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Is it too little too late?
We found out this morning from Dave West from an article in the HSJ that HM Treasury has agreed an unannounced £740m increase to the health revenue budget for the current financial year.
Since mainstream parties agreed to sign up to ‘efficiency savings’, a euphemism for making cuts in budgets, NHS Trusts all over the land have been trying to reconcile PFI debt with running a bargain basement staff. The current Government and key political stakeholders have resisted at all costs a national minimum staffing level, arguing primarily that this is not the overall number of nursing staff which matters but their suitability of skill sets in nursing environments.
These efficiency savings, nonetheless, have been made by NHS hospitals. Some hospitals have been more successful than others. The idiotic nature of the NHS drifting towards a market, being ensnared by the EU competition laws, that such financial assistance of hospitals come dangerously close to “state aid” which is deemed unlawful.
In England, “state aid” already exists in the form of foodbanks which have exploded in number under this Government. The consensus is that they have primarily supplied a need demanded from deserving members of the public, many of whom have been waiting for unreasonable time for benefits. This is a direct effect of the crass incompetence of operations in handling of benefits under this Government. This incompetence has seen emotional distress from people who are disabled. Some, it is alleged, have even taken their own lives.
The problem with running the country’s “safety net” in such a ‘lean matter’, means that there is no reserve in the system. If a nurse or Doctor goes off sick, the entire rota is thrown into chaos. The NHS ends up chasing its own tail, for example by employing expensive locum staff when it has not had the competence to employ the correct number of staff in the first place.
The mainstream political parties are still, overall, committed to the ‘private finance initiative’, although there have been some noises about how little value for money it represents. Despite the successful campaigning by some on the NHS, the political motivation for providing a solution to this problem appears lacking. There is an issue not only about the exorbitant demands of loan repayments, akin to a corporate ‘Wonga’ strangehold on the State’s finances, but also how private equity firms seemed to have got an amazingly good deal out of it effecting having a level of control and ownership on NHS hospitals which the general public, if they know, would balk it.
The next Labour Government is expected to introduce ‘whole person care’. Everyone agrees that social care is on its knees, but invariably most people agree that this situation has not come about suddenly in the last few years. There has been an insidious promotion of marketisation in the social care sector, which Labour had much to do with. Anyway, living in the now, the social care sector is in utter chaos. NHS hospitals are not able to discharge, often, their patients into social care in a timely fashion. Health and care sectors are intimately dependent on one other.
There is a growing feeling now that the drift in health and care policy across several governments, with a feeling of ungenerous funding, PFI, personal budgets, etc., albeit catapulted with the chaos over competitive tendering over the Health and Social Care Act (2012), has somehow resulted in an almighty mess. Like Lord Sugar, people are scrabbling around for a quick fix, but this is not going to be easy. Some of the strategies are clearly ‘science fiction’, unmarketable, or incapable of any teamwork. There appears to be too many Chiefs and not enough Indians. To coin the phrase by David Cameron, “We can’t go on like this?”
But in the meantime – the first management step must to be to say to Mr. Jeremy Hunt those immortal words…
“You’re fired”
We need to talk about the NHS
I’m essentially in two minds about whether the NHS is ‘a political football’.
On the one hand, I don’t think it should be.
I felt the way Mid Staffs meant some hardworking staff in that region came to be pilloried and demonised by the media was more than indecent.
On the other hand, I think you can clearly apportion blame for the current Government’s performance about A&E waiting times and other key metrics.
On balance, I’d like Labour to have a strong majority to get through repeal of the Health and Social Care Act (2012), without say relying on the Liberal Democrats who enacted it in the first place.
There’s also important legislative work to be done in bringing together health and care; and also an Act of parliament to consolidate regulation of clinical professionals.
While I have much sympathy for NHS campaigners, I most certainly do not want a weak Tory-led Government because of incessant criticism of Labour.
There is a huge amount to discuss about the NHS.
I believe, for example, that the private finance initiative, whilst it had a useful aim in improving the infrastructure of buildings of the NHS, clearly did not represent value for money.
I don’t think it’s ever justifiable to bring in the private sector because the NHS can’t ‘cope’. I don’t see why you should want to bring in locums either, because of ‘unforeseen circumstances’.
And, in total agreement with Jackie Ashley at a fringe meeting of the Fabians this year, there needs to be had somewhere a discussion of how health and care sectors are to be properly funded.
There is almost universal agreement that the NHS cannot function at anywhere near its best with social care in such chaos.
I do blame a supine media for not allowing discussion of ‘whole person care’, or discussion of topics that even Labour would like to talk about (such as PFI; see Margaret Hodge’s remarks).
We’ve got some brilliant brains involved – Prof Allyson Pollock, whose brilliant analysis of PFI shines, has had some very pertinent points about the Clive Efford Bill with Peter Broderick. Yes, Andy Burnham MP does not support ISPS/TTIP, but this policy is still being left hanging in an uncomfortable way.
I am fundamentally a socialist, so I take the perspective that if we’ve got money for war we’ve got money for the health service. And I think with debt going through the roof, and with the economy being fuelled with insufficient till receipts, we are a long way from the energy which saw the NHS created in the first place from the spirit of ’45.
Whilst supporting Labour, I don’t wish this to descend into tribalistic nonsense. I will support anyone who has decided that the current performance of the NHS is unacceptable, but I have no intention of actively campaigning against Labour.
I personally wish to see policy for living well with dementia progress under Labour, irrespective of whether Ed Miliband can eat a chip butty.
Whatever, we certainly need there to be a public discourse about the NHS more than Europe or immigration, for example. Socialism is social-ism; if you want to see how collectively we can pull through, just look at the energy generated by Jon Swindon (here) or Eoin Clarke (here).
The presentation may be awful, but sharing of information can be very useful for clinical decision making
Whenever I hear of somebody refer to ‘Big Data’ and the NHS, it’s an immediate ‘facepalm’.
When I saw a blogpost shared by a Twitter pal shared yesterday, a blogpost written by Sir Jeremy Heywood, my first instinct was completely to ignore it.
I am, though, mindful of the Civil Service’s prolonged campaign to measure wellbeing; this first came across my RADAR from Lord O’Donnell.
I have a disclaimer to make: I am not a corporate shill.
