Campaigners – your NHS needs you!

 

Andy Burnham MP recently commented,

“David Cameron used to say that his priority could be summed up in three letters: NHS. Now, it seems, he prefers not to talk about it. The word in Westminster is that, on the advice of Lynton Crosby, the Prime Minister has asked his ministers for a period of pre-election silence on the NHS. So the Queen’s Speech came and went without even a mention of Mr Cameron’s erstwhile priority.”

The NHS says 299,031 patients arrived at A&E departments last week – the highest number on record.

The NHS is set to be a key battleground at the general election and Labour intends to keep it at the forefront of the public mind in the coming months. The plan is now it will use a private member’s bill to lay out how it would repeal the coalition government’s controversial Health and Social Care Act (2012), which had a number of after shocks.

The bill, proposed by Clive Efford MP, would rewrite the rules that put competitive market tendering of services as the default option until proven otherwise. It will be debated in the Commons in November and Labour candidates in marginal seats will call on Tory and Lib Dem incumbents to back the bill, while highlighting examples of how current rules waste money and fragment care.

In fact, this legislative manoeuvre is necessary whichever party comes to power on May 8th 2015. The current legislative framework makes it very difficult for services to be commissioned which promote integration, for fear of breaching competition regulation.

The Shadow health secretary claimed the vote on the bill would “without doubt be the defining moment of what remains of this parliament”.

This private member’s bill is designed, presumably, to keep the NHS on the political and news agenda. Given the blanket reluctance of the BBC to discuss this £3bn re-disorganisation, campaigners will mainly have to resort to the social media to get their message across.

The bill is also designed to drive a wedge between the Conservatives and the Liberal Democrats. At some stage before the general election on May 7th 2015, the Liberal Democrats might wish to distance themselves from the current Conservative policy. It is nonetheless noteworthy that Paul Burstow remains adamant that opposition to hospitals suddenly closing from Labour will not work in the long run.

The Liberal Democrats, to put it simply, need this ‘differentiation strategy’ to survive. Otherwise, it will be completely annihilated as a political force. The Liberal Democrats were instrumental in getting the Lansley Act onto the statute books in both the lower and upper houses. The concept of them repealing their own legislation in a coalition after 2015 is completely unacceptable for many in the Labour Party.

And there is plenty that all NHS campaigners can unite upon, whatever political creed.

First and foremost, it would be motherhood and apple pie for the duty of the Secretary of State for Health for the National Health Service to be restored.

Secondly, it is likely that Labour will wish to see the increase in the ‘private patient income cap’ abolished. I have written about it in great detail here.

The current situation regarding the “private patient income cap” (more correctly an “income cap for non-NHS work“)  in the Health and Social Care Act, through s. 164(1)(2A), is described as follows:

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.

In an interesting development reported this morning, hospitals are to be banned from charging patients up to £72 a day to park their cars under plans being drawn up by ministers. It is reported that some hospitals charge up to £4 an hour – and in some areas £72 per day – for parking spaces, with costs running to hundreds of pounds for those who make repeated visits for treatment.

It is also claimed that the worse-affected include cancer patients who cannot take public transport because they have reduced levels of immunity, and the parents of premature babies, whose children are often kept in hospital for several weeks.

The abolition of this lifting of the income cap for non-NHS work would go far wider than the Coalition’s targeted strike on car park charges.

A grave concern has been that competition rules ‘hold back quality‘. I first wrote about this at the beginning of January 2013 on this blog. The provision (“section 75”) puts rocket boosters into aggressive pimping of NHS services in the private sector, and the rest as they say was history.

In October 2013, it was reported that two NHS hospital trusts in Dorset would not merge on the basis of clinical need, according to the Competition Commission, an economic regulator overseeing the implementation of competition law applying to this country.

Whilst Jeremy Hunt never mentions the Lansley Act, there’s no doubt that Labour will wish to repeal it in the first Queen’s Speech of a Labour government. It appears to have appeared to have come from nowhere, though a very good description of how it came about comes from Matthew d’Ancona’s outstanding “In it together” and Nick Timmins’ outstanding “Never again”.

