from the so-called ringfenced NHS budget every year), and four years of cuts are enough to put that service to the edge. Four years of a deteriorating service is more likely to have an effect than a 20 month old policy, however cracked-pot that police was.</i><i><br /></i><i>Your Wales argument is a red herring. Wales is mostly rural, it has higher levels of deprivation than England and is arguably too small and too dispersed to be an effective health system. The problem in Wales is not Labour, it is Wales, and maybe we should accept that devolution of the NHS to Wales was a mistake.</i></blockquote>
Bear in mind that Morgan works for a public relations company and its a fair bet that they have a contract with someone or other connected to the Conservative party, so the piece is more PR than anything else. I thought I would fill in the gaps in the PR piece.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com2tag:blogger.com,1999:blog-7462652546051300479.post-69220316616612122282014-11-12T10:48:00.000+00:002014-11-12T10:48:07.187+00:00Private patients and the Efford BillThe <a href="http://www.publications.parliament.uk/pa/bills/cbill/2014-2015/0018/15018.pdf">Efford Bill</a> is a good start into reversing the damage that is the Health and Social Care Act (the Act that "senior Tories" who couldn't be bothered to listen to experts now describe as <a href="http://www.ibtimes.co.uk/tory-regret-over-nhs-gobbledygook-reforms-smack-pre-election-stunt-1469791">gobbledegook</a>). However, as you would expect with such a short bill there are few details. In this post I will cover one issue: NHS trust providing private services.<br />
<br />
<b>Private Patients and Foundation Trusts</b><br />
<br />
The 2006 NHS Act has a section to restrict the income from private patients that a Foundation Trust (FT) can generate <a href="http://www.legislation.gov.uk/ukpga/2006/41/section/44">s44</a>:<br />
<blockquote class="tr_bq">
(1) An authorisation may restrict the provision, for purposes other than those of the health service in England, of goods and services by an NHS foundation trust.<br />
(2) The power must be exercised, in particular, with a view to securing that the <b>proportion of the total income of an NHS foundation trust which was an NHS trust in any financial year derived from private charges is not greater than the proportion of the total income of the NHS trust derived from such charges in the base financial year</b>.<br />
(3) "Base financial year" means the first financial year throughout which the body corporate was an NHS trust or, if it was an NHS trust throughout the financial year ending with <b>31st March 2003</b>, that year.</blockquote>
This says that the income from private patients as a proportion of the total income of a Foundation Trust must not be higher than the proportion in the financial year 2002/03. If an FT generates a higher proportion it will be in breach of its "terms of authorisation" and this may result in regulatory action (most likely a look of stern disapproval from Monitor).<br />
<br />
The section also implies that an NHS Trust which intends to apply to become a Foundation Trust must make sure that its private income generation was proportionally the same as it was in 2002/03 financial year. Since the then government said that every NHS Trust had to become a Foundation Trust this section was more influential on aspirant NHS Trusts than on authorised FTs (GOSH authorisation as an FT was delayed by several years because of its rampant private business). However, the rule was easily circumvented since the section involves <i>income</i> and not numbers of patients, and trusts came up with clever dodges like joint ventures (The Christie) or moving the private work to a charity (GOSH) so that the income to the NHS Trust was the profit of the joint venture company (or the surplus of the charity, donated to the trust) rather than the revenue for private patient treatment. Although the regulator, Monitor, took action against such dodges, the action was closer to a stern look of disapproval than to actual action that would reduce private patient activity.<br />
<br />
Although every NHS Trust "had" to become a Foundation Trust, there was no rigid timetable and no sanctions against NHS trusts that failed to become an FT, and so, in practice, NHS Trusts with large incomes from private patients just generated more private business. There were lots of criticism of section 44, particularly in the case of patents. If a trust creates a new device, drug or treatment and decided to create a worldwide patent, the income from licencing under this patient (even if it does not involve UK patients) was still considered part of the private patient income. Furthermore, the omission of the <i>numbers</i> of private patients in the law meant that a trust could treat lots of private patients but charge them small amounts and still meet the s44 criteria.<br />
<br />
<b>Health and Social Care Act</b><br />
<br />
The Health and Social Care Act (HSCA) <a href="http://www.legislation.gov.uk/ukpga/2012/7/section/165/enacted">repealed</a> section 44 and replaced it with a more lax restriction. The Tories hoped that repealing this section would result in Foundation Trusts creating private businesses, but this has not happened, certainly not at the rate that the Tories hoped for.<br />
<br />
<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/164/enacted">Section 164</a> of the HSCA replaced the old s44 with this section:<br />
<blockquote class="tr_bq">
(2A) An NHS foundation trust does not fulfil its principal purpose unless, in each financial year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.</blockquote>
This says that NHS income of a Foundation Trust (again, omitting NHS Trusts) must be more than the income from its non-NHS services. It is erroneously quoted as "49% private patients" for two reasons. First the non-NHS income can be more than 49%: it can be 50% less £1. (Does this matter? Yes it does. A <i>small</i> NHS trust will have an income of £200m so the 1% difference between 49% and 50% is £2m, and £2m is not a small amount of money.) The second reason this is not a "49% private patient income" rule is that the section does not mention private patients, it says "<i>total income from the provision of goods and services for any other purposes</i>". That is, any income other than income from Clinical Commissioning Groups (CCGs) or from NHS England. This "<i>any other purposes</i>" includes local authorities, charities and even car parking charges (paid by NHS patients). So a trust that has no private patients will have a non-NHS income under this section, potentially an income of many millions. Yet again, our law makers have made a bad law.<br />
<br />
Neither s44 of the NHS Act, nor the new section created by s164 of the HSCA covered NHS Trusts. It is clear that about a third of NHS trusts will never become Foundation Trusts, which means that those third will know that the private patient income restriction does not apply to them in practice. Further, both sections have downsides, covering services other than private patients.<br />
<br />
<b>Efford Bill</b><br />
<br />
The Efford Bill has two clauses that cover private patient income: clause 7 covers private patients in Foundation Trusts and clause 8 covers NHS Trusts. In effect, they say the same thing (and hence finally applies private patient income restrictions on NHS Trusts): The following is from clause 7:<br />
<blockquote class="tr_bq">
(3) An NHS foundation trust shall ensure that its total income from the provision of goods and services for provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness otherwise than for the health services or for which charges are made by the trust is not greater than either—<br />
(a) such percentage of its total income from the provision of goods and services in connection with the prevention, diagnosis or treatment of illness <b>as the Secretary of State shall direct</b>; or<br />
(b) such higher percentage as shall be determined <b>by the Secretary of State for an individual NHS foundation trust</b>.</blockquote>
This says that there will be a private patient income cap, and it will either be a universal cap or it will be set on an individual trust basis. This does not say what that proportion will be, so a Tory Secretary of State can set the cap to 50% to get the same effect as the HSCA. Allowing the Secretary of State to set individual caps is a sop to the rampant privatisers in trusts like Royal Marsden or GOSH who have built up their private businesses to be significant proportions of the trusts' income.<br />
<br />
The phrasing of the clauses "<i>for which charges are made by the trust</i>" implies private patients, however, it still covers <i>income</i>, not the actual services or numbers of private patients.<br />
<br />
<b>Two Tier NHS</b><br />
<br />
The main reason for restricting private patients is to prevent the creation of a two tier NHS, where NHS patients in an NHS hospital will get second rate services compared to private patients. The Efford Bill clauses do not address this issue.<br />
<br />
There are two basic principles that need to be met to prevent the creation of a two tier system:<br />
<br />
<ol>
<li>The treatment of private patients do not adversely affect the treatment of NHS patients</li>
<li>Private services must not be subsidised by the trust from NHS income.</li>
</ol>
<br />
The first principle says that NHS patients should not see the quality of their treatment deteriorates when the trust treats private patients. "Quality" is a broad term, and it could cover things like private patients not having to wait their turn at an outpatients clinic, so the NHS patients have to wait longer, or the re-scheduling of NHS patients treatment because a private patient has chosen to be treated at that time. However, I think the best metric is waiting times, indeed, I think that waiting times are so important that this is effectively a subclause to principle 1:<br />
<ol>
<li>a) A trust will not be allowed to treat private patients in a speciality where it is not meeting the 18 week referral to treatment target for NHS patients.</li>
</ol>
The 18 week referral to treatment target (RTT) is a guarantee to NHS patients. A common cause for patients to pay for private treatment is that they are waiting too long. A trust that wants to have private patients (and there are many reasons why they will want this, other than income) there is an incentive to have long waiting lists, so NHS patients have to suffer so that the trust can increase the numbers of private patients.<br />
<br />
The second principle says that a trust's private income must be calculated in a business like way, and that there should be no overt or covert subsidies. An example of overt subsidies are diagnostics. If a private patient has a MRI scan that patient should be charged a commercial rate for the scan, they should not be charged the NHS tariff rate which is typically lower than commercial rates.<br />
<br />
Covert subsidies are more nuanced. For example, every NHS trust treats emergency patients and so have intensive care units (ICU) able to treat the most ill of patients. Private hospitals typically do not have ICUs, or if they have a unit it is a low level unit. This means that if something untoward happens the private hospital calls 999 and the patient suddenly becomes an NHS patient. Private patients in an NHS hospital have the reassurance that the skills and equipment to handle emergency patients are on site, and indeed, this is often a marketing point for the trust's private patient unit. However an ICU is not cost free, the unit is paid by emergency tariffs and capital charges are paid from the trust's general income. The unit exists for every patient treated by the trust since potentially every patient may need it, and hence the payment for every patient will include a contribution to pay for the ICU. Similarly, private patients should contribute to the funding of the facility, if they don't then that is a covert subsidy.<br />
<br />
<b>Amending the Efford Bill</b><br />
<br />
The Efford Bill should have sections to address the principles given above. On an annual basis, an NHS Trust or Foundation Trust must meet the two principles. In the case of NHS Trusts there should be an annual declaration from the trust board that the two principles have been met. In the case of a Foundation Trust the trust's Council of Governors should provide this declaration. In both cases, the declaration will typically come from the trust's auditors who will have a duty to inspect the trust's private patient business.<br />
<br />
Meeting the RTT target is so important that on a quarterly basis achievement the RTT target should be evaluated and if the target is not met the trust should only be allowed to treat private patients in the failing speciality following quarter if the trust can give credible assurances that it will meet the target in that quarter.<br />