Having done certain training, I am aware of the hard sell of ‘Big Data’ as the next big thing by the multi-national corporates. “Big data” seem to have been given a somewhat pedestal status, like 3-D printers.
We are often told how intelligent technology rather than being a costly burden to the NHS could bring great benefits and outcomes for the NHS.
Undoubtedly, a lot of democratic deficit damage was done by the Health and Social Care Act (2012). At close to 500 pages, it was very easy to say it was too incomprehensible to be analysed. I always felt the Act, for anyone trained in commercial and corporate law, was in fact relatively straightforward.
The Health and Social Care Act (2012), often called “the Lansley Act”, has three essential prongs of attack: one to introduce a competitive market through legislation for a heavy penalty for non-one-commissioning not going out to tender, a beefed up regulator for the market (Monitor), and some detail about insolvency regimens (but not all).
In this, it was completely consistent with work by Carol Propper; and other noises from ‘independent think tanks’, such as the King’s Fund.
However, the acceleration of this Act through parliament by two parties which are extremely sympathetic to the free movement of multinational capital has done long-lasting damage.
I think there are problems with having data so transparent. When I did my Masters of Law practice-focused dissertation in cloud computing law, I unearthed a huge literature on data security and data confidentiality/sharing.
When I later did my pre-solicitor training, I discovered the regulatory requirements on the balance between confidentiality and disclosure to be complicated.
When I later came to revise ‘Duties of a Doctor’ (2013), the General Medical Council’s code of conduct, I found there to be equally onerous considerations.
I am aware of the problems in my own field of work; about concerns that NHS patients will be scared from going to see their GP for fear of being diagnosed, incorrectly, with ‘incipient dementia’ because of a GP’s practice wanting to meet a financial target.
Or a junior Doctor not wishing to share his alcoholism with his own Doctor, for fear that this information will end up with the clinical regulator, with a super-un-sympathetic sanction. This is a subject close to my heart, as you will well know.
Indeed, if you’ve been following me on Twitter, you’ll know that a year after erasure by the GMC (in 2006 to be endorsed by the High Court in 2007), I spent a year sitting in a pub with no family or job. I later was then admitted to the Royal Free Hospital having had a cardiac arrest and epileptic seizure, then to spend six weeks in a coma.
I am now knowledgeable about what both the legal and medical regulators expect me to do, as I am regulated by them.
The next Government will be wishing to implement ‘whole person care’. While I think some of Jeremy Heywood’s claims are a tad hyperbolic (for example saying unleashing data will lead to wellbeing improvements), and while I don’t feel he currently ‘owns’ the data (the data are confidential property of the people who provide the data), there are clinically-driven merits to information sharing.
From now on, I will avoid the word ‘data’ and use the word ‘information’. But ‘information’ does not necessarily mean ‘knowledge'; and it certainly doesn’t necessarily mean ‘wisdom’.
One scenario is somebody prescribed Viagra for erectile dysfunction in the morning. He then has sex with his partner in early evening, and has Angina. He has longstanding ischaemic heart disease, and then takes his GTN spray. His blood pressure then goes through the floor, and he collapses. He then is blue lighted into his local emergency room.
Do not take this anecdote as ‘medical advice’ or any such like where I could get into regulatory trouble please.
Viagra is a class of drug which can interact with the GTN spray to send blood pressure through the floor. If this information were known to an admitting Doctor in the emergency room, this would be useful.
I can come up with countless examples.
A lady from a care home turns up in hospital at 4am. An admitting Doctor wishes to prescribe a heavy-duty blood pressure lowering drug, but notes she has had a series of falls. This is found out by looking at her electronic medical record. She indeed has a history of osteoporosis; weak bones could mean that she might fracture a bone if she had another fall.
But I could come up with countless examples. And I won’t.
I am not a corporate shill. I understand completely the concerns about the loopholes in current legislation meaning that ‘big data’ could go walkies to drug companies, though this is vehemently denied.
I am also aware of ‘cloud failures’ – the Playstation one for some reason springs to my mind.
That’s another reason to keep an eye on ‘My NHS’.
But we do need, I feel, to take a deep breath and to discuss this calmly.
The general public have never needed the NHS campaigners as much before. The situation is critical.
“The past is a different country. They did things differently there.’
One of the favourite weapons in the armoury of supporters of the present Coalition is that the warning claims over the NHS have been in the past ‘exaggerated’ or ‘scaremongering’.
And yet today broke records being broken, for the longest waits in the Accident and Emergency departments in England; and a record number of emergency admissions.
The National Health Service currently has a statutory duty to promote innovation. But nobody would have thought that Mr. Hunt (who is not a professional surgeon, or professional medic, to my knowledge) would have ‘done things differently'; by adding a ‘Spring Crisis’, ‘Summer Crisis’ and ‘Autumn Crisis’ to a ‘Winter Crisis’.
Put simply, sadly the claims by NHS supporters do not constitute merely ‘scaremongering’. It may have been urgent to ‘save the NHS’ in the past; as indeed Labour had to do in 2007 when the service was teetering on the brink last time. But the situation is now critical.
The last few years have seen a litany of errors in public health policy; such as in standard packaging of cigarettes, or minimum pricing of alcohol. It has been impossible for the Conservatives and the Liberal Democrats, who are both devoted to the multinational free movement of capital, to act in the true public interest.
But by far the worst event to have happened were the Conservatives and Liberal Democrats getting onto the state books the ‘Health and Social Care Act’.
The Liberal Democrats’ contribution to this statutory instrument cannot be underestimated by any means. Despite the noblest actions of a minority of ‘good LibDems’, such as Dr Charles West, the cheap words of some LibDems Peers in the debate over the toxic ‘section 75′ made their position perfectly clear.
Section 75 of ‘the Lansley Act’, which senior Conservatives now claim not to have understood, couldn’t have been clearer. It was a clear departure from the previous law. It laid out a clear threat in law for the first time a legal threat to any commissioners departing from putting contracts out to formal competitive tender, if there were not a sole bidder.
The Liberal Democrats, Conservatives and UKIP may now show what can best be described as ‘amnesia’ over this instrument which some of them actually legislated for, as well as the £3bn ‘top down reorganisation’ which David Cameron swore blind would never be introduced, but “the facts speak for themselves”: or, as my learned legal colleagues, put it, ‘res ipsa loquitur’.