It’s undoubtedly a turgid piece of law, which reads like a patchwork quilt of commercial and corporate law relating to competition, regulation and insolvency. There’s only clause on patient safety, and that enables the abolition of the National Patient Safety Agency. In fact, the Draft Bill on regulation of clinical professionals, proposed by the English Law Commission, thought to be a landmark piece of legislation to promote patient safety, has been bounced into the lifetime of the next parliament.

Despite its length, the Lansley Act has three clear aims: firstly, to outsource NHS services into the private sector as easily as possibly, to bolster the functions of an economic regulator (“Monitor”), and to accelerate the managed decline of NHS units which run into financial trouble. It is indeed a result of a need to ‘liberalise the NHS market’, but as Iceland found out in their large experiment of deregulating the banks, the Lansley Act experiment may be just about to go horribly wrong. NHS campaigners, if they unite, can help to seal its fate.

 

Fighting each other on the left is a waste of resources

We keep on being told that there is a finite amount of resources to share. So why on the left are we not channeling our energy into things we care about?

Among the various things I have been witness to in the last year have been endless discussions on procedure and constitution. Such discussions while possibly well intended by some have virtually ended up being circular and being presented in summary in an incredibly unimpressive manner.

There are serious matters afoot. There was a draft Bill proposed by the Law Commission, which didn’t make it into the Queen’s Speech, on the regulation of clinical professionals. This promises to be a landmark piece of legislation, and has now been bounced into the next parliament’s lifetime. Clearly this Bill will prioritise patient safety, on which there was not a single clause in the Health and Social Care Act (2012) apart from abolition of the National Patient Safety Agency.

Many of us have allowed the narrative to be articulated in terms of ‘sustainability’, in other words we can’t afford the National Health Service – but curiously can afford war, and afford a lengthy inquiry into the legality of it. We have allowed a ‘there is no alternative’ closure of ‘failing’ hospitals, but have not addressed the principal issue of how clinicians and patients can be in charge of their own services without a firestorm by the Trust Special Administrator.

We have lost time on how we can make the health service function nationally, not in a piecemeal fragmented way like the privatised railway industry. We have lost time on implementing serious methods of keeping vulnerable frail patients out of hospital, or people living with dementia, in cases where they’d be better off with some proactive intervention out of hospital.

It is simply impossible to have this sort of discussion of what the left wishes to do in terms of solidarity, justice, equity and equality, while certain people are at each other throats. Whilst I am not a big fan of Tony Blair by any stretch of the imagination, it cannot be said that the previous Labour administrations can be the root of all of the ills of the National Health Service.

Basic things being done well matter a lot to people, like seeing their local GP or being attend an A&E unit in a timely matter. Andy Burnham MP has a golden opportunity to make sure medical records are shared freely between one part of the health and care service with the other, to prevent reduplication and poor medical decision-making based on information asymmetry. There is a key chance to break down barriers between health and social care, so urgently need, for example, in my academic field of living well with dementia.

There are many people who are now publicly concerned about the effect of competition in English health policy. Margaret Heffernan, of ‘wilful blindness’ fame, is just about to have a bestseller on her hands on this subject.

So can we cut the incessant concerns about how the Labour Party is still a cover for corporate Britain? That Labour hasn’t learned anything from the past, which includes John Major activating the private finance initiative initially before badly negotiated contracts under the early years of the Blair administrations?

It is impossible to divorce the needs of physical and mental health of a person from social care needs. So we can we put a sock in the movement that integrated care of any variety can only be a Trojan Horse for privatisation? There is a possibility that a future Labour government might be able to provide a fully funded national care service, if there were a momentum of public support.

Labour’s position on personal health budgets (“PHBs”) for the last few years has been clear. Whilst there are noteworthy successes, there have been a plethora of concerns, including safeguarding issues for people with dementia. It was never intended that they should be compulsory, despite the subject of PHBs at all being promoted previously by some very senior in the Labour Party.

There’s a battle to be fought indeed, but the outcome of that battle should not a Conservative-UKIP coalition. You’ll find that they will not be the answer to all your concerns about the NHS.