<br />
There are two more changes that should be made to the Efford Bill as described in the next section.<br />
<br />
<b>Reasons for Private Income</b><br />
<br />
The usual reason given by trusts for treating private patients is that it provides extra income for the trust (hence why principle 2, above, is important). However, the income from private patients is rarely large (not every trust has a thriving private patient business like GOSH). Using private patients to subsidise NHS treatments has several issues, not least because few private patients like to be treated like a cash cow to subsidise NHS treatments. If NHS tariff is too small to cover the cost of the treatment the solution is to increase tariff, not to subsidise NHS treatments by other activity.<br />
<br />
To address this issue the Efford Bill should have a section that says that NHS patients must be taxpayers funded. At the beginning of the bill is a section that says that NHS treatment should be free at the point of use (a version of this section has appeared in NHS Acts since the 1946 Act):<br />
<blockquote class="tr_bq">
(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.</blockquote>
The mention of charges here refers to the co-pay that exists in the NHS: dental charges, prescription charges, charges for devices like wigs etc. While such charges are abhorrent it is unlikely that they will be removed. There should be an additional clause that says that notwithstanding the income from the charges mentioned in section 1(4) NHS treatments should be funded wholly by the taxpayer. This will remove the excuse that many trust's give that they have to have a private business to subsidise NHS patients. It also puts an onus on Monitor and NHS England, who set the NHS tariff, to ensure that tariff covers the costs of treatment.<br />
<br />
The main reason for private patients is HR. Consultants are currently able to do private work even though they are contracted to an NHS organisation. Private patient units in NHS hospitals mean that the consultants do not have to go offsite to run their private business. In all other sectors of the economy this would be called moonlighting and would be disallowed. So to remove this incentive there is a need to change the consultant contract so that they can only work for the NHS organisation that they are contracted to. I doubt if such a change will ever happen, so an alternative would be to say that all income from private patients treated in an NHS organisation should be treated as income of the trust. This will ensure that the consultant is still an NHS consultant regardless of whether the patient is private or NHS. The intention of this rule will be to persuade consultants to treat their private patients in a private hospital, and hence prevent the creation of a two tier NHS.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com2tag:blogger.com,1999:blog-7462652546051300479.post-25788989375466759002014-11-09T22:00:00.000+00:002014-11-09T22:00:13.684+00:00NormalThe aim of every clinician is to make each patient with a long term condition as "normal" as possible. The definition of "normal" depends on the clinician, but it <b>should</b> be as close to the patient's definition of "normal" as possible. If the patient feels they are living a "normal" life then the clinician has succeeded.<br />
<br />
When I was first diagnosed with type 1 diabetes, in 1976, I had a glass syringe and reusable needles stored in a plastic pot filled with ethanol, and two vials of bovine insulin. The routine was quite involved. Take out the syringe, push the plunger back and forth a few times to expel the alcohol, then attach the needle, pull the plunger back to the dose and, holding the syringe and vial upright, push the needle into the rubber stopper of the vial, and pump the dose equivalent of air into the vial; then draw out insulin, remove the needle, tap the syringe to get any bubble to rise to the needle end and gently push the plunger to expel the bubbles. Finally inject the insulin. It is not normal to do this in a restaurant, at school, or at a friend's house. This is not normal, so injections were kept to a minimum: twice a day at home. When insulin pens were introduced it became possible to be discreet about injections. It was possible to inject under the table at a restaurant, or nip to the toilet and inject. You could act "normal" while still doing something unusual - injecting in public.<br />
<br />
Over my 39 year of type 1 diabetes I have been as "normal" as I can. I don't use my diabetes as an excuse. I try to be like my relatives, my friends and the people I work with, by doing the things they do and living like them. Indeed, it is not unusual for a friend to say "I didn't know you were diabetic". No, like you, I am normal.<br />
<br />
The problem comes when clinicians try to turn normal people into patients. Recently, when talking to a GP at my local Clinical Commissioning Group about their new design for diabetes services I asked about the diabetes annual review. The GP told me that in his opinion a review annually was not often enough and he would like to see his diabetics four times a year. Four times a year: that's not normal, that would be changing me into a dependent patient. I don't want to be a patient, I want to be normal.<br />
<br />
For 39 years I have collected my prescriptions four times a year and although that is enough of a chore, I have learned to put up with it because I know that without my insulin I won't be conscious for long. However, I have just found out that my GP will only issue repeat prescriptions monthly. That means twelve visits to the pharmacy every year. To a pharmacy that has opening times the same as most people's work time, and closes when most people have lunch. That is, the only time a normal person can collect a prescription is during work time. A normal person will have to take time off work to collect the prescription and this identifies them as not being "normal".<br />
<br />
In the last 20 years or so, I have been able to be "normal" while still having diabetes. Now, it appears, I have not choice: I have to be a patient. I won't change without a fight. I am quite happy for my GP to send me four diabetic clinic appointments every year: that gives me a choice of which <b>one</b> I want to attend. And if my GP wants me to collect a prescription every month. Well, fine, instead of requesting my prescription electronically, I will collect the script from the surgery. Yes I do know that I will get in the way of the smooth flow of patients through reception, but it was <b>you</b> who decided to make me collect my prescription from reception every month.<br />
<br />
And then there is the issue of the drugs I take. Half of them I take on faith. I take these drugs because my GP tells me to take them, but I know from the occasions that I have forgotten to take them that these drugs have no discernable effects on me. I have a big incentive to take insulin because if I miss an injection I start to feel ill within an hour or two. But I have no incentive to take the statins and the two hypertension drugs other than to make my GP happy*. Yet I will have to make monthly visits to the pharmacy to get these "on faith" drugs, drugs that I have no incentive to take. If I run out of statins, but I still have insulin in the fridge, why should I make an additional trip to the pharmacy? After all, since the statins and the hypertension drugs have no noticeable effects on me, if I don't take them I will still feel "normal".<br />
<br />
[* I am diabetic, my GP gets a QOF payment based on my blood pressure and cholesterol blood tests. Although I have no incentive to take statins and hypertension drugs, there is a financial incentive for my GP to make sure that I do. This game of incentives may get interesting.]richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com1tag:blogger.com,1999:blog-7462652546051300479.post-65282119928836592432014-10-17T18:37:00.002+01:002014-10-17T18:37:27.365+01:00CCG Pay MultiplesThe Hutton review was set up in response to "public concern" (actually, Tory generated witch hunt) to the level of payments of public servants. The Hutton recommendation was that public bodies should publish the ratio between the salary of the highest paid staff member (usually a manager) to the median pay of all staff. Clearly the lower this ratio the more "equal" the organisation is.<br />
<br />
While going through CCG annual accounts I have found quite a variation of the pay multiple, mostly because there is a large variation in the median pay (there's not much variation in the highest paid executives). However, some CCGs have made their declarations look like the pay multiple is lower than it actually is. Whether this is a genuine mistake or not, the results are clearly misleading.<br />
<br />
As an example, here are the calculations for NHS Fareham and Gosport CCG. The section on pay multiples says this:<br />
<blockquote class="tr_bq">
<i>"The banded remuneration of the highest paid director in the CCG in the financial year 2013/14 was £85 - £90k. This was 2.1 times the median remuneration of the workforce, which was £40- £45k."</i></blockquote>
When I read this I thought three things. First, £45k is about normal for the median; second, 2.1 is low for the pay multiple; and third, £90k is low for an executive who handles many hundreds of millions of public money. So I decided to do the calculations myself.<br />
<br />
The remuneration for their governing board looks like this.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-dJRvcOfrIlk/VEFLcUel0wI/AAAAAAAAAac/s5V6m0tRr3c/s1600/FG_rem.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/-dJRvcOfrIlk/VEFLcUel0wI/AAAAAAAAAac/s5V6m0tRr3c/s1600/FG_rem.jpg" height="163" width="320" /></a></div>
<br />
I have edited this table to show only the highest paid staff and to remove the columns that list bonuses (zero), taxable benefits and pensions. The figures are as they appear in the CCG's annual report.<br />
<br />
Clearly the "highest paid director" is Dr Chivers, the Chair of the CCG. (A figure of £85k is quite high for the Chair of a CCG, but not unusual.)) But note the right hand column. This lists the amount of time the manager spends working for the CCG. These are not part time jobs because the asterix indicates that these managers work for South Eastern Hampshire CCG or Portsmouth CCG as well as Fareham & Gosport.<br />
<br />
The NHS England guide to calculate pay multiples says<br />
<blockquote class="tr_bq">
<i>"The calculation is based on the full-time equivalent staff of the clinical commissioning group at the reporting period end date on an annualised basis and is subject to audit."</i></blockquote>
So the salary is an FTE and annualised. Clearly this is so, because it makes no sense to compare a part time job with the median of FTE jobs. However, this is what Fareham & Gosport have done because they have ignored the staff that are shared with other CCGs.<br />
<br />
The highest paid executive is actually Richard Samuel, the Accountable Officer; it is usually the case that the Accountable Officer is the highest paid executive. Mr Samuel is paid £65-70k by Fareham & Gosport CCG and another £65-70k by South Eastern Hampshire CCG (say £130-140k, a median of £135k). Using the median pay as £42.5k, the pay multiple should be 3.18, not 2.1. 3.18 is not exceptionally high for a pay multiple (I have seen values of around 7), but it is clearly a more honest figure than 2.1.<br />
<br />
For the record, the pay multiple for NHS South Eastern Hampshire CCG is quoted as 3.2, but this has not been calculated from Mr Samuel's salary. This reason for the higher value is because: firstly, the median pay is lower (£35-40k); and, secondly, the other staff are paid much higher than Fareham & Gosport. SE Hampshire have a GP on the board, Dr Andrew Douglas, who is described as a "clinical member" (no, not even the chair) who is paid £120-125k.<br />
<br />
The whole point of quoting a "pay multiple" is to try to show that the CCG's salary policy is "fair". But tricks like this make CCGs look like they are deliberately trying to mislead.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-67398011834156372272014-09-15T11:50:00.002+01:002014-09-15T11:50:57.591+01:00ParticipationWe had got ourselves a bit of a reputation, but this chap clearly wasn't aware of it. As usual the administrator, Sarah, had arranged a senior manager to give us a talk, and David had turned up with his laptop and powerpoint and relaxed into his presentation. We were a polite lot, we let David work his way through the first ten minutes of the professional-looking slides, and the script, clearly prepared by a team of people.<br />
<br />
Then it happened. Jonathon said "<i>But...</i>"<br />
<br />