Andy Burnham MP this morning in an article in the New Statesman laid bare the sheath of lies by Nick Clegg in the House of Parliaments over the NHS.
Sadly, while Jeremy Hunt and Dan Poulton fiddle while the NHS collapses, there is a record number of admissions in emergency departments in England, and the most vulnerable people are labelled ‘bed blockers’ by a supine and ineffective English media as they cannot leave hospital to a social care system which has now collapsed through starvation.
Labour argues that it last used the private sector in needing to address a ‘backlog’ in demand, but the question is how the NHS get to this state in the first place? It’s because for decades, as NHS campaigners rightly argue, the NHS and social care systems have been given the bare minimum to carry out their functions.
NHS managers, many of whom are generously paid more than their ability might suggest, and certainly much more than frontline nurses implementing a policy savaged by staffing cuts in the name of ‘efficiency savings’, have been trying to balance the books through a number of mechanisms, such as laying off staff, not giving existent staff a pay rise, or paying corporates loan repayments for PFI or lawyers for doing their administration.
Labour possibly can argue then it was a temporary measure to pay off people in the private sector to do the work the NHS had been carrying out, but the mainstream parties should be in the business of delivering a well functioning NHS. As Andy Burnham MP said in launching his party’s campaign on the NHS in the European Election in 2014, we’ve got a sad state when the Conservatives and LibDems are competing for the lowest social care bills irrespective of whether the services are awful.
And it’s sacracant to criticise the NHS managers, but any reasonable guardian of these managers will ask why they have allowed their own senior pay to balloon;
why performance management of Doctors and nurses in the NHS is so poor, with performance management being regularly done by the regulator not by human resources;
why so much money has been siphoned off for ‘transaction costs’ of law and admin the implement the NHS reforms;
why PFI contracts have been so poorly negotiated such that the cost to the State is enormous;
how come so many private providers are being directly paid out of the NHS monies provided by taxpayers;
why there seems to be an enthusiasm to pay short-term locum staff at exorbitant rates instead of investment in the current workforce;
and so on?
The Health and Social Care Act (2012) drove the NHS over the edge. Put simply, the NHS and social care systems would not be able to survive another sudden legislative mechanism designed to privatise the NHS?
On this Camilla Cavendish is simply incorrect. You would have thought with all her experience she should have come up with a better definition of ‘privatisation’ on BBC Question Time last night. it is the standard argument of those who say it is not privatisation to say that privatisation is accompanied by a ‘tell Sid’ type flotation (also called the “initial public offering’).
It is not.
Privatisation is simply wholesale transfer of assets and resources from the public sector to the private sector.
There has been every possible last-ditch effort to deny this was NHS privatisation from the current neoliberal Coalition parties. It is definitely privatisation. The taxpayer is paying private companies for functions which the State should be providing, without private companies footing properly their part of the ‘bill’ including for training of the current workforce of professionals.
The ratcheting up of how ‘it is not privatisation’ or ‘we should look at whether private provision is a bad thing’ is a testament to this.
Quite simply, the NHS would not survive another five years of the Conservatives. We should rally around NHS campaigners of all parties to ensure the Conservatives and Liberal Democrats are not re-elected nationally to run the NHS for their benefit.
The National Health Service is not supposed to be run for the benefit of private sector ‘rent seekers’, or MPs who also have interests in the private health industry. Keep our NHS public. Keep the NHS National run for the public good.
Support your NHS campaigner. He or she needs you.
George Osborne’s “duty of candour”
I’m pretty certain that George Osborne is actually quite a nice guy.
I know of people who know people who’ve had dealings with him on a chat-chat level. And apparently he’s perfectly harmless.
George Osborne’s one job was to run the UK economy. And he’s failed at that.
The LibDems had a job to deliver to deliver ‘a strong economy and fair society’. Add in the murder of English legal aid, we can confidently say the LibDems failed on their side of the bargain.
It doesn’t matter which particular metric you wish to use. The only good soundbites came from the rose garden soundbites from the Office for Budget Responsibility in 2010 informing us of the shiny uplands.
But it turns out that the incline of the uplands was steeper than we first thought. Osborne kept on telling us this was due to the Eurozone crisis. This is the same Eurozone crisis which has suddenly disappeared with one us being one of the ‘best performing economies’ in the G20.
Osborne’s pitch is that he needs just a little more time, as the famous Reet Petite song goes. He needs to ‘finish the job’ to put the UK back ‘on the path to prosperity’. This is the “long term economic plan”.
Except… the long term economic plan is not working. A record number apparently in employment with really bad income from as receipts? How did that happen?
Was it something, perhaps, to do with a record number on low security “zero hour contracts”, topped up with tax credits, who do not end up paying much income to the State?
The Conservative (Ronald Reagan) doctrine of a small state is creepy. The drastic diet of an ‘over bloated’ State has left a State which is anorexic – and which is dangerously fragile.
The Coalition’s anorexic state is consequently far from resilient. Most reasonable people agree that the anorexic State would simply be unable to cope with the Conservatives’ further planned cuts in the next term of office.
This is not the “shock doctrine” of Greece. It is a reality of something happening in the UK not seen since the 1930s.
The current Government has successfully relaunched the ‘duty of candour’. The duty of candour, about being open in the NHS when a mistake is made, already existed in the regulatory codes of the clinical professionals.
And again – it’s not actually the legal instrument as drafted which is the main problem (though there are problems here). It’s whether anyone is observing them properly: see for example ‘wilful neglect’ (section 44 Mental Capacity Act), national minimum wage, or deprivation of liberty safeguards.
Osborne does not want to come even close for apologising for the record debt, the colossal borrowing, the poor living standards, or the fact that his plan to pay off the deficit has been tragically bad.
I don’t know whether this is a pride thing, but in the real world it has a knock on effect for whether you can pay for health and care. We know the social care budget has been on its knees for years.
Many NHS Trusts are in deficit. This can’t be due to the nurses, most of whom have not experienced a pay rise for years. It may be due to the salaries of top CEOs in the NHS who have to ‘deliver’ on metrics which do not necessarily reflect high quality care (e.g. the ‘four hour wait’). Or it could be due to paying off the loan prepayments for PFI under successive governments.