As regards the NHS, Dave Cameron is also being a tad economical with the truth

 

We keep on being told from the right wing that “money does not grow on trees”, but the Chilcot Inquiry on the Iraq War has so far cost millions (the actual war was costly in many senses too.)

These are #pmqs from my 40th birthday.

Nick Brown MP asks the Prime Minister about the underlying causes of the £2bn forecast deficit for NHS Trusts, and what the remedies might be.

This topic hit the headlines big time yesterday, but it had been copiously discussed by John Appleby by the King’s Fund in one of their documents previously.

The exchange as reported in Hansard went as follows:-

Specifically, the Prime Minister contends that, “money has been ploughed back into better patient care in our NHS.”

This is likely to be true as a half-truth as he does not say “the” before the word “money”.

But where did the money actually go?

It appears it has traditionally gone to HM Treasury, NOT directly to the Department of Health budget.

Everyone knows that the pay settlement for the NHS was tight this year, given the pay freeze discussed at the #RCNCongress this year.

Crispin Dowler reported in the HSJ in October 2012:

“The Department of Health has returned nearly £3bn of its funding to the Treasury over the past two years, despite facing its tightest financial settlement for five decades.

“A Treasury spokesman this week confirmed to HSJ the department had handed back around £1bn of the funding it was allocated for health spending in 2011-12. Just £316m of the £1.4bn that the DH left unspent last financial year has been carried over for it to use in 2012-13.

“The final sum clawed back from last year’s health allocation is double the £500m estimate that was published in chancellor George Osborne’s March Budget.”

Sofia Lind in the Pulse magazine reports a similar story in 2013.

My brief Twitter chat yesterday with @DaveWWest went as follows.

about #NHS ‘efficiency savings’ 12.17 pm PM ‘..that money has been ploughed back into better patient care in the NHS’ true? @DaveWWest

— shibley (@legalaware) June 18, 2014

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@legalaware largely paid for increased activity, so yes in a sense but you could point to the annual DH underspends til 13/14, which are not — Dave West (@Davewwest) June 18, 2014

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@Davewwest Thanks Dave. I’ve never worked out where in fact the surplus goes – I had thought it goes back into HM Treasury not DoH.

— shibley (@legalaware) June 18, 2014

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@legalaware yes you’re right — Dave West (@Davewwest) June 18, 2014

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Andy Burnham MP has claimed that the Prime Minister no longer wishes to talk about the NHs in the run up to the general election on May 7th/8th 2014.

There did seem, however, to be a record number of questions on the NHS in #pmqs?

Dementia care in the whole person care age

The Australian jurisdiction have recently provided some helpful inroads here.

The narrative has changed from one of incessantly referring to people living with dementia as a ‘burden’ on the rest of society. For example, to push a sense of urgency that we have an ‘ageing population timebomb’, the cost of the ageing people with dementia flies completely in the face of other public health campaigns which emphasise, for example, “dementia is not a natural part of ageing”.

“The NHS as a whole and individual hospitals recognise that dementia is a significant, growing and costly problem for them” is the opening gambit of the Alzheimer’s Society “Counting the cost” report.

An easy to use online resource, Valuing People from Alzheimer’s Australia has been developed in collaboration with community aged care providers who have helpful in stablishing a person centred approach to service delivery.

Person centred care is a development to provide ervices provided in a way that is respectful of, and responsive to, the preferences, needs and values of people and those in the care and support network.

I cannot recommend this resource highly enough. The main source is here.

In fact, it summarises succinctly the conclusions I came to after my exploration of personhood in my book ‘Living well with dementia’.  The late great Prof Tom Kitwood said of personhood, “It is a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect and trust”.

If a Labour government is elected on May 8th 2015, the first necessary step is to legislate for the repeal of the Health and Social Care Act (2012) and to enact new legislation to allow for integrated packages provided they are justified by clinical outcome. For this to happen, it will be necessary for Labour to undergo a ‘conscious uncoupling’ from all the baggage of EU competition law. For this, it is essential also that the UK government is able to carve out provisions from the investor protection clauses and/or the rest of the EU-US free trade treaty (TTIP).