A wry smile drew across the faces of everyone there, we all knew that someone would interrupt the manager from the distant big office, and we knew that the most likely person was Jonathon. Actually, if I am honest, we knew it would be Jonathon because it always was him. He was polite, concise and asked pertinent questions that would make a manager stop and think, so he was the ideal person to ask the first question.<br />
<br />
"<i>But what you say on that slide is not 100 percent correct. I use that service and I know that two times out of ten it will fail.</i>"<br />
<br />
David stopped. The look on his face was puzzlement: someone had interrupted his talk. In years of being a senior manager, no one ever interrupted his talks, he didn't quite know how to react.<br />
<br />
There were thirty of us in the room and he knew that everyone there was regarded as being a 'critical friend', people who wanted the service improved. And that was his intention too. He was used to giving presentations to employees, who, careful of their future career, would never interrupt someone as senior as him. None of us were employees, but we weren't 'the public' either since we had been invited to these regular meetings as people who were part of the community and thus closer to the service. The look on his face changed as he made up his mind that engaging with Jonathon was the best course of action.<br />
<br />
"<i>Going forward we will ensure that the service will succeed in ten times out of ten...</i>"<br />
<br />
A valiant try from someone not used to engaging with the public, but it was rather poor and Jonathon would have nothing to do with it.<br />
<br />
"<i>But</i>", continued Jonathon, "<i>I can assure you that it will not improve if you do what you say in the slides, and I can explain why...</i>"<br />
<br />
The room was quiet, waiting for the response.<br />
<br />
It came, and this time David chose the right thing to do, he took out a notepad from his jacket pocket and asked Jonathon to explain why the service failed in a fifth of cases. After the quick explanation, David realised that Jonathon knew what he was talking about, and - concerning for him - the failures were real and no one had ever told him about them. David wrote down the details, telling Jonathon that he would get 'someone on my team' to look at the issue once he had returned back to his office.<br />
<br />
The management spell had been broken. David was talking with us, not at us. To his credit, David recognised that as a group we had an experience of the service that no one on his team had, and he was listening to us because he knew that he would learn from us.<br />
<br />
As soon as Jonathon had finished Peter started talking. He too had an issue with the service, and showed that he was knowledgeable and knew what needed to change to fix the issue. As with Jonathon's issue, David had not come across Peter's issue, and he scribbled more in his notebook.<br />
<br />
It was clear now that the slides had been abandoned, and the rest of the hour long presentation was a two way conversation between David and the group. There were a long list of questions. Sometimes David would answer them, but mostly the direction of travel of information was from the group via David and his notebook to his 'team'.<br />
<br />
After the presentation was finished we paused for a break to have coffee. I went to talk to David.<br />
<br />
"<i>What do you think our group?</i>"<br />
<br />
It was clear to me that he was looking a bit tired, but relaxed.<br />
<br />
"<i>It was tough. I have never had a session like that before. Do you do that to everyone?</i>"<br />
<br />
I smiled, "<i>Yes, everyone, it's why we are here</i>".<br />
<br />
He laughed. "<i>You are very difficult to please. I don't usually get this level of detail from my team, I didn't know there were these issues with our service. It was a great session, I really enjoyed it. I will definitely come back and next time I will be able to tell you that those problems have been fixed.</i>"<br />
<br />
This all happened, though the names have been changed (well, not Jonathon's, everyone who knows him will recognise him from this story).<br />
<br />
Now you are thinking about which of the patient participation groups that I attend I am describing, and when this happened.<br />
<br />
It is not a patient participation group, it is a Microsoft user group and it happened a decade ago. For a decade from 1996 to 2006 I was involved with Microsoft user groups, mostly helping software developers use Microsoft's tools and libraries. I was not paid to do this, it was peer-to-peer support. I would answer people's questions on newsgroups and forums, and I would ask my own. Since I tended to answer more questions than I asked, and the quality of my help was good, Microsoft decided that I was a "community leader" and invited me to attend these user groups every quarter at Microsoft's regional headquarters in Reading. The manager I mentioned above was from Redmond, and yes he did return and he had ensured that the issues were fixed. In return we gave him a whole pile of additional issues to fix.<br />
<br />
My involvement with Microsoft meant that I was asked to beta test most of their products, but the involvement went further. I was also asked to do alpha testing (very early version of products while they were being developed, and often before it was even publicly known that Microsoft was working on the product). However, the most useful part of this relationship was having access to the product team. On regular occasions I was invited (and my travel and hotel expenses paid) to visit the product team, usually in Redmond, to review the design of the next version of the product. I got to see the product on the "drawing board" years before the product would appear. Of course there were Non-disclosure Agreements (NDAs), but even so, I was not an employee, I was totally independent of Microsoft and I could say what I wanted. And I did. I was chosen to be there because I was a user, I knew what the product should do, and because of my involvement with "the community", I knew what other users of the product wanted.<br />
<br />
This is how I expected NHS Patient Participation to work. Sadly, it is a million miles away. Most of NHS Patient Participation is a tick box: the CCG invite patients to a meeting, tell them what they are going to do and then tick the box marked "patient involvement". We are involved because, right at the end of changing a service, we have been told that the service is to be changed. This is not how it should be. Patients should be, but <i>are not</i> invited to be part of the commissioners' meetings when designing a service.<br />
<br />
Patients are held at arm's length by commissioners, it is as if commissioners do not trust patients to know about the services they use. In the few meetings I am invited to I feel like I am a "guest": everyone there is polite to me, but I rarely feel that the meeting has any influence over the service involved, or that any of my concerns are noted. I find that when a patient raises issues about a service, the first reaction from commissioners is to be defensive and to blame someone else, usually the local hospital (now that CCGs are GP-led, there can never be an issue with primary care). I rarely find a commissioner reply to me that the service is poor and would be changed in response to my comments.<br />
<br />
And then there are areas of the NHS where patient involvement appears to be forbidden. You know who I am talking about, NHS England and Local Authorities.<br />
<br />
Primary care, GPs, dentists, opticians, pharmacies, very local patient services, are commissioned at a large population level in aloof and distant offices with no patient involvement by NHS England Area Teams. Does the Area Team know whether there are enough GPs in a town? They certainly don't bother to ask the patients who use the existing GP practices. Most GP practices have a patient participation group (PPG) where patients have joined <i>specifically</i> to improve the practice's services, but NHS England never consult these groups. That they choose not to consult GP PPGs shows that NHS England have a contempt for patient participation.<br />
<br />
Now (in a bizarrely ill thought out decision) "public health" has been transferred to local councils. To be clear, I am happy for "healthy living" services - smoking cessation, health eating and campaigns to lose weight - to be transferred to local authorities. But for odd historical reasons, some healthcare services were classified as "public health" and these have been transferred out of the NHS, where they belong, to local authorities. For example sexual health services, school nurses and health visitors. Local authorities don't do patient participation, so by re-classifying a former NHS service as "public health" politicians have removed a legal requirement to involve the public in their commissioning.<br />
<br />
The NHS has a lot to learn about patient involvement. It could learn a lot from how user groups provide peer-to-peer support and how they feedback to the companies providing the products they use. The current version of patient participation does not work. I have never been told that my comments about a service will result in a change in an existing service, and I have never been invited to be part of the team designing a service that I will use as a patient. Indeed, and more concerning, I have specifically been told that I cannot attend such meetings. I know that it will make some people wince, but the NHS could learn a lot from Microsoft.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-6908356799720456412014-08-05T11:25:00.000+01:002014-08-05T11:25:20.366+01:00Been there, done that!This <a href="http://t1international.com/insulin-access/my-insulin-scare/#comment-8911">blog</a> from a type 1 diabetic about losing her insulin while in the US reminded me of my own experiences. Here's the comment I left on that site (just in case it does not get past moderation).<br />
<br />
I live in the UK and for five years I used to speak at US conferences four or five times a year. My T1D was usually not an issue, although there were a few issues - like security at Birmingham International telling me I had to put my insulin in the cargo hold and me demanding the airline book me an ambulance at Chicago because I would arrive "unconscious" without my insulin (OK, a bit over the top, but they "made an exception" for me).<br />
<br />
On one occasion I was a bit lax. I had enough insulin for the trip, but on the way back the transatlantic plane was delayed and I had to stay overnight in a hotel. I needed to change the basal insulin in my pen and I did it in the bathroom. (Lesson: don't change cartridges in the bathroom, the floor is hard). I dropped the cartridge and it broke. This was my 'spare' (I was in the US for one day more than I had planned).<br />
<br />
What to do? If you are a clinician, do not read on.<br />
<br />
I had the same dilemma mentioned in the blog, except my only option was #3 - find a doctor and get a prescription. However, this was 1 am, so the choice of doctor and pharmacy was limited. I didn't want the option of spending hours and hundreds of dollars that it would cost. I had travel insurance, but the administration involved in getting the refund was far too much. Anyway, I had also spent a day travelling, I was tired from a week's work at a conference, and wanted to go to bed.<br />
<br />
So I got a spare disposable syringe and sucked as much insulin as I could out of the smashed cartridge. (Lesson: carry disposable syringes, you never know when you'll need one.) There was enough for that injection. But what about the plane trip home? Usually, to take into account time zones, I would inject a half dose half way across the Atlantic. There wasn't enough remaining insulin in the smashed cartridge for that.<br />
<br />
However, while travelling I had got into a habit when changing cartridge of putting the spent cartridge in my wash bag to dispose of at home. Except I didn't remember to dispose of the cartridges at home, so there was quite a collection in my wash bag. So I had spent basal cartridges from this trip, and from other trips in my wash bag. In each was a little bit of insulin and, with the syringe, I was able to draw out enough for the half dose on the plane. The insulin was old, and not stored at a cold temperature, but in that situation, any insulin was better than none.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com2tag:blogger.com,1999:blog-7462652546051300479.post-56668114406209828022014-07-28T00:09:00.003+01:002014-07-28T00:09:37.027+01:00I Want Personalisation Not a PHBI have multiple long term conditions, one of which is hypothyroidism - my thyroid does not produce enough thyroxine and I have to take a replacement dose in tablet form. I take 175 micrograms in three pills 100mcg, 50mcg and 25mcg:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-LyKHlfdW7BE/U9WCE7p2XpI/AAAAAAAAAZw/vF0YW7oMqvY/s1600/01.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-LyKHlfdW7BE/U9WCE7p2XpI/AAAAAAAAAZw/vF0YW7oMqvY/s1600/01.JPG" height="320" width="315" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