I really like members of the NHS campaigning parties, but discussions about the NHS have to be linked with the discussions of the state of the economy. It’s an elephant in the room.
Likewise, for all of the slagging off of the Efford Bill, I can guarantee that the statutory instrument UKIP would like to introduce would be far more controversial.
UKIP at least do entertain a discussion on leaving Europe and European law, sort of, even if they do not have any plans for the UK economy.
The Efford Bill was seen in some quarters as ‘the trojan horse for privatisation’, and I can see how interpretation of the clauses might result in this conclusion. I think a problem the Efford Bill was ‘reverse engineering’ to comply with EU competition law – i.e. clauses which perhaps sound as if they’re providing exemptions from EU law, but nobody actually knows.
Not even the best legal minds in the country, of which I am not one, know.
But the EU is founded on free movement of people. Tick – I remember working as a junior in NHS hospitals in London, and simply the day to day operations of these Trusts would have been impossible without the hard work of staff nurses predominantly from India and the Philippines.
And it is also founded on free movement of capital.
There is a genuine feeling of ‘I wouldn’t start from here’ for NHS campaigners in NHAP and Keep our NHS Public. They certainly want to go to a NHS inspired by Nye Bevan which had never heard of section 75 or TTIP.
But it is impossible to have this debate in the absence of a discussion of Europe. It’s impossible to have a debate on the NHS in the absence of a wider debate on the economy.
Russell Brand and Nigel Farage may be grandstanding, but on the face of it they seem to be coming from different places, and with huge followings.
This all matters as it is highly unlikely a Labour-UKIP coalition could be made to work on the NHS, given we know such little about what accommodations UKIP might make on EU competition law or the economy.
We don’t know whether UKIP supports ‘efficiency savings’ however.
All of this is not a leading to a conclusion of ‘Vote Labour’. Labour has not overtly apologised for some thorny apsects of NHS policy, in the same way that Osborne has not apologised over the economy. But it does seem to have apologised for a lot – like letting the market in too far – but curiously not PFI?
I am particularly mindful that there are some ‘real’ experts in NHS policy who are far more experienced and wiser than me. I am also in strong admiration of campaigners wherever they hail from; many of whom have experience of seeing patients regularly.
I never see patients unless they’re friends of mine; and that’s purely for social reasons.
But the next Government’s policy on the NHS will be severely affected by the mistakes of the current Government, part of which ironically has a catchphrase ‘strong economy, fair society’.
Yes, I am getting totally sick of NHS campaigners too
The tragedy about the context to what I am about to say is that the NHS is THE issue of the next election.
Cameron is not a leader. He’s a manager, and not a very good one.
A couple of days ago, the ‘New Economics Foundation’ published an interesting report on how the NHS reforms had been sold on false pretences.
It was an excellent report.
The story starts in the 1980s with full gusto.
Market-based reforms began in the 1980s, when support services were first contracted out, but, according to the report, continued in the 1990s, with the creation of an internal market for clinical services.
The claim was that increased competition can improve both efficiency and quality of care is a central justification of market-based reforms and the Health and Social Care Act.
The King’s Fund thought it might do too.
But many of us knew this was utter bollocks.
Reams and reams of evidence was published to the contrary, such as on the LSE blogs.
On page 5 of the Report, the experience from Serco makes chilling reading:
“Before pulling out of the Cornwall contract, Serco had replaced clinicians on its out- of-hours service with call-handlers who did not have medical training but followed a computer-generated script. The new system quadrupled ambulances called. Call handlers were then told to make new checks before calling 999 when they received what appeared to be emergency cases, so that managers could cut down the number of referrals they made to the ambulance service. A leaked management email to staff described how they should use their computer system to meet targets set down in the company’s contract on 999 responses.”
Often the NHS discussion goes round and round and round and round and round and round in circles of who started it and who continued it.
On the “private finance initiative” –
“This is a scheme that enables private companies to design, build and operate NHS (and other) facilities, using capital raised through financial markets, and then rent them back under long-term contracts lasting 30 years or more.
First introduced by the Major government, this approach was popular with New Labour, with nearly three-quarters of hospital building schemes funded through PFI between 1997 and 2009.”
And desperate Dan Poulter pulled the same rabbit out of the same that last week.
Labour “started it” with their NHS Competition and Co-operation units. They started it with their “Independent Sector Treatment Centres”.
Except… Labour didn’t start two things in particular.
One – the breach of the “four tests” in reconfiguration, which saw Lewisham win both in the High Court and Court of Appeal.
Second – the legal provision in section 76(7) Health and Social Care Act (2012), from the current Government, of a threat if services do not go to out to competitive tender if there is not a sole bidder.
We saw the same crap last week.
People saying the Clive Efford Bill didn’t go far enough – except nobody said it would abolish the purchaser provider split, PFI, the £2bn funding gap, Foundation Trusts or mutuals, or advance integration of health and care.
NHAP and KONP have gone mute on integrated care and whole person care.
There is absolutely no doubt that the situation where NHS hospitals cannot discharge patients to social care is a situation which cannot carry on.
NHS campaigners seem more concerned about proving how correct they are, than offering constructive thoughts on, say, how to improve wellbeing in long term conditions.
Mid Staffs in some quarters has furthered a toxic atmosphere of malice and retribution, and a culture of fear and nastiness, rather than thinking about how things can improve.
And it has produced a generation of journalists who are the new model jury of the health and care professions.
… except regulation of primary care was not built entirely around Harold Shipman… Harold, under a Tory Government, in case you’re wondering.
No wonder the Staffs area was plunged into a recruitment crisis after all their negative publicity.
GP surgeries are shutting like no tomorrow, and yet Hunt puts pathetic above more pathetic, while some of us are trying to put people before profit.
There will be only one party of Government on May 8th 2015. It might be a temporary Government but we don’t know who it is yet.
UKIP has made utterly contemptible comments about the NHS in the past which are well documented. The idea that Labour can work with UKIP in promoting the NHS is more than disgusting.
So another week and it’s the same old same old tired discussions.
It’s clear to me that some people prefer the foreplay to the actual act.
And it’s entirely all driven by egos. Again.
Who exactly is in denial over the Clive Efford Bill?
The Private Member’s Bill brought forward by backbencher Clive Efford MP passed by 241 votes to 18.