The “whole person care model” has become attractive to those who wish to break down silos between different physical health, mental health and social care “silos”. It has been worked up in various guises by various parties.

A helpful construct is provided in the document, “Healthcare for complex populations: the power of whole-person care models” originally published by Booz & Company in 2013.

A major problem with dementia care, however it is delivered, is that it is full of divisions: public vs private care, fragmented vs national care, competitive vs integrated models.  Operating in silos can’t work because of the nature of the dementias: the mood and cognition of a person with dementia profoundly affects how they might interact with the outside world, for example perform activities in the outside world. And we know that taking part in leisure activities can promote a good quality of life.

Their model is, though, a useful starting point.

Dementia cannot be only addressed by the medical model. In fact, it is my sincere belief that it would be highly dangerous to put all your eggs in the physical health basket, without due attention to mental health or social care. For example, last week in Stockholm, the international conference on Parkinson’s disease, a condition typified by a resting tremor, rigidity and slowness of movement, which can progress to a dementia, often is found to have as heralding symptoms changes in cognition and mood.

So it’s pretty clear to me that we will have to embark on a system of multidisciplinary professionals who could all have a part to play in the wellbeing of a person with dementia, depending on his or her own stage in life, and ability or need to live independently. “Care coordinators” have traditionally been defined incredibly badly, but we do need such an identity to navigate people with dementia, and actors in the care and support network, through the maze.

“Care collaborators” in their construct are very wonkily articulated, like “pre-distribution”, but the concept is not stupid. In fact it is very good. One idea is that people with dementia could act as support as other people with dementia, for people on receiving a diagnosis of dementia. The rationale for this is that people living with long term conditions, such as for example recovery from alcoholism, often draw much support from other people living with other long term conditions, away from a medical model. There needs to be safeguards in the system to safeguard against a lot of unpaid goodwill (which currently exists in the system.)

Informatics would have a really helpful rôle here, being worked up in telecare and assistive technology. But even simple disruptions such as a person living with dementia at risk of falling from problems with spatial depth perception being able to ‘hot email’ a care coordinator about perceived problems could trigger, say, an early warning system. And with various agents in the provision of care being involved in differing extents it will be up to NHS England to work out how best to implement a single accountable tariff. Falls are just the sort of ‘outcome metric’ which could be used to determine whether this policy of ‘whole person care’ for people living with dementia is working. And, even though everyone ‘trots it out’, the performance on avoided hospital admissions could be put into the mixer. It’s already well recognised that people with dementia can become very disoriented in hospital, and, and despite the best efforts of those trying to improve the acute care pathway, people with dementia can often be better off away from hospital in the community. But it’s imperative that care in the community is not a second-rate service compared to secondary care, and proper resourcing of community whole person care is essential for this before any reconfiguration in acute hospital services.

But the private sector has become such a ‘bogey term’ after arguably the current Government overplayed their hand with the £3bn Act of parliament which turbo-boosted a transfer of resource allocation from the public to private sector. Any incoming government will have to be particularly sensitive to this, as this is a risk in strategy for the NHS.

In October 2005, Harold Sirkin, Perry Keenan and Alan Jackson published a highly influential article in the Harvard Business Review entitled “The hard side of change management“. Whilst much play has in fact been made of politicians having to be distant from running the NHS, a completely lubricous line of attack when it is alleged that Jeremy Hunt talks regularly to senior managers and regulators in the NHS, the benefits of clear political leadership from an incoming Labour government are clear.

Andy Burnham MP has already nailed his colours to the mast of ‘whole person care’ on various occasions, and it is clear that the success of this ambitious large scale transformation depends on clear leadership and teamwork from bright managers. Take for example the DICE criteria from Sirkin, Keenan and Jackson:

But this is perfectly possible from an incoming Government. The National Health Service has a chance to lead on something truly innovative, learning from the experience of other jurisdictions such as Australia and the USA.