From the bottom upwards the dose increases, doubling each time. There is a clear danger here, while I know that the smaller strip is 100mcg, it is easy for me to mistake the 50 for the 25. Overdosing on thyroxine can have detrimental effects on the heart.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
When I open a new box of pills, I personalise it:</div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://3.bp.blogspot.com/-f5uRyg01lMc/U9WCGRDer_I/AAAAAAAAAZ4/LRFa08MxmZs/s1600/02.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-f5uRyg01lMc/U9WCGRDer_I/AAAAAAAAAZ4/LRFa08MxmZs/s1600/02.jpg" height="320" width="315" /></a></div>
<br />
Clearly, the best solution would be for the manufacture to print the dose in big numbers on the front (as opposed to the current situation of printing it in tiny numbers on the low contrast back).<br />
<br />
Will a personal health budget deliver this? No.<br />
<br />
Firstly, personal health budgets (at the moment) do not apply to medicines. This is a bit silly since people who have a PHB cannot use the money to pay their prescription charges. Yes, that's right, people can spend a PHB on reiki or some other nonsense that does not work, but they will not be allowed to spend their PHB on the government imposed sickness tax that is called prescription charges. As PHBs are rolled out to more people we will see cases where people will not take their prescribed medicines because of the cost of prescription charges, but will be able to buy ineffective "alternative" medicine with their PHB. Madness.<br />
<br />
Secondly, and most importantly, I am an individual and drug companies do not listen to me. Giving me a PHB will not make the drug companies any more likely to listen to me. Indeed, the only way that the drug company will take any notice is if I accidentally take an overdose and die - at that point they may consider changing their packaging, if my death can be attributed to it. However, the drug companies will listen to the NHS, since the NHS represents a market of 50 million people in England. So if the NHS wants drug doses printed on the front of blister pack strips, it would happen.<br />
<br />
People who have PHBs are effectively removing themselves from the NHS since they are purchasing healthcare rather than the NHS purchasing healthcare for them. In this example, under the current rules, medicines will still be NHS responsibility, but nevertheless the same principle applies: a PHB turns patients from part of the collective NHS into isolated individuals with less influence.<br />
<br />
I really do want personalisation, but a personal health budget will not give it to me.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-52838033856322238652014-07-15T11:05:00.004+01:002014-07-15T11:05:42.666+01:00NHS Mutual PrivatisationsThe Coalition’s <a href="https://www.gov.uk/government/publications/liberating-the-nhs-white-paper">White Paper</a> on the NHS in 2010 had this to say about the future of NHS Trusts and Foundation Trusts (section 4.21):<br />
<blockquote class="tr_bq">
<i>As all NHS trusts become foundation trusts, <b>staff will have an opportunity to transform their organisations into employee-led social enterprises</b> that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients. For many foundation trusts, a governance model involving staff, the public and patients works well but we recognise that this may not be the best model for all types of foundation trust, particularly smaller organisations such as those providing community services. We will consult on future requirements: <b>we envisage that some foundation trusts will be led only by employees; others will have wider memberships</b>. The benefits of this approach will be seen in high productivity, greater innovation, better care and greater job satisfaction. Foundation trusts will not be privatised. </i></blockquote>
The government clearly intended for most Foundation Trusts to be “<i>employee-led social enterprises</i>” in other words, no longer state owned, but instead, become not-for-profit private businesses. The statement at the end that “<i>Foundation trusts will not be privatised</i>” is contradictory since if a state-owned organisation is taken out of state ownership and into private ownership (as social enterprises are) then this is privatisation. Although the clause mentions "social enterprises" the same statements hold for mutuals. Mutuals are not state owned, they are in private (if mutual) ownership.<br />
<br />
The government received 6,000 responses to the White Paper and summarised these responses in a paper called “<a href="https://www.gov.uk/government/publications/the-governments-response-to-the-2010-consultation-on-nhs-reform">Legislation Framework and Next Steps</a>”. Section 6.16 in this document comments on the plan to turn hospitals into “social enterprises”:<br />
<blockquote class="tr_bq">
<i>Regulating healthcare providers discussed the prospect of enabling FTs to have employee-only memberships. <b>Not many respondents commented on this proposal but, with some exceptions, those that did were generally not supportive.</b> The CQC said that staff-only models without patient and public involvement could be at odds with public accountability and should be avoided, while the BMA thought they would do nothing to improve patient care. The Government has considered these concerns and <b>concluded that staff-only membership would not be compatible with the foundation trust model.</b> </i></blockquote>
The comments from CQC and the BMA are relevant not only for the government’s then plans for NHS hospitals, but also for social enterprises in general: there is no public accountability and the model does not necessarily result in better care. The final comment appeared to dismiss all possibilities of Foundation Trusts being taken out of public ownership. <b>The policy was killed off.</b><br />
<br />
A few weeks ago George Osborne made a curious and worrying announcement reported in the Daily <a href="http://www.telegraph.co.uk/news/politics/conservative/10917232/New-Government-cuts-could-see-a-million-state-jobs-go.html">Telegraph</a>.<br />
<blockquote class="tr_bq">
<i>Ministers are drawing up radical measures, to be announced in George Osborne’s Autumn Statement, which will see widespread privatisations and at least one million public sector workers removed from the government payroll by the end of the decade. </i></blockquote>
The Telegraph, slathering in its small-state dotage, misinterpreted what this statement meant, they thought the government would simply sack public sector workers:<br />
<blockquote class="tr_bq">
<i>Ministers have been told that the government workforce will fall by about one million between 2011 and 2019. At a rate of 36,000 per quarter, this is the equivalent of sacking one state employee every four minutes, every day, for the next five years. </i></blockquote>
When you “<i>sack a state employee</i>” there is a good chance that at the same time you are increasing unemployment, and no government can survive on five years of increasing unemployment.<br />
<br />
According to <a href="http://www.ons.gov.uk/ons/rel/lms/labour-market-statistics/june-2014/sty-public-sector-employment.html">ONS</a> there are 5.4 million people employed in the public sector (or 17.7% of the workforce). We have to be careful about what this figure means, because since 2008 it has included the workforce of the banks that were nationalised. These banks are only temporarily in public ownership, and anyway, they can hardly be regarded as providing a social good, in contrast to the NHS and education. Regardless of this issue, a cut of one million would be a fifth of all public sector workers. <a href="http://www.ons.gov.uk/ons/rel/lms/labour-market-statistics/june-2014/table-a01.xls">ONS</a> provides a breakdown of this figure:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://3.bp.blogspot.com/-qSx99s3yoZg/U8T1BxA5FJI/AAAAAAAAAY0/n36VCUcgIv0/s1600/public_sector.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-qSx99s3yoZg/U8T1BxA5FJI/AAAAAAAAAY0/n36VCUcgIv0/s1600/public_sector.jpg" height="230" width="320" /></a></div>
<br />
In March 2014 there are 1.6m people in the NHS, 1.5m in education and 1.1m in public administration (councils). Removing a million people from these figures will be ambitious and the resulting rise of unemployment figures would be catastrophic for any government. <b>The plan is clearly not to sack public sector employees, so what is Osborne planning?</b><br />
<br />
If we go back to the first quote from the Telegraph there is a huge clue about what Osborne intends:<br />
<blockquote class="tr_bq">
<i>will see widespread <b>privatisations </b>and at least one million public sector workers removed from the government payroll </i></blockquote>
The simplest way to reduce the “government payroll” is to privatise a service. In October 2013 the “government payroll” was reduced by 150,000 when the government privatised the Royal Mail. The problem for the government is that the majority of the public sector is in politically sensitive areas like the NHS and education: privatisations in these sectors can only be done piecemeal and is unlikely to yield the promise cut of a million jobs.
<br />
<br />
There is another issue to consider. The following <a href="https://twitter.com/DuncanWeldon/status/486957382615203840">graph</a> is from Duncan Weldon, the Economics Editor of Newsnight:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://2.bp.blogspot.com/-uhgoSRXMLfA/U8T4RIWKXiI/AAAAAAAAAZQ/qZuesHkKFkg/s1600/self-employ.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://2.bp.blogspot.com/-uhgoSRXMLfA/U8T4RIWKXiI/AAAAAAAAAZQ/qZuesHkKFkg/s1600/self-employ.jpg" height="144" width="320" /></a></div>
<br />
(I have shifted the axes a little – specifically, the y axis starts at 10% not 0% in the original – so that the graph takes less space.) Duncan makes no comment other than the graph is interesting and he wondered “<i>if the lines will eventually cross?</i>”. The graph shows that the public sector workforce has reduced consistently since Q3 2009 and self employment has increased since at least Q4 2002. There is some connection between the two lines. The Coalition have cut the number of NHS managers since 2010, but it has appeared that many of those manager have been <a href="http://www.telegraph.co.uk/health/10702318/Number-of-NHS-managers-re-employed-after-receiving-redundancy-doubles.html">re-employed</a> as self-employed “consultants”! The effect of the government's "sacking" of NHS managers was essentially to <i>privatise</i> them, turning a public sector employee into a private sector, cab-for-hire, "consultant".<br />
<br />
So now let’s return back to the 2010 NHS White Paper. If a public service is turned into the more politically acceptable mutual or “social enterprise” then the people who work for the service are employed by the new organisation, not the public sector. (This is one reason why it is important to highlight these changes as <i>privatisations</i>, since the staff will no longer work in the public sector.) Osborne’s promised cut of one million public sector jobs can be achieved simply by turning public sector organisations into “social enterprises”.<br />
<br />
Since the NHS White Paper was published the term “social enterprise” keeps cropping up when it comes to describing a Foundation Trust. This is naive, wrong and in some cases duplicitous. A Foundation Trust is owned by the taxpayer, just like an NHS Trusts: the clue is the bottom line of the annual accounts of both NHS Trusts and Foundation Trusts which lists a single figure that is the <i>Taxpayers Equity</i>. There is no difference in the ownership of NHS Trusts and Foundation Trusts. For this discussion, the only difference is that if an NHS Trust makes a surplus (that is, it spends less during the year than it receives in income) the surplus must be returned to the NHS (and ultimately, the government). If a Foundation Trust makes a surplus that money is retained by the trust and is used to provide healthcare. Some people claim that this is similar to social enterprises. It isn’t. However, the talk of Foundation Trusts being "social enterprises" persists, mostly because this is the eventual aim of policy makers.<br />
<br />
The idea to turn NHS trusts into mutuals or “social enterprises” is a “policy zombie”: once you've killed it off it comes back to life a few years later. <a href="http://www.hsj.co.uk/news/hospital-trusts-should-be-free-to-become-mutuals-dh-advised/5072962.article#commentsubmitted">HSJ are now reporting</a> that the Kings Fund are advising the Department of Health to re-introduce this idea.<br />
<blockquote class="tr_bq">
<i>Professor Ham says there should be an “option… <b>for NHS trusts to become staff-led mutual</b>… including trusts providing acute services”.