“From crisis to opportunity — putting citizens and companies on the path to prosperity: A better functioning internal market is a key ingredient for European growth” was updated in November 2014.
This publication is part of a series that explains what the EU does in different policy areas, why the EU is involved and what the results are.
It provides that, “The European internal market, also referred to as the single market, allows people and businesses to move and trade freely across the 28-nation group. In practice, it gives individuals the right to earn a living, study or retire in another EU country.”
It further adds that, “It also gives consumers a wider choice of items to buy at competitive prices, allows them to enjoy greater protection when shopping at home, abroad or online and makes it easier and cheaper for companies large and small to do business across borders and to compete globally.”
Not wanting to be part of Europe was of course how the late great Tony Benn used to be in agreement with Enoch Powell, even though they came from totally different political stables.
On 1 January 1973, Britain joined the “Common Market”, the European Economic Community, under a previous Conservative administration.
There has of course been a strident debate as to whether the free movement of capital, so important for capitalism, is inherently compatible with socialism at all.
Being a member of the EU, the UK has to sign up to the rules and regulations of EU law.
The current position of Labour is that the market ideology went too far under previous Labour administrations.
Critics of Labour say that they are still in denial over the “sweetheart deals” to encourage private provision under a previous administration. Labour argues that this private provision was necessary to improve clear a backlog in NHS work which existed at the time, rather than introducing private provision for the sake of it.
Much criticism centres around the “independent sector treatment centres”. John Rentoul unsurprisingly found himself in agreement with the approach Labour took at the time.
Many still within Labour still loathe what happened here. NHS campaigners affiliated to other parties have been critical of Labour in inadvertently contributing to the privatisation of the NHS, and are concerned it will happen again.
Critics point to unconscionable transactions under the private finance initiative, for example.
But historically this strand of policy started under a previous Conservative administration under Lord Major.
Clive Efford MP even referred to his local hospital in Eltham having been set up as the country’s first PFI hospital in last week’s debate on “The Clive Efford Bill”.
Given that we are under treaty obligations, unless there were a radical renegotiation of an unilateral exemption of the market aspect of the EU, we are stuck with a market in some form.
To argue otherwise would be in denial.
None of the front team of Labour have argued for abolition of the market altogether, to my knowledge.
But that is not to say that the ‘purchaser provider split’ might be abolished internally within England, notwithstanding treaty obligations.
The argument is that the market costs billions as it introduces “transaction costs”. The ‘household analogy’ is often used to explain the diversion of resources needed to monitoring the various transactions within a household at microlevel.
The market has become particularly problematic for the NHS, as was widely predicted before the Health and Social Care Act (2012). I myself wrote an article on the impact that section 75 Health and Social Care Act (2012) would have on the Socialist Health Association blog on 7 January 2013.
And the former CEO of NHS England, Sir David Nicholson, himself drew attention to how it had become a magnet for competition lawyers.
This was entirely to be expected as it was this clause which signalled a marked diversion from previous law under the most recent Labour government (viz section 76 sub 7 Health and Social Care Act 2012).
Elsewhere in the legislation it says that you do not have to put contracts out to competitive tender if there is only one sole bidder, which hardly ever happens.
To deny that the current legislation departs from the previous legislation is, arguably, denial.
So the “Clive Efford Bill” was finally debated last week. You can read it here. The official explanatory notes for the Bill are here.
The guidance given to the legislature is useful.
For example, for clause 6, it is provided: “The clause also enables the NHS to take advantage of exemptions to procurement obligations as set out in the European Union Directive 2014/24/EU.”
The Directive provides the ‘codification of the Teckel exemption‘.
The Teckel Exemption has proved important as an exemption from EU competition law when applied to the NHS.
Clause 1 posits that the NHS is a system based on ‘social solidarity’.
Solidarity is another mechanism of providing an exemption from EU competition law. In fact, the lack of solidarity was one of the criticisms of the Health and Social Care Bill made at the time made by ‘Richard Blogger’.
The Poucet and Pistre Case C-159, 160/91 case sheds light not heat on the ‘social solidarity’ exemption of competition law.
A reasonable concern is whether the ‘Clive Efford Bill’ hangs on by its claws to the notion of the NHS being comprised of ‘units of economic activity’ as per s.1 sub (2)(b):
But here it is the “Clive Efford Bill” which may be in denial.
Scrutiny in the Committee stage will have to be given as to whether the term here should be “general economic interest” or “general interest”.
The Government’s own guidance on this implementation of EU law is here.
If the direction of travel for all mainstream governments is genuinely to keep the proportion of private provision low, “general interest”, arguably, would be more suitable if the majority of health provision is not intended for profit.
It has been a consistent mantra from the Labour front bench “to put people before profit”, for example.
There are other issues about the significance of the words ‘deliver’ and ‘promote’ in the duty of the Secretary of State for Health.
The view of David Lock QC is here. The view of “The Campaign for the NHS 2015 Reinstatement Bill” is here.
Would a rose by any other name smell as sweet? It is a deeply entrenched position of the legal profession that lawyers look at the substance not the form.
As a statutory aid to the wording of this legislation, there is this paragraph lurking on the internet from David Lock QC from June 2013 which lends support to the notion that it is most useful if the ‘Clive Efford Bill’ is a statutory instrument best read as a whole.
Assuming that events do not overtake us, in other words we do not get chucked out of Europe imminently or the UK does not get bound in indefinitely over TTIP, we should in theory have some freedom to legislate for what sort of health service we want.
This is provided for in Article 168(7) TFEU.
It is therefore crucial we draft this legislation correctly.
Taking the position that there must be no criticism of the drafting of the Clive Efford Bill, arguing that it will undermine its implementation at Committee Stage, I think is an unreasonable position to adopt.
Likewise, grandstanding over “who is right” is inappropriate as well. There are possibly as many legal opinions as there are lawyers. We will not know with any certainty unless the Clive Efford Bill, if enacted, is put to the test by the judiciary; and even then, it will not be absolutely certain.
I think the Clive Efford Bill clearly positions itself as exempting itself from the overall gambit of EU competition law.
“It says what it does on the tin”. It is an immediate mechanism, if enacted, for getting rid of the toxic section 75 and baggage. It has been a useful campaigning tool.