As alluded to in the new resource from the Alzheimer’s Australia, this cultural change will require substantial ‘unfreezing’ from the current mindset for provision of care for people with dementia. It will require a change in explicit and implicit sources of knowledge and behaviours, and will need to be carefully brought about by learning from the successes and failures of pockets of implementation.

The whole project’s pretty high risk, but the rewards for people living with dementia, and members of the care and support network, are potentially vast. But it does require the implementation of a very clear vision.

 

 

@legalaware

 

[First posted on the ‘Living well with dementia‘ blog]

Yesterday we broke the record for most views of the @SocialistHealth blog website

Here are the official figures for the most ‘viewed’ blogposts yesterday (15 June 2014).

 

My experience of being a sick Doctor		2,286
The Black Report 1980		74
Home		69
Home page / Archives		63
The five core messages of ‘Dementia Friends’ are consistent with the current literature		51
Black Report 6 Explanation of Health Inequalities		50
National Insurance a bad way to pay for the NHS		34
Like Nick Clegg, I was taught by ‘unqualified teachers’ at the same school. His hypocrisy stinks.		27
Black Report 10 Summary and recommendations		24
Aneurin Bevan and the foundation of the NHS		22
Other posts		546
Total views of posts on your blog		3,246

 

It meant a lot to me having so much positive feedback from people in the #Twitter community on my blogpost which was the first time I’d blogged on my experiences of being a sick doctor in such a public forum.

I reproduce a sample of these tweets here.

It was a really big deal for me to write this, but I wrote it entirely spontaneously this morning. I’ve been churning around these issues every day of my life since waking up from my coma in 2007, and of course on #FathersDay it is impossible to ignore how awful it must have been for my late father.

@legalaware @TriciaHart26 @LisaSaysThis thanks for sharing I admire your struggle and your honesty thank you

— David Nicholson (@DavidNichols0n) June 15, 2014

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@legalaware so honest, so transparent, reaching out to many with permission to speak up , weakness can be a true strength , sharing stories

— Tricia Hart (@TriciaHart26) June 15, 2014

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@legalaware ….Thank-you Shibs…..always xxx

— Gerry (@archangelolill) June 15, 2014

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@legalaware @WOWpetition Excellent blog that!

— Yvonne (@yvonneburko) June 15, 2014

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@legalaware A difficult but excellent read Shibs-sharing such a private difficult experience in hope others will benefit-so generous. xxx

— Gerry (@archangelolill) June 15, 2014

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@legalaware @archangelolill That was a v interesting, brave, honest piece and I am sure will help many – practitioners AND patients.

— Anne Booth (@Bridgeanne) June 15, 2014

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@legalaware *Love* this piece Shibley, thanks for sharing. Will PHP become countrywide @clarercgp ?

— Andrea James (@HealthRegLawyer) June 15, 2014

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Beautiful, heartfelt, insightful and searingly honest blog from @legalaware http://t.co/a8pEs18ChB do please read this

— Tim Lloyd-Yeates (@alivetim) June 15, 2014

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Very powerful post by the wonderful @legalaware: My experience of being a sick Doctor http://t.co/HUa1HNARwN

— Jonathon Tomlinson (@mellojonny) June 15, 2014

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@legalaware thanks for your inspiring piece and truth saying that is constantly needed. Oh and also your kind words!

— Michael Farrell (@MichaelFarrellE) June 15, 2014

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@legalaware Love it! As always, u hv fab taste. Hope all ok? Am off 2 bed, v sore throat + lots on this wk #MyLast20Days @withoutstigma xxx

— Lisa Rodrigues (@LisaSaysThis) June 15, 2014

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Insightful blog about being a sick doctor @legalaware http://t.co/yxsSUGBB7p See http://t.co/upUJ1lDq0r via @drphilhammond

— Lesley Russell Wolpe (@LRussellWolpe) June 15, 2014

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Amazingly honest, insightful blog about being a sick doctor @legalaware ‘anything can happen to anyone at anytime http://t.co/1D01nMwOpY

— Dr Phil Hammond (@drphilhammond) June 15, 2014

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@legalaware yes, I read it. I hope it gets the audience it deserves x

— Nicky Richmond (@lawyer_eats) June 15, 2014

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@legalaware @deborahbowman @Jos21 @mason4233 @Dr_LEGO_Tom Incredibly moving and powerful Shibley – thank you for sharing — Jo Moriarty (@Aspirantdiva) June 15, 2014

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@legalaware fantastic post thank you for sharing. Hopefully openness with help create understanding.