He says another approach could see “emerging models of integrated care choosing <b>to become mutuals</b> where several organisations come together to create a <b>joint venture</b> to deliver services such as urgent care and care for older people”. The report says this should be voluntary for trusts.
The <b>DH has welcomed the report</b> but HSJ understands it does not plan to respond by allowing NHS acute trusts to become mutuals. </i></blockquote>
This plan appears not to be just the fantasy of Prof Ham, since HSJ reports<br />
<blockquote class="tr_bq">
<i>the DH is expected to identify around 10 organisations, including acute providers, to pilot greater engagement of staff. There will be £1m funding available for the initiative, jointly from the Cabinet Office and DH. The programme will begin this summer and last until spring next year. I<b>t is understood the DH will use the work to identify regulatory, legal and practical steps it could take to allow new ownership and governance models such as mutual in the future</b>. </i></blockquote>
Notice the phrase "<i>practical steps it could take to allow new ownership</i>". If you change the ownership of an organisation owned by the nation then this is privatisation.<br />
<br />
The big sell off of the NHS will begin after the next election. Labour were keen on "public sector mutuals" in the last government and started the privatisation of Community Health Services into so-called "social enterprises". This process was halted when the current government tried to privatise Community Health Services in Gloucestershire and the plan was halted after a <a href="http://www.bbc.co.uk/news/uk-england-gloucestershire-16966274">judicial review</a>. The big question is, will Labour support the public sector and kill off Ham's zombie fantasy?richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-31030483120157901492014-07-13T15:27:00.001+01:002014-07-13T15:27:14.855+01:00Why John Rentoul is WrongYet again John Rentoul is wrong.<br />
<br />
In today's Independent <a href="http://www.independent.co.uk/voices/comment/general-election-latest-computer-model-predicts-the-lib-dems-might-have-even-more-influence-9602315.html">John Rentoul</a> describes an electoral scenario that he describes as "shocking", "alarming" and "one of the least attractive" electoral outcomes. While I agree with these statements (for purely polemic reasons, they suggest yet another coalition), I disagree with his naive arguments. Rentoul says that the situation will lead to "the Liberal Democrats might have even more of an influence on government than they have at the moment". I disagree, the result will be a short-lived and unstable government.<br />
<br />
Let's look at the <a href="http://nhsvault.blogspot.co.uk/2010/08/numbers.html">2010 election results</a>. These figures have changed a little bit since 2010, but not so much as to make any difference, I will use them because they describe the situation in 2010, rather than now.<br />
<br />
Cons 306<br />
Lab 258<br />
LD 57<br />
Others 28<br />
<br />
Assuming that the five Sinn Féin MPs (included in Others) do not participate this means a majority coalition requires 323 MPs. For the Tories to get a majority of 323 out of these figures they needed 17 more votes.<br />
<br />
The Coalition works because the Lib Dems provide 57 extra votes, right? Not necessarily. Over the last four years Lib Dems have voted against government bills, so the Coalition cannot rely on all of those 57 Lib Dem MPs (nor all the Tory MPs, but that is another story...). What if the Tory-majority government brings in a bill that goes against everything that the Lib Dems stand for, will the Coalition still have those 57 votes? No, but even so, the government (assuming it has the votes of all Tory MPs) will still have a majority. The reason is the "payroll vote".<br />
<br />
The payroll vote are those MPs who hold government posts. These vary between paid ministerial positions to unpaid posts like <a href="http://www.theguardian.com/politics/blog/2014/mar/11/coalition-faces-revolt-over-clause-119-hospital-closure-law-politics-live-blog#block-531f4c18e4b01de5bcb67a0e">chairing important parliamentary committees</a>. If we just restrict ourselves to the paid positions, here are the figures <a href="http://nhsvault.blogspot.co.uk/2010/09/numbers-redux.html">from 2010</a>:<br />
<br />
Cabinet members (23); 18 Tory; 5 Lib Dem<br />
6 Tories ministers also attend<br />
<br />
Minister of State (32); 26 Tory; 6 Lib Dem<br />
<br />
Parliamentary Under Secretary of State (33); 28 Tory; 5 Lib Dem<br />
<br />
Whips (non-cabinet 5); 3 Tory; 2 Lib Dem<br />
<br />
All of these people will always vote for the government. This is a guaranteed 93 votes for any government bill (88 ministers and 5 whips). Eighteen of these people are Lib Dem. So if the Coalition brings in a Bill that will turn the stomach every Lib Dem the vote will pass because eighteen Lib Dems are on the payroll and will always vote for the government.<br />
<br />
Why are eighteen of the 88 ministers Lib Dems? This is because the Lib Dems have 16% of the Coalition MPs (57 out of 363) and hence have to have at least 16% of the ministerial positions. 16% of 88 is fifteen, rounding up judiciously. Since there are sixteen Lib Dem ministers it means Lib Dems are over represented in government, but this is advantageous because it guarantees the Coalition a majority. (Fifteen plus the five whips still gives a figure above that magical seventeen majority, but only just, hence the need to have an additional three guaranteed Lib Dem votes.)<br />
<br />
Now onto why John Rentoul is wrong. He quotes a "prediction" that at the next election the breakdown will be:<br />
<br />
Cons 295<br />
Lab 296<br />
LD 31<br />
Others 28<br />
<br />
Rentoul says that this will make the Lib Dems much more powerful than they are now. It won't, all it will do is create an unstable government and make a new election much more likely.<br />
<br />
To get a 323 majority one or the other of the two large parties would have to find 27 or 28 votes. They <i>cannot</i> get these from the Lib Dems because they <i>cannot</i> guarantee that all Lib Dems will vote for the resulting coalition. Let's assume that Labour form the next coalition. This will mean that 9% of the coalition's 327 MPs will be Lib Dem hence 9% of the payroll vote, or eight MPs. Add this to the whips votes and the Labour-led coalition will have 309 votes, well short of the 323 needed. Essentially, this will be a minority government, not much different to what we would have now if the Lib Dems pulled out of the Coalition. It would be unstable.<br />
<br />
So Rentoul is wrong to say that "the Liberal Democrats might have even more of an influence on government than they have at the moment" since that government will be short-lived and probably will achieve nothing for the Lib Dems to influence.<br />
<br />richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-78558106621127682432014-06-29T19:59:00.001+01:002014-06-29T23:15:16.003+01:00Name and Shame and Patient Choice of GP PracticesJeremy Hunt's latest announcement is that GPs should be "named and shamed" for poor cancer referral rates. (The article is in the Mail on Sunday, I won't link to it here, but you can find it through an internet search.)<br />
<blockquote class="tr_bq">
<i>"Under the Government’s planned reforms, surgeries will be ranked as ‘green’ for cancer on the NHS Choices website if they quickly refer patients to hospital when they are showing possible signs of cancer. But if they miss too many cancer cases – or if patients have to return numerous times before being sent for tests – they will be classed as ‘red’."</i></blockquote>
This plan has been criticised by doctors,<br />
<blockquote class="tr_bq">
<i>"the Royal College of GPs has criticised the proposed rating system as ‘crude’ and said the Government should be ‘supporting GPs, not criticising them’"</i></blockquote>
This sentiment was repeated on BBC Broadcasting House on Radio 4 by Dr Sarah Wollaston, Chair of the Health Select Committee and a GP. Dr Wollaston said that the policy could lead to over-referral which would "clog up the system".<br />
<br />
There are other reasons to reject this idea. Over-referrals are bad for patients because they cause anxiety to "false positive" patients, cause unnecessary tests and potentially damaging interventions.<br />
<br />
The announcement also doesn't recognise that cancer is more effectively beaten with improved public health.<br />
<br />
The whole "naming and shaming" idea is flawed. At present GP patient lists are geographically based, and while there is some choice at the boundaries, most patients are registered at the practice in the area where they live. It is well known that this ideologically-driven government want to change this.<br />
<br />
What happens when the cancer diagnosis rankings appear on the NHS Choices website and a patient finds that their practice is 'red' rated? Hunt's gut feeling is that the patient will move to another practice with a better rating, and this "market" behaviour will improve incentives and quality. However, under current situation, this will not happen because changing practices is not a simple thing for patients to do. A 'red' rating will cause unnecessary anxiety amongst a community who will have no choice other than the practice badly rated (even though it may well be unwarranted). So why has Hunt come up with this policy?<br />
<br />
In the 2010 Health White Paper the government said:<br />
<blockquote class="tr_bq">
<i>"Give every patient a clear <b>right to choose to register with any GP practice</b> they want with an open list, without being restricted by where they live. People should be able to expect that they can change their GP quickly and straightforwardly if and when it is right for them, but equally that they can stay with their GP if they wish when they move house."</i></blockquote>
So what has happened to this policy? The results are mixed. The <a href="http://www.bbc.co.uk/news/health-26654617">BBC</a>, as ever acting as the mouthpiece for the Department of Health says:<br />
<blockquote class="tr_bq">
<i>"The lead author, Prof Nicholas Mays, said: "While demand for the pilot was modest, our evaluation found that patients had positive views of the scheme."</i></blockquote>
However, <a href="http://www.pulsetoday.co.uk/political/practice-boundaries/one-third-of-practice-boundary-pilot-surgeries-failed-to-register-a-single-patient/20006157.article#.U6_n20DBNQ4">Pulse Magazine</a>, the trade magazine for primary care, is less enthusiastic:<br />
<blockquote class="tr_bq">
<i>"The long-awaited report into pilot sites concluded that, despite positive feedback from users, there was little demand from patients or practices and called on the Government to consider alternatives to support increased access."</i></blockquote>
Pulse reported figures from the study that the BBC chose to ignore: <i>"More than a third of the practices taking part in the Government’s
‘choice of GP practice’ pilots failed to register a single patient from
outside their area"</i>. This is hardly the "modest demand" that the BBC reported, it is a wholesale rejection of the idea.<br />
<br />
There are good reasons why this idea should be rejected. Pulse says of the study:<br />
<blockquote class="tr_bq">
<i>"It also found that commissioners had big concerns about the potential destabilisation of general practice and impact on the wider health service if it was to be rolled out nationally."</i></blockquote>
Commissioners are under immense pressure at the moment to meet increasing demands due to an aging population, government diktats about integration and moving care out of hospitals, while at the same time having to meet unachievable targets to reduce A&E attendances. All of this must be done with a budget that is static and inadequate. The last thing they need is one more destabilising policy.<br />
<br />
The "choice of GP practice" pilot has shown that few people want to change practice, so it is possible that someone in the Department of Health has said: if there's no demand for this policy, why not create it? If a GP practice has been labeled "poor" at cancer diagnosis then there will be demand from <i>some</i> worried patients to change to a practice that has a good rating. Thus cancer diagnosis rating has a potential to create the demand for patients to practices.<br />
<br />
<b>It is not too far fetched to suggest that the whole point of Hunt's cancer rating announcement is to create the demand needed for the failed "choice of GP practice" policy.</b><br />
<b><br /></b>
<b>UPDATE 23.00</b><br />
<br />