But, if there is a Labour government of some sort in May 2015, it is already proposed that there will be regulation of health and care professionals as per the recommendations of the English Law Commission. This should have been in the last Queen’s Speech just gone, but the current Government chose to park this issue. Furthermore, quite drastic changes to the law will still be needed to promote integration of health and care to make whole person care work smoothly and legally. I first wrote about that issue here on this blog in June 2013. Decisions, made on clinical grounds, must be clear of competition obstructions, Enmeshing the NHS with the Enterprise Act over mergers has been a disastrous development in national policy, for example witnessed in the Bournemouth and Poole merger.
So it’s pretty likely that “The Efford Win” is the opening salvo in a war for the soul of the NHS. Time will tell whether UKIP are genuinely against privatisation. I’d bet my life on the fact are far from cuddly socialists. Their policy across a number of areas changes very rapidly, so only time will tell. The more parsimonious explanation is that UKIP are acting completely opportunistically, and wish to win seats off disaffected members across all the mainstream parties. A Labour-UKIP coalition would be very difficult to implement, whatever one thinks of Ed Miliband’s ability to negotiate a bacon butty.
An overview of my book ‘Living better with dementia: champions for enhanced communities”.
I hope you find this overview of my book ‘Living better with dementia: champions for enhanced communities’ useful.
It is written by me.
And the Forewords are Prof Alistair Burns, the England clinical lead for dementia, Kate Swaffer (Alzheimer’s Australia, Dementia Alliance International, and University of Wollongong, Australia), Chris Roberts (Dementia Action Alliance Carers Call to Action, Dementia Alliance International), and Dr Peter Gordon (Consultant Psychiatrist in dementia and cognitive disorders, NHS Scotland).
It will primarily assess where we’ve got to, along with other countries, in improving diagnosis and post-diagnostic care, and assess realistically the work still yet to be done.
My thesis will articulate why the ‘reboot’ of the global “dementia friendly communities” must now take account of various issues to be meaningful. It will argue for a difference in emphasis from competitive ‘nudge’ towards universal legal and enforceable human rights promoting dignity and autonomy.
It will also argue that dementia friendly communities are meaningless unless there is a shift in the use of language away from ‘sufferers’ and ‘victims’, while paying tribute to the successful “Dementia Friends” initiative.
It will, further, argue that dementia friendly communities are best served by a large scale service transformation to ‘whole person care’, and provide the rationale for this. A critical factor for enhancing the quality of life of people living better with dementia will be to tackle meaningfully the social determinants of health, such as housing and education.
The thesis will also argue that dementia friendly communities must also value the behaviours, skills and knowledge of caregivers in wider support networks. This is essential for the development of a proactive service, with clinical specialist nursing input deservedly valued, especially given the enormous co-morbidity of dementia.
This title will be published by Jessica Kingsley Publishers, in early 2015.
Chapters overview
Chapter 1 provided an introduction to current policy in England, including a review of the need for a ‘timely diagnosis’ as well as a right to timely post-diagnostic care. This chapter also provided an overview of the current evidence base of the hugely popular “Dementia Friends” campaign run by the Alzheimer’s Society and Public Health England, to raise awareness about five key ‘facts’ about dementia. It was intended that this campaign should help to mitigate against stigma and discrimination that can be experienced by people living with dementia and their caregivers.
Chapter 2 comprised a preliminary analysis of stigma, citizenship and the notion of ‘living better with dementia’. This chapter explained the urgency of the need to “frame the narrative” properly. This chapter also introduced the “Dementia Alliance International” which has fast become a highly influential campaigning force by people living with dementia for people living with dementia.
Chapter 3 looked at the various issues facing the timely diagnosis and post-diagnostic support of people living with dementia from diverse cultural backgrounds, including people from black, Asian and ethnic minority backgrounds, people who are lesbian, bisexual, gay or transsexual, and people with prior learning difficulties.
Chapter 4 looked at the issue of how different jurisdictions around the world have formulated their national dementia strategies. Examples discussed of countries and continents were Africa, Australia, China, Europe, India, Japan, New Zealand, Puerto Rico and Scotland.
Chapter 5 looked at the intense care vs care debate which has now surfaced in young onset dementia, with a potentially problematic schism between resources being allocated into drugs for today and resources being used to fund adequately contemporary care to promote people living better with dementia. An example was discussed of how the policy of ‘Big Data’ had gathered momentum across a number of jurisdictions, offering personalised medicine as a further potential compontent of person-centred care. This chapter also considered the impact of the diagnosis of younger onset dementia on the partner of the person with dementia as well. A candid description was also given about the possible sequelae of the diagnosis of young onset dementia on employment, caregivers, and in social isolation.
Chapter 6 focused on delirium, or the acute confusional state, and dementia. It considered the NICE guidelines for delirium, and the pitfalls in considering the relationship between delirium and dementia in English policy.
Chapter 7 was the largest chapter in this book, and took as its theme care and support networks. An overview of how patient-centred care is different from person-centred care was given, and how person-centred care differs from relationship-centred care. The literature inevitably has thus far focused on the ‘dyadic relationship’ between the person with dementia and caregiver, but a need to enlarge this to a professional in a ‘triangle of care’ and extended social networks was further elaborated and emphasised. Finally, the importance of clinical specialist nurses in ‘dementia friendly communities’ was argued, as well as the Dementia Action Alliance’s “Carers Call to Action”. Different care settings were described, including care homes, hospitals – including acute hospital care, and intermediate care.
Chapter 8 considered eating for living well with dementia. This chapter considered enforceable standards in care homes, including protection against malnutrition or undernutrition. The main focus of the chapter was how people with dementia might present with alternations in their eating behaviour, and how the mealtime environment must be a vital consideration for living better with dementia.
Chapter 9 looked at a particular comorbidity, incontinence. The emphasis was on conservative approaches for living well with dementia and incontinence. Other issues considered were the impact of incontinence on personhood per se, and the possible impact on the move towards an institutional home.
Chapter 10 argued how the needs for people living better with dementia would be best served by a fully integrated health and social care service. This chapter provided the rationale behind this policy instrument in England. The chapter also considered various aspects of what would be likely to make ‘whole person care’ work, including data sharing, collaborative leadership, care-coordinators, responsible and accountable ‘self care’, and the multi-disciplinary team. This chapter also considered how it was impossible to divorce physical health from mental health and social care, and explained the intention of the longstanding drive towards ‘parity of esteem’ in English policy.