— Deborah Alsina (@DeborahAlsina) June 15, 2014

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@legalaware @deborahbowman @Aspirantdiva @Jos21 @Dr_LEGO_Tom excellent Shibley, well done you — Chris Roberts (@mason4233) June 15, 2014

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@juliewintrup @legalaware being content is the greatest gift you can offer others. Not everyone manages it! Thanks for sharing your story

— Dr. Lucia Gannon (@LuciaGannon) June 15, 2014

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The five core messages of ‘Dementia Friends’ are consistent with the current literature

I first posted this blogpost on my ‘Living well with dementia‘ blog.

“Dementia Friends” is an initiative from the Alzheimer’s Society and Public Health England to raise awareness of the dementias amongst the general public.

Ideally, at the end of a ‘Dementia Friends’ session, each participant will have learned the five key things that everyone should know about dementia, and aspired to turn an understanding into a commitment to action.

In this blogpost, I wish just to discuss a little bit these messages in a way that is interesting. If you’re interested in finding out more about ‘Dementia Friends’, please go to their website. Whatever, I hope you become interested about the dementias, even if you are not already.

I’ve got nothing to do with writing ‘Dementia Friends’, but the following I reckon is a view which would be given by anyone like me who has worked in this academic field for a very long time.

 

Anyway, I do wish ‘Dementia Friends’ well, and I hope very much you will book yourself into an information session at the first available opportunity.

 

1. Dementia is not a natural part of aging.

This is an extremely important message.

However, it is known that the greatest known risk factor for dementias overall is increasing age. The majority of people with Alzheimer’s disease, typically manifest as problems in new learning and short term memory are indeed 65 and older.

But Alzheimer’s disease is not just a disease of old age. Up to 5 percent of people with the disease have early onset Alzheimer’s (also known as younger-onset), which often appears when someone is in their 40s or 50s.

 

[For a further discussion of this statement, please see another blogpost of mine.]

 

2. It is caused by diseases of the brain.

Prof John Hodges, who did the Foreword to my book, has written the current chapter on dementia in the Oxford Textbook of Medicine. He also supervised my Ph.D. The chapter is here.

There is a huge number of causes of dementia.

The ‘qualifier’ on this statement is that the diseases affect the brain somehow to produce the problems in thinking. But dementia can occur in the context of conditions which affect the rest of the body too, such as syphilis or systematic lupus erythematosus (“SLE”).

 

[For a further discussion of this statement, please see another blogpost of mine.]

 

3. It’s not just about memory loss.

This statement is perhaps ambiguous.

“Not just” might be taken to imply that memory loss should be a part of the presenting symptoms of the dementia.

On the other hand, it might be taken to mean “the presentation can have nothing to do with memory loss”, which is an accurate statement given the current state of play.

John (Hodges) comments:

“The definition of dementia has evolved from one of progressive global intellectual deterioration to a syndrome consisting of progressive impairment in memory and at least one other cognitive deficit (aphasia, apraxia, agnosia, or disturbance in executive function) in the absence of another explanatory central nervous system disorder, depression, or delirium (according to the Diagnostic and Statistical Manual of Mental Disorders , 4th edition (DSM-IV)). Even this recent syndrome concept is becoming inadequate, as researchers and clinicians become more aware of the specific early cognitive profile associated with different dementia syndromes.”

I remember, as part of my own Ph.D. at the University of Cambridge on the behavioural variant of frontotemporal dementia,virtually all the persons with that specific dementia syndrome, in my study later published in the prestigious journal Brain, had plum-normal memory. In the most up to date global criteria for this syndrome, which should be in the hands of experts, memory is not even part of the six discriminating features of this syndrome as reported.