Dr Clare Gerada <a href="https://twitter.com/clarercgp/status/483348371701497856">tweeted</a> the following at 21:36:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-Z92vif2yoI8/U7COlsTO75I/AAAAAAAAAYY/uMuTXYyO7L4/s1600/cancer.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-Z92vif2yoI8/U7COlsTO75I/AAAAAAAAAYY/uMuTXYyO7L4/s1600/cancer.jpg" height="134" width="320" /></a></div>
<br />
This puts another perspective on Hunt's cancer name & shame: cancer is rare and so the diagnosis rate of each GP is small. This means that it will be difficult for NHS Choices to come up with a criteria to use to determine when to give a "green" or a "red" flag. Going on this tweet, it seems that the cancer diagnosis rating flag will be a non-starter.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-48953187905744194792014-05-01T18:17:00.002+01:002014-05-01T18:17:07.106+01:00Self-care "Payment by Results"For forty years I have had regular doctors' appointments for my diabetes. This has been mostly with hospital doctors, but from about the mid 90s it was GP diabetic clinic appointments too. For the first thirty years they all had the same format: blood results, told to do better, given form for the next blood test, dismissed. Years after I had taken my last exam, every six months I would be given a test, fail it and then be chided for not trying harder. I would always leave those appointments angry. My blood tests were not bad, they were simply not perfect; and it wasn't that I was not taking responsibility for my condition, I was, I just had a busy life and sometimes I could not understand why I had high results or how to get them lower.<br />
<br />
Then about ten years ago, for some reason, my diabetic appointments changed from a personal test of my responsibility to a conversation with my doctor. No longer were my non-perfect results treated as a personal failure, and entirely <i>my</i> responsibility. Now the doctor was interested in how I could be helped to understand my results and improve them. The doctor no longer looked down on me as a problem, but instead treated me as part of the solution. This is Shared Decision Making.<br />
<br />
Today the right wing organisation, <a href="http://www.2020health.org/2020health/Press/Latest-News/Press-Release-1-5-14.html">2020Health</a> have come up with an idea that the rate of tax I pay should depend on my blood sugar.<br />
<blockquote class="tr_bq">
<i>We propose ‘Payment by Results’, a financial </i><i>reward for people who become active partners in their health, whereby if you e.g. keep your blood sugar levels </i><i>down, quit smoking, keep weight off, take on more self-care there will be a tax rebate or an end of year bonus. </i><i>This could be monitored by the GP, linked to QUOF or facilitated by electronic patient records.</i></blockquote>
(I have no idea what <i>QUOF</i> is. Are they referring to the <i>Quality and Outcomes Framework</i> that is usually initialised to <i>QOF</i>?)<br />
<br />
So now, the very person who I hold in my deepest confidence - my GP - will be determining my tax bill. Does this make sense?<br />
<br />
We know that type 2 diabetes is associated with deprivation, <a href="http://www.hscic.gov.uk/catalogue/PUB02573/nati-diab-audi-09-10-exec-summ.pdf">National Diabetes Audit 2009-10</a> says "<i>Type 2 diabetes is strongly associated with age, ethnicity and social deprivation</i>":<br />
<blockquote class="tr_bq">
<i>The prevalence of Type 2 diabetes rose from <b>3.18 per cent in </b></i><i><b>the least deprived quintile (Q1) to 4.49 per cent in the most </b></i><i><b>deprived quintile (Q5)</b>. Furthermore, the effect of deprivation </i><i>on the prevalence of Type 2 diabetes is most pronounced </i><i>in the 16 to 55 years age range (Table 2). In those aged 70 </i><i>years and over, similar numbers of Q1 (12.1 per cent) and </i><i>Q5 (14.8 per cent) have Type 2 diabetes, but <b>under the age </b></i><i><b>of 55 Type 2 diabetes is more than twice as common in Q5 </b></i><i><b>(3.0 per cent) as Q1 (1.3 per cent)</b>. This may reflect lifestyle </i><i>differences in exercise, diet and weight.</i></blockquote>
Because there are more type 2 diabetics in the most deprived areas, this means that the 2020Health's "<i>Payment by Results</i>" will be applied to the poor, who are least able to afford a healthcare plan that has a financial basis, rather than the rich. Further, after the debacle of the <i>care.data</i> programme, where Tim Kelsey will be selling your GP medical records to insurance companies, we now have an equally abhorrent idea that your "<i>electronic patient records</i>" will be made available to HMRC. When will these right wingers realise that our confidential medical records should remain confidential?<br />
<br />
Finally, it is worth quoting <a href="https://twitter.com/drphilhammond/status/461887724988170240">Dr Phil Hammond's</a> reaction to this report:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-hO-h6cADs0M/U2J_peNIHnI/AAAAAAAAAYA/8VgWhGlsJfM/s1600/hammond.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-hO-h6cADs0M/U2J_peNIHnI/AAAAAAAAAYA/8VgWhGlsJfM/s1600/hammond.jpg" height="230" width="400" /></a></div>
<br />richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-7206596084413355872014-04-29T16:10:00.004+01:002014-04-29T16:10:34.388+01:00Real Personalisation Will Never HappenI really get sick of a small minority of people with vested commercial interests saying that personal healthcare budgets (PHBs) delivers "personalisation". I am sick of it because they don't seem to understand what personalisation is. Such people insist that by turning patients into consumers will personalise their care. It won't, it just turns them into consumers with the responsibilities and worries that come with spending budgets carefully.<br />
<br />
Let me give you an example of where we need personalisation, where PHBs will not deliver this personalisation, and a subject which commissioners obsessed with their version of "personalisation" have shown no interest. Prescription medications.<br />
<br />
I have three long term conditions and so I take seven different drugs. Since one of those drugs is not available in the dose I take, I take three pills of it. That means I take five pills in the morning, two before I go to bed (the other medication I take is two types of insulin). That is a small number of pills compared to many elderly people. I am middle aged, with relatively good eyesight (OK I have diabetic retinopathy, so that increases my count of long term conditions to four). I have good co-ordination and memory. Yet I still forget to take medication. Sometimes I get to the end of the fortnight and realise that there is one pill left over in the blister pack, so clearly I had missed that pill sometime during the last 14 days, with no idea when.<br />
<br />
My pharmacist knows what drugs I take, it's on my prescription script and she attaches a label telling me when to take them. Instead of me having blister packs for seven drugs, why not blister packs for the seven days in the week? Half of the strip for morning, half for evening. It's Tuesday, so I take the strip that is marked (<b>IN BIG BOLD LETTERS</b>) Tuesday. I do not have to go hunting for the right blister pack for the right drug, because that has been done by the pharmacist already.<br />
<br />
That strip of pills can only be used by me, because no one else has my combination of long term conditions requiring exactly those doses. This is real personalisation and it will never happen.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-77193952407001686472014-04-12T17:18:00.002+01:002014-04-12T17:18:31.519+01:00What I would have saidNorman Lamb was on BBC Radio 4 <i>Any Questions</i> last night. The things he said about the NHS made me decide to call <i>Any Answers</i> today to refute his assertions. I called their number and spoke to a researcher who noted my response and said she would pass it on to a producer. I was then called back by a producer who checked my details but warned me that there was unlikely to be the time to discuss the NHS on this edition. She was right, the public apparently are more interested in a fiddling minister, an English Parliament or the middle class habit of taking kids on holiday in term time than the NHS.<br />
<br />
This is what I told the researcher, and I would have said on air.<br />
<blockquote class="tr_bq">
I am calling to refute the statement from Norman Lamb that the NHS is "<i>horribly fragmented</i>" and that his government is moving to a "<i>joined up system</i>". The effect of Norman Lamb's government's policies are that we are going in the opposite direction, the system getting more fragmented, not more integrated as Lamb claimed.</blockquote>
<blockquote class="tr_bq">
I have had diabetes for 40 years and for the last 20 years I have had diabetic eye disease - retinopathy. I use diabetic services in my local hospital, I use services at their eye clinic and I use GP diabetic services. Before the election all three services were commissioned by one commissioner, the local Primary Care Trust. The commissioner plans a service and ensures that patients are able to access the service, and since there was one commissioner this meant that they could decide which services were carried out in hospital and which were provided by GPs.</blockquote>
<blockquote class="tr_bq">
Since the Health and Social Care Act was enacted last April my care is commissioned by three different commissioners. The local Clinical Commissioning Group commission diabetic hospital services, the NHS England Area Team commission GP services and Public Health England commission the monitoring of my diabetic eye disease. Three different commissioners instead of one. Norman Lamb talked about "<i>treating the whole person</i>" but his policies have made that more difficult because there are three commissioners instead of one. I know where the CCG is located because the CCG are high profile, the other two organisations are not. I have only just found out that the NHS England Area Team who commission GP services are based 40 miles away from where I live and they commission GP services for 1.6 million people. GP are a thoroughly local service but are now commissioned by a remote and aloof organisation. I still do not know where Public Health England are based, they keep themselves to themselves.</blockquote>
<blockquote class="tr_bq">
These three commissioners do not work together. I know this because my local CCG have announced that they intend to cut the number of hospital diabetic outpatients appointments by a third, but when I asked at their public board meeting if they will ensure that local GPs have the skills to care for these diabetics denied access to the hospital clinic, I was told: "<i>we do not commission primary care</i>". So the CCG are allowed to decommission services at the local hospital without first ensuring that local GPs will be able to care for the patients from the cut service. If the PCT had decided they wanted to move services out of the hospital they would have been able to do this because they commissioned both hospital services <i>and</i> primary care.</blockquote>
<blockquote class="tr_bq">
The result of the mess of my care being commissioned by three different organisations who do not talk to each other is that NHS services are becoming far more fragmented.</blockquote>
<br />richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-29839347007701518052014-03-23T13:54:00.001+00:002014-03-23T15:24:59.815+00:00Sweet Tea and Diabetic WeeThirty eight years ago, aged eleven, I was discharged after a week in hospital. I was sent home with a glass syringe, a plastic tub and a bottle of surgical spirit to store the syringe, five <i>reusable</i> needles (a year's supply), a couple of bottles of insulin and a chemistry set.<br />
<br />
I had been diagnosed with <i>juvenile onset diabetes</i>, later called <i>insulin dependent diabetes</i> and now known as <i>type 1 diabetes</i>. Simply put, my body had ceased to make any insulin and so I could no longer control my blood sugar. The treatment was to inject insulin refined from the pancreases of cows. The chemistry set was so that I could determine whether I was injecting the right amount of insulin. It contained a test tube, an eye dropper and a bottle of tablets containing caustic soda and copper sulphate. Five drops of urine, ten drops of water, then drop a tablet in the tube and wait 30 seconds while it fizzed and turned the liquid a colour between blue (no sugar: good) and bright orange (2% sugar: bad). The value was recorded in a notebook to show the consultant at the six monthly appointments. Although it is almost forty years ago, I remember my book was littered with 1% and 2% readings.<br />
<br />
Just think about this: regularly, 2% of my urine was sugar. If a teaspoon holds about 4g of sugar, and a mug of tea is about 200ml, a mug of tea with a teaspoon of sugar is about 2% sugar. On a regular basis, my urine was as sweet as your tea*. (Diabetes mellitus comes from the Greek word <i>diabetes</i> meaning siphon - to pass through - and the Latin word <i>mellitus</i> meaning honeyed or sweet, in other words <i>sweet urine</i>.)<br />