Chapter 11 considered the importance of the social determinants of health. A focus of this chapter was on education, and its impact on a person living with dementia. However, the main focus of this chapter was housing, including ‘dementia friendliness, downsizing, and green or public spaces.
Chapter 12 considered whether ‘wandering’ is the most appropriate term. The main emphasis of this chapter were the legal and ethical considerations in the use of ‘global positioning systems’ in enhancing the quality of life of persons with dementia and their closest ones.
Chapter 13 considered a number of important contemporary issues, with a main emphasis on human rights and “rights based approaches”. While there is no universal right to a budget, the implementation of personal budgets was discussed. The chapter progressed to consider a number of legal issues which are arising, including genetic discrimination in the US jurisdiction, dementia as a disability under the equality legislation in England, and the importance of rights-based approaches for autonomy and dignity. Finally, the issue of engagement was considered.
Chapter 14 was primarily concerned with art and creativity. This chapter took as its focus on how living with dementia could lead to art and creativity, and how the cultural needs of people living with dementia could best be furnished through laughter, poetry and art galleries or museums. This focus also looked at the exciting developments in our understanding of the perception of music in people living with dementia, and how music has the potential to enhance the quality of life for a person living well with dementia.
Chapter 15 looked at the triggering of football sporting memories in people living well with dementia. This chapter considered the cognitive neuroscience of the phenomenon of this triggering, and presented a synthesis of how the phenomenon could be best explained through understanding the role of emotional memory in memory retrieval, how autobiographical memories are represented in the human brain usually, the special relevance of faces or even smells such as “Bovril”.
Chapter 16 looked at the impact of various innovations in English dementia policy, giving as examples including service provision (such as the policy on reducing inappropriate use of antipsychotics or the policy in timely diagnosis) and research. This chapter also contemplated the principal factors affecting how innovations can become known, and what ultimately determines their success.
Chapter 17 looked at how leadership could be promoted by people living with dementia. This chapter considered who might lead the change, where and when, and why this change might be necessary to ‘recalibrate’ the current global debate about dementia. This chapter considered how change might be brought about from the edge, how silos might be avoided, the issue of ‘tempered radicals’ in the context of transformative change to wellbeing as an outcome; and finally how ‘Dementia Champions’ are vital for this change to be effected.
Please note that Beth is not endorsing this book – this image is entirely separate and is taken from the main event for G8 dementia – we’re all proud of Beth’s work meanwhile!
The general election isn’t a referendum about a bacon butty. It’s a referendum on the NHS.
The 2015 general election isn’t a referendum about what exactly someone eating a bacon butty looks like. It’s a referendum on the NHS.
The Tories think the general public is utterly stupid. They think that if they subject Wales to an intense smear campaign about the NHS discussing the English NHS will be ‘out of bounds’.
The Tories must think English voters were all born yesterday. They think nobody will care about the £2.4 billion disastrous reforms which propelled competition law and costly admin into the NHS. They think nobody will care about these reforms which nobody voted for.
If the Health and Social Care Act (2012) was the solution, what was the exact problem? It can’t have been patient safety, even though Jeremy Hunt has repeatedly referred to Mid Staffs since becoming the Secretary of State for Health. Cheap political point scoring has been vulgar under this Government. Labour never cited Harold Shipman’s style as a Doctor as a failure of a Conservative administration.
It’s perfectly correct that Labour should ask about what has happened under the lifetime of this Government in units such as Colchester. There the “major incident” is not an outbreak of Ebola, but an outbreak of dangerous staffing. What is not reasonable to do is to engulf the hardworking nurses and Doctors in a culture of blame and shame, vilifying them for not having been given the tools to do the job.
The Health and Social Care Act (2012) cannot have been the solution if patient safety was the solution, as there is only one clause in this Act regarding patient safety. And that clause was in fact to abolish the National Patient Safety Agency. The real petrol in the tank of this Act is the mechanism which puts contracts out to competitive tendering, meaning that NHS services had a way of being aggressively pimped to the private sector.
It’s simply utterly fraudulent to say that this is how it’s always been under Labour. For a start, Justice Silber in the Lewisham judgment gave clear reasons how the law had changed under this Government, and why Jeremy Hunt’s decision was unlawful in the High Court. It was not only unlawful in the High Court, but it was also unlawful in the Court of Appeal. And was that a good use of hardworking taxpayers’ money? To pay Hunt’s lawyers for this dead-duck case, money was used which could have been used to give a pay rise to the majority of nurses, a pay rise which they were denied yet again.
Furthermore, this Government at shotgun notice legislated for a torpedo hospital closure clause, with the Liberal Democrats on the accelerator pedal. None of us are Luddites, but it’s utterly vulgar to present cuts under the cover of reconfigurations.
Things have fundamentally changed, in that people are now genuinely scared about the direction of travel. The National Health Service should be run for people, not profit. It should offer integrated health and care, not competitive tendering. Before the last election, the NHS was not an issue. Now people are taking to the streets over hospital closures and GP surgery closures. The record all-time high in satisfaction before the last election has now disappeared following the top down reorganisation which nobody voted for.
A&E waits have been disastrous. The length of time it takes to see your GP for a ‘routine appointment’ has become a joke in some parts of the country. And yet the current Government seem utterly divorced from reality – while Rome burns, Jeremy Hunt is fiddling away another sham policy in the guise of a 24/7 NHS.
What is clear is that Lynton Crosby wants to make the general election of May 7th 2015 a referendum on Ed Miliband eating a bacon butty.
It’s not that. It’s a referendum on the state of the NHS.
The ‘NHS Five Year Forward Plan’ is a clever marketing stunt, and is barely a statement of strategy
There’s no “magic money tree”, except when you’re signing off HS3 on a ‘nod and a wink’ for £7 billion, or interventions in Iraq and Afghanistan for £30 billion.
As a piece of marketing, for Simon Stevens to set out a stall for the rôle of the NHS in a global economy, “the five year plan” was nice and succinct. As a piece of strategy, it is dreadful. It’s dreadful – even if you decide to take the view that health policy is entirely market-driven or “value-based”, and not in any way written through a sophisticated clinical prism.