Exactly the same arguments hold for dementia syndromes which might be picked up through a subtle but robust problem with visual perception (e.g. posterior cortical atrophy) or in language (e.g. semantic dementia or progressive (non-) fluent aphasia, logopenic aphasia.) <- note that this is in the absence of a profound amnestic syndrome (substantial memory problems) as us cognitive neuropsychologists would put it.

 

[For a further discussion of this statement, please see another blogpost of mine.]

 

4. It’s possible to live well with dementia.

I of course passionately believe this, or I wouldn’t have written a book on it. It is, apart from all else potentially, the name of the current English dementia strategy.

 

[For a further discussion of this statement, please see another blogpost of mine.]

 

 5. There is more to the person than the dementia.

This is an extremely important message. I sometimes feel that medics get totally lost in their own clinical diagnoses, backed up by a history, examination and relevant investigations; and they become focused on treating the diagnosis rather than the person with medications. But once you’ve met one person living with dementia, you’ve done exactly that. You’ve met only one person living with dementia. And it is impossible  to generalise for what a person with Alzheimer’s disease at a certain age performs like. We need to get round to a more ‘whole person’ concept of the person, in not just recognising physical and mental health but social care and support needs, but realising that a person’s past will influence his present and future; and how he or she interacts with the environment will massively influence that.

 

[For a further discussion of this statement, please see another blogpost of mine.]

My experience of being a sick Doctor

 

“Anything can happen to anybody at any time.”

This one principle does guide what I think about people and health.

It’s what I think when a friend of mine living with dementia suffers a bereavement. It’s what I think when a friend of mine gets told he has bladder cancer.

It’s also how I come to rationalise my six week coma in 2007 due to acute bacterial meningitis. I was rushed into the intensive care unit of the Royal Free Hospital Hampstead, having been resuscitated successfully by somebody I used to work with in fact. He knows who he is.

His team stopped me fitting in an epileptic seizure. His crash team got a pulse back on their third cycle of jumping down on my chest after I had been flatlining in cardiac asystole. He managed to put a tube down me as I had stopped breathing.

I then spent six weeks in a coma, and my mother and late father came to visit me every day in intensive care, and in the neurorehabilitation unit (Albany Ward) at the National Hospital for Neurology and Neurosurgery, London (a hospital in which I had worked in 2002 in a rotation which included an interest of mine, dementia).

I am now living with physical disability. I can now walk, and I remember my protracted time in a wheelchair. I remember people’s reactions to you in the street. I remember how ‘available’ black cabs would simply drive past. I was, in effect, taught how to work again by inpatient and community physiotherapy.

Due to my meningitis, I could barely speak; the “speechies” helped me with that. I had difficulty planning a cup of tea; the “OTs” helped me with that.

I can relate to all the current NHS concerns how you become stripped of identity in the modern NHS: you become a bed number, or at best a surname.

But in many ways, as my late father kept reminding me shortly before his own death in November 2010, that meningitis in a way saved my life.

I then engaged properly with the NHS as a patient. I used to see my GP regularly.

As a medical student, I had felt as if I was too busy to see my own GP. Big mistake.

As a young house officer in hepatology, I used to be surrounded with very pleasant patients; but for whom I had to perform an abdominal paracentesis, as they were often bright yellow due to liver failure (but awaiting a liver transplantation).

I slowly became alcoholic and isolated. I have often been asked when did I start to drink heavily. This is very difficult for me to place, as most people like me go through a phase of problem drinking.

My official diagnosis for the alcoholism is severe alcohol dependence syndrome in remission. I have now not drunk alcohol for seven years. I know I am an alcoholic as it is unsafe for me to have an alcoholic drink. If I have an alcoholic drink, I would either end up in A&E or in a police cell. I am incapable of having a social drink.

Receiving a medical diagnosis for my mental health condition, in my particular case, helped me to rationalise the cause of my problems which had caused so much distress to others including especially my mother and late father.

I was listening to LBC last night and the presenter was joking that he had a listener rung up “I am an alcoholic. I haven’t had a drink for 35 years.” But