<br />
To get that sweet, empirical measurements show that on average my blood sugar would have to be about 12 mmol/l and this is about double the recommended level for a diabetic. The urine tests gave results up to 2%, so when I got the bright orange result it mean that the concentration of sugar in my urine was 2% <i>or more</i>. Since the test didn't show a value higher than 2% I have no way of knowing how high my urine sugar really got. (In fact, I now know that I could have repeated the test with two drops of urine rather than five, and this could have measured up to 5% of sugar.) I was also prescribed urine dipsticks to test for ketones. Ketonuria occurs when the body breaks down amino acids to get energy rather than glucose, and in a diabetic this can occur when blood sugar is over 15 mmol/l (due to too little insulin). From memory, I occasionally detected ketones, so my blood sugar was likely to be three times or more the recommended level.<br />
<br />
The problem with urine testing is that it is hours after the fact. My bladder could have several hours of urine (eight, for the early morning pee) and hence my blood sugar could be high for all of this time. Worse, four decades ago, there was not the concept of taking an <i>adjustment dose</i> of insulin to correct a bad result. Re-usable needles meant that injecting was an unbearable pain, and blunt needles (and the impure animal insulin) affected the injection sites (scarring and fat loss) so it was always best to have as few injections as possible. For the first ten years I had two injections a day: one before breakfast and another before dinner. Consequently, without an adjustment dose, a high urine test could mean a high blood sugar for at least half a day. Controlling blood sugar in the 70s and 80s was not easy.<br />
<br />
These days diabetics have finger prick blood testing monitors, so we can instantaneously test blood sugar, we also have insulin pens that can accurately deliver small adjustment doses of insulin and (the most significant innovation) we have <i>sharp</i> needles. Controlling blood sugar, though easier, is still not easy because injected insulin does not act immediately, and (depending on the type of insulin) it may continue to affect blood sugar for a couple of hours. Further, some foods are digested quicker than others and hence affect blood sugar in different ways. Managing diabetes is always a case of finding out what works and then sticking with it. <i>Change</i> is the worst word in a diabetic's life.<br />
<br />
In my next blog I will describe the issues with the controlling diabetes using finger-prick blood glucose tests, and what could be done to improve the situation.<br />
<br />
[*] This is all very approximate, but <a href="http://adc.bmj.com/content/54/5/371.full.pdf">figure 1 in this paper</a> suggests that 2% Clinitest represents between 2.5g and 4.5g (say about 3g) in 100ml of urine, which means my urine was as sweet as <i>one and a half teaspoons</i> of sugar in a mug of tea.richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0tag:blogger.com,1999:blog-7462652546051300479.post-42128464772985068822014-02-22T21:01:00.001+00:002014-02-22T21:01:31.562+00:00Are You Involved?<b>Whose Patient Are You?</b><br />
<br />
There really is just one type of patient: a patient. A patient is a person who is ill and needs care, simple as that. It could be elective or emergency care, but it is still care. It could be a single episode, or a lifetime of treatment for a long term condition, but it is still care. The patient is the receiver of care.<br />
<br />
When pushed, I would set up a dividing line between NHS and private patients for the simple reason that private patients have made a conscious decision that they want to opt out, and are choosing not to be the same as everyone else. People who choose to have private care have the same rights to NHS care as the rest of us, but they choose - for a variety of reasons - not to exercise those rights. It is their choice, but they can opt back in any time they like. However, for the rest of us, private care is not an option, which is why it is so important to defend our access to the NHS and to get involved in the improvement of NHS care.<br />
<br />
Thus, there are just two types of patients: private patients and NHS patients. This is pertinent to this blog because this is about <i>public and patient involvement</i> which is a concept unique to the NHS. The relationship private patients have with their healthcare provider is a simple customer-provider relationship, if you do not like the service you take your money to another provider. The relationship an NHS patient has with their healthcare provider is far more complicated than this. NHS patients do not have control of the money spent with providers and I would argue it is <b>incredibly important</b> that they don't. The reason is that providing good care is very different to providing a profitable service. Many NHS services cost more than the money provided, so "<i>taking your money elsewhere</i>" is often a case of "<i>taking the deficit elsewhere</i>".<br />
<br />
<b>Which Parts of the NHS Do You Use?</b><br />
<br />
The NHS is often viewed by managers and politicians as primary, secondary and tertiary care, but from the patients perspective this is either GPs (primary care) or hospitals (secondary and tertiary care). There is also a dividing line between acute (or physical health) and mental health; and typically, if you have a mental health issue which results in hospitalising that will be in a mental health hospital even if you have a physical health condition that would otherwise mean that you should be in an acute hospital. In addition, there is a grey area within the NHS: community health services. As the name suggests these are services delivered in the community, in small clinics or in the patient's home. Community services are largely a historical relic of local authority involvement in healthcare before the establishment of the NHS. You could argue that community services are primary care that should be delivered by GPs, or alternatively, you could argue that they are step-down services of hospitals, and in some cases (like Continuing Healthcare) hospital services delivered in the patient's home. In some areas community services are delivered by acute hospital trusts, in others they are delivery by mental health trusts, and in others they are delivered by private companies.<br />
<br />
To us patients, we need care from the NHS as a whole. We may have physical or mental issues, we may need episodic care or have a long term condition needing long term care. We may need the care in our homes, in a GP surgery, a community clinic or in a hospital. In all cases we are simply a patient. Treating us as a patient rather than a consumer of multiple services is the philosophy behind <i>whole person care</i>.<br />
<br />
<b>Getting Involved</b><br />
<br />
Public and Patient Involvement (PPI) is a legal responsibility of NHS organisations. The <a href="http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted">Health and Social Care Act 2012</a> (HSCA) created two new commissioners, NHS England and Clinical Commissioning Groups (CCGs) and the Act created a responsibility for PPI for both (as outlined in <a href="http://www.nationalvoices.org.uk/sites/www.nationalvoices.org.uk/files/how_the_act_may_help_involvement_in_care.pdf">this document</a> by National Voices). <a href="http://www.legislation.gov.uk/ukpga/2012/7/section/23/enacted">Section 23</a> and <a href="http://www.legislation.gov.uk/ukpga/2012/7/section/26/enacted">section 26</a> of the Act, add section 13H and two sections 14U and 14Z2 to the <a href="http://www.legislation.gov.uk/ukpga/2006/41/contents">NHS Act 2006</a> to place a duty of PPI on, respectively, NHS England (called "The Board" in the Act) and CCGs.<br />
<br />
PPI is a legal requirement of NHS commissioners and there are requirements for NHS providers to have patient involvement too; private providers of NHS care do not have to have PPI and consequently do not.<br />
<br />
<b>An NHS England Patient?</b><br />
<br />
NHS England commissions primary care (GPs, opticians, dentists, pharmacies), care for prisoners and military personnel. They also commission tertiary care and care for rare conditions. The HSCA places a duty for NHS England to "<i>promote the involvement of patients, and their carers and representatives (if any)</i>" in the decision making of "<i>the prevention or diagnosis of illness in the patients</i>" and "<i>their care or treatment</i>". NHS England has put some effort into the PPI for <a href="http://www.england.nhs.uk/2013/09/12/ppv-reps/">rare conditions</a> but have been largely quiet about the much bigger issue of PPI in the commissioning of primary care. Primary care is commissioned on a regional basis by the so-called <a href="http://www.nhs.uk/services/Pages/AcuteTrustList.aspx?trustType=LocalAreaTeam">Area Teams</a>. These rather shadowy groups do not hold meetings in public and their board papers are not published, so the public do not know what these groups are doing, nor able to challenge their decisions.<br />
<br />
Logically, the Area Team should be recruiting patients through GPs, opticians, dentists and pharmacies because they commission the services patients use from these providers, but there is little evidence that Area Teams are doing this. If you want to be involved in the commissioning carried out by your Area Team there is little information about who to contact.<br />
<br />
Shadowy is perhaps being too kind to them, the Area Teams seem to want to avoid the public entirely.<br />
<br />
<b>A Clinical Commissioning Group Patient?</b><br />
<br />
Clinical Commissioning Groups commission secondary care (ie hospital care), mental health, GP out of hours services, urgent care services like ambulance and 111, and community services. CCGs are membership organisations in that every GP practice has to be a member of a CCG. (These GP members of CCGs are involved in their decision making, but unfortunately the so-called <i>members councils</i> emulate NHS England by meeting in secret and refusing to publish their minutes.)<br />
<br />
The new section 14U that the HSCA adds to the 2006 NHS Act a duty to promote PPI on CCGs, and in addition it says that NHS England should publish guidance on how CCGs should do this. This statement appears to be the case of the tail wagging the dog: CCGs can tell NHS England a lot more about PPI than the other way around. The new section 14Z2 goes into more detail about the responsibilities of CCGs. This says that patients should be involved "<i>in the planning of the commissioning arrangements</i>" and in the "<i>changes in the commissioning arrangements</i>" of the CCG.<br />
<br />
As part of their authorisation CCGs had to provide their PPI strategies to, and these be approved by the largely PPI-free NHS England. Consequently every CCG has some form of Patient Participation Group (PPG), and most of these are based upon the PPGs of their member GP practices.<br />
<br />
<b>A GP Practice Patient?</b><br />
<br />
General Practices have had <a href="http://www.napp.org.uk/">PPGs</a> for many years. PPGs are paid for through <a href="http://bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/contracts/gps/patientparticipation_directedenhancedservice_england_updatemay2013.pdf">Directed Enhanced Services (DES)</a> (until the end of this financial year) so GPs are actually <i>paid</i> to provide them. Most practices take this money because they recognise the benefit that patient feedback from a PPG can provide. One requirement of the DES payments is the annual patient survey which practices can use, through locally determined questions, what patients want and how the practice can improve their facilities and services.<br />
<br />
There is another distinct advantage that practices gain from having a PPG that GPs are only now starting to realise: CQC. If a practice is CQC inspected the first thing the inspector will ask is "<i>can I talk with your PPG?</i>". A negative response is not going to allow the rest of the inspection to go well, and, as practices are starting to learn, a friendly PPG can do wonders for their CQC rating.<br />
<br />
<b>Or A Foundation Trust Patient?</b><br />
<br />