The irony of a “five year plan” for the National Health Service is pretty quick to see. “Five year plans” were, of course, used by Stalinist Russia. Nazi Germany preferred ‘four year plans’ as a strategy for war readiness, in comparison.
It is reported that the “Five Year Forward View”, published last week by NHS England, is a collaboration between six leading NHS groups including Monitor, Health Education England, the NHS Trust Development Authority, Public Health England, the Care Quality Commission and NHS England.
And yet ironically the future of two of the contributing organisations is under doubt. In a fringe meeting earlier this at the Labour Party Conference, it was again mooted what the precise function of Monitor might be. This is because it is definite that an incoming Labour Party government, in its first Queen Speech, will repeal the Health and Social Care Act (2012), a much loathed piece of legislation. This leaves the precise functions of Monitor uncertain.
One possibility which Burnham is seriously contemplating is whether Monitor, if it continues to exist, serves to regulate the integration of services as would be expected in ‘whole person care’. Burnham intends to introduce ‘NHS preferred provider’, which could insist on the NHS being the lead provider in contracts for as long as ten years in the ‘prime contractor model‘.
And the future of the Care Quality Commission was put on a cliff-edge with the report of the Sir John Oldham Commission, again to do with whole person care. It would make much more sense to reform the regulators to oversee health and care with a single regulator in future. This would again be in line with the regulation of health and care professionals, much needed, and proposed by the English Law Commission, but kicked into the long grass by the current Government as it ran out of time.
The “5 year Forward View” to all intents and purposes reads like a marketing document, a wish-list for further privatisation of the NHS. It may ‘pack a punch‘, from the BBC which has unreservedly succeeded in throttling any discussion of the NHS reforms. But talk of ‘accountable care organisations’, as developed in Spain and the United States, and the emphasis on preventive health packages so keenly sold by multinational corporates, are paradigmatic of a wish-list of a privateer.
The document is a naked shill, intended to carry on the ‘case for change’ which has been made exhaustively by think tanks such as the King’s Fund which, some might say, were instrumental in giving the catastrophic policy of market competition in the National Health Service some legs in the first place.
But the runes are clearly there.
Take, for example, the seemingly-modest proposal of “integrated care commissioning”. The policy of personal budgets in the full glare of sunlight looks incredibly anaemic. Unanswered questions exist how a universal health system is going to be successfully merged with a means-tested care system. NHS England tried, unsuccessfully, to head this issue off at the pass as far back as in 2012.
Personal health budgets, which Simon Stevens has continued to speak moistly of, are the perfect vehicle for introducing ‘top ups’ and ‘copayments’, threatening the fundamental principle of universal, free-at-the-point-of-need.
And moves, not contained in the ‘5 year plan’, spell out an ominous direction of travel. It has just been announced that the much maligned contract for processing ATOS, given under the last Government to ATOS, is to be given to a company called Maximus, which has a proven track record in handing long term care packages in other jurisdictions.
“Independent” think tanks have never shrugged off successfully the “power of the prepaid cards”, see for example the DEMOS initiative. It has always been vehemently denied that there will be no merging of universal credit and healthcare provision, although Liam Byrne’s account of Jennie Macklin in Australia painted a rather different story in an article in the Guardian provocatively entitled “Let’s help disabled people achieve their full potential“.
Like a multi-national corporate document, the “5 year plan” is high on marketing but poor on strategy. A good example of this is given on page 36 in relation to a ‘threat’ facing the National Health Service, that of recurrent pay freezes to the majority of nurses whilst the economy is reputed to be recovering.
The seemingly innocuous line, at the end of page 35, reads: “For example as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff.” But it is well known that any wish to pay nurses a wage that reflects the value that runs through their work like letters in a stick of rock will be strongly resisted by the Treasury, while the Conservative Party will prefer further to tattoo the words of low taxes onto his breast plate of ideology.
There are other clear examples of the document clearly lacking in clarity. For example, page 33 sees a promotion of ‘personalised medicine’, how the NHS and “our partners” (meaning in the third and private sector, actually) might deliver the genome based ‘revolution’. Again, the document’s thrust is one of marketing, not clear strategy. There is no mention of the changes in resource allocation which would be required to serve this revolution, essentially seeing hardworking taxpayers subsidise the shareholder dividends or surpluses of large corporate-like charities. There is absolutely no mention of the changes in the legislative framework that would be needed, as in the United States, to prevent genetic information non-discrimination. But here again the document serves its marketing function – as a prospective prospectus for would-be investors wishing to spot lucrative opportunities in the NHS as a data mine.
Like there is no mention of “NHS preferred provider”, unsurprisingly there is no mention of “whole person care”. And yet, even if Labour fail to win an outright majority, it will seek to implement this being the largest party in Government. And this policy is set to see a profound change in the landscape of health and care provision for England.
In any business strategy, one is obliged to think of the political, economic, social, technological, legal and environmental headwinds (affectionately known as “PESTLE” to business strategists). A good example of social changes in the five years might have been, for example, a change in direction of the NHS being seen as resentment as costing much money, despite its striking efficiency, but one which values its workforce (for example in the salary of most of its nurses).
Looking at the political headwinds, it is quite incredible for example there is no mention of trade agreements such as TTIP and the investor-to-state dispute settlement clauses. If this ‘5 year forward plan’ had been at all serious, it would have been included, not least as it is a headwind which could drastically throw off course further the direction of travel of the NHS as a state-run health service.
Simon Stevens’ vision is a ‘charismatic vision’ of sorts. But a vision does not have to be particularly credible for it to get populist appeal or succeed. It just needs to be communicated clearly, with supine and compliant supporters in the trade media.
If the document were a ‘heads up’ for how we could afford a NHS through general taxation which was genuinely universal and free at the point of need, this document would have served a function. As it is, the document is a lubricator for mechanisms which could optimise the part that the private sector has to play, with no mention of the dogs being unleashed in the global marketplace – in much the same way Cameron refused to signpost “the top down reorganisation”. It is impossible for a strategy document for the NHS simply to airbrush out the political and legal factors which will be at play in the lifetime of the next Government. As it is, the NHS ‘5-year forward view’ is a basic piece of marketing, which as a strategic plan scores 0/10.