Foundation Trusts (FTs) are a special case because they are the only part of the NHS where there is elected patient representation. Foundation Trusts have a membership (usually opt-in for public and patient membership, but opt-out for staff membership). The membership elects governors to the FT's Council of Governors. More than half of the Council must be public or patient elected governors and the remainder of the Council are elected staff governors and stakeholder appointed governors. The public and patient elected governors represent the constituencies that elect them but the HSCA (<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/151/enacted">section 151(4)</a>) says that in general governors "<i>represent the interests of the members of the corporation as a whole and the interests of the public</i>" (the "<i>corporation</i>" here refers to <i>Public Benefit Corporation</i> which is the legal term for a Foundation Trust).<br />
<br />
In general governors have a responsibility "<i>to hold the non-executive directors individually and collectively to account for the performance of the board of directors</i>". Foundation Trust Board of Directors meetings must be held in public (<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/152/enacted">section 152(5)</a>) however, as a public body it means that the Foundation Trust can use the <a href="http://www.legislation.gov.uk/ukpga/Eliz2/8-9/67">Public Bodies (Admission to Meetings) Act 1960</a> to exclude the public (which includes governors) from parts of the Board meeting where it "<i>would be prejudicial to the public interest by reason of the confidential nature</i>". In spite of this, Foundation Trust governors have a right (<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/152/enacted">section 152(4)</a>) to have access to all Board minutes including the minutes of the confidential section of the Board from which they are excluded, so although governors cannot attend the confidential section, they can see what was said.<br />
<br />
Other than the general responsibility to hold non-executive directors "<i>to account for the performance of the board of directors</i>", there are specific responsibilities. For example, if a Foundation Trust intends to increase its income from private patients by more than 5% of the total income of the trust (an event that is as a rare as finding a hen's tooth) more than half of the Council of Governors must approve. In addition, governors must inform the Board of Directors whether it is satisfied that treating private patients "<i>will not to any significant extent interfere</i>" with the treatment of NHS patients (<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/164/enacted">section 164(3)</a>). This last responsibility is fairly toothless because governors do not have any power to stop an FT from treating private patients.<br />
<br />
The two most powerful powers of governors are to appoint and remove non-executive directors, and to determine whether <i>significant transactions</i> should go ahead. Governors appoint the non-executive directors (NEDs, including the Chair of the trust) and can remove them, governors also determine the pay of these directors. NEDs are members of of the Board of Directors, and board decisions are made collectively by all directors. NEDs do not have an operational role, they do not manage the trust, instead their role is to challenge the executive directors. NEDs also form the appointments committee that appoint, and determine the pay of the executive directors. Although the NEDs appoint and remove the chief executive, governors have to approve such decisions. Possibly the most powerful responsibility of governors is covered by the term <i>significant transaction</i> (<a href="http://www.legislation.gov.uk/ukpga/2012/7/section/167/enacted">section 167</a>). The Foundation Trust can only enter into a significant transaction if more than half of governors approve. The Act does not define what a significant transaction is other than saying that they must be specified in the trust's constitution. Any changes to the constitution must be approved by Governors and the trust Board of Directors.<br />
<br />
<b>What About Private Providers?</b><br />
<br />
The government says that there is a "fair playing field" when it comes to commissioning services, however, the one area where the playing field is not "fair" is where it comes to patient involvement and patient representation. There is no legislation that requires private providers to involve patients in the provision of the care they provide. There is no legislation that requires private providers to have public board meetings or publish their board minutes. If the provider is a charity or a social enterprise, they will have their own rules about patient involvement, however, usually such third sector providers behave as if they are private businesses when providing NHS commissioned services.<br />
<br />
If you are offered an NHS service from a private provider bear in mind that no patient was involved in designing the service. No patient is involved in the continuing improvement of the service nor in holding the senior management to account for the service. As a patient you will not have an opportunity to be consulted about the provision of the service. All of this is worth bearing in mind before you consider using a private provider for your NHS care.<br />
<br />
<b>So What Sort Of Patient Are You?</b><br />
<br />
If you want to get involved in the planning and delivery of NHS services, you have lots of opportunities. The problem is that the different parts of the NHS do PPI in different ways and some parts (particularly commissioners) define involvement as "<i>help us performance manage those other people</i>". When you combine this with the total lack of PPI in the private sector, it all adds up to a mess.<br />
<br />
Patient involvement in improving services come from two perspectives: the provider and the commissioner. The commissioner designs the service and monitors delivery, patients can be involved in the designing of a service, and as the recipient of the service, they can be involved in feeding back how well the service is performing. Commissioners monitor services to enforce the contracts they have with the providers, most contracts have some kind of penalty or incentive and often patient feedback is involved in these. Contractually, providers clearly want to avoid the penalties and gain the incentives, so patient participation is important to them.<br />
<br />
For example, patients join a GP practice PPG to help improve the services at the GP practice from a provider's perspective. GPs are mostly commissioned by NHS England Area Teams (there are a few GP services that CCGs commission) but the lack of PPI in Area Teams means that there is little commissioner patient involvement in improving GP services. It is very clear that patients join GP PPGs to improve GP services, if they want to improve hospital services the obvious route is to join a hospital PPG (or equivalent PPI). However, most CCGs draw from GP PPGs to form their own patient groups. CCGs do not provide services, and they do not commission GPs, so a patient who joined a PPG to be involved in the improvement of their GP services will find that they are asked by the CCG to improve services they originally did not volunteer to be involved with.<br />
<br />
CCG patient participation groups are involved in the commissioning, and improving, of hospital services, mental health services, community services, urgent care services and out of hours through the commissioner-provider relationship. In other words, very few services that involve GPs.<br />
<br />
<b>Conflicts of Interest</b><br />
<br />
Commissioners are quite open about that they will use the contract with the provider as a lever to improve services: threats of commissioning another provider, or moving the service to the free-for-all that is Any Qualified Provider. Collaboration has largely disappeared due to the recently introduced procurement regulations.<br />
<br />
Gone are the days when the patient group of a provider could collaborate with commissioners to improve the service. The patients of a provider's PPG will have direct experience of the service and are a valuable resource: a patient involved with a public sector provider will have more experience about the service being commissioned than a patient who is not involved with the provider. Thus, it makes a lot of sense for a CCG to involve those patients in redesign of those services. Similarly, if a CCG wants to improve a service, the best course of action would be to consult the existing service provider, since that provider will be more of an expert about the delivery of the service than the commissioner. However, CCGs wary of litigation under the new procurement regulations are reluctant to seek advice from those providers and their patient groups because they may appear to be giving unfair competitive advantage to those providers. From a PPI perspective, if a CCG involves a patient in commissioning and that patient is a member of a PPI group at a provider, that could be regarded as being anti-competitive.<br />
<br />
It works the other way around too: there is no incentive for an existing provider to help design services if those services will be put out to competitive tender with the possibility that the provider may not win the tender. The new procurement regulations are a barrier to the improvement of services.<br />
<br />
CCGs are rather inconsistent in applying the strictures of the procurement regulations. CCGs can commission <i>Locally Enhanced Services</i> from GPs, and these may replace services formerly delivered in secondary care (so-called "<i>move services to the community</i>"). Since CCGs are membership organisations where the members are GP practices, CCGs have to take steps to prevent "<i>conflict of interest</i>" when awarding LES to member GPs. However, these steps are usually just for show. For example, the GP members of a governance board declining to take part in a vote that awards services to GPs when the decision has already been made out of the boardroom. This, we are told, is acceptable. Furthermore, if a CCG involves its patient group in commissioning LES there is a high chance that it will involve patients who are members of the PPGs of the GP practices who would benefit.<br />
<br />
<b>I Am Just A Patient!</b><br />
<br />
Patients are patients, they are not <i>your patient</i> or <i>our patient</i>, they are NHS patients. It is quite clear that public and patient involvement is getting fragmented because of the new competition-based procurement regulations. Patients are excluded to prevent perceived "<i>conflict of interests</i>", while real conflicts are not being addressed. Patient involvement is vital to the NHS, not only does it give a legitimacy to the commissioning by a public organisation, but it has the potential to make significant improvements to the services being commissioned. No patient is restricted to one provider or one service, no patient pathway is limited like that, so why should patient involvement be limited?<br />
<br />
Before the fragmentation of services and PPI gets much further we need to stop and rethink. Ultimately we need to remove competition from healthcare planning because it is resulting in competition lawyers determining which providers are commissioned. While we wait for that to happen, the next best thing would be a declaration from the Secretary of State that patients are far more important than competition laws and to tell commissioners that they cannot exclude patients from commissioning on the grounds of "<i>conflict of interest</i>". To ensure that such a declaration is followed, a neutral third party should have not only the responsibility to ensure that patient involvement occurs, but also to enforce it. Such a neutral third party should have the same power over all commissioners and providers: NHS England, NHS England Area Teams, CCGs, Local Authority social care commissioners, NHS providers, GPs and private providers.<br />
<br />
At the moment there is no such patient organisation, but there is a possibility that local Healthwatch could be given new powers, responsibilities and resources to do this. Such a revitalised Healthwatch would be able to support patient groups so that they are independent of providers and commissioners, being able to discuss the issues that concern the patients. Healthwatch could be given the power to delay the commissioning of a service on the groups of inadequate patient involvement. It could also have the responsibility to ensure that all providers (NHS and private) have patient engagement and involvement in the delivery of services. Such power would give meaning to Healthwatch.<br />
<br />
<i><span style="font-size: x-small;">(Richard Blogger is an elected Foundation Trust governor and a patient representative at his local CCG PPG. He has been excluded from patient involvement in commissioning by the CCG on the grounds of "conflict of interests".)</span></i>richard.bloggerhttp://www.blogger.com/profile/10589364986804437392noreply@blogger.com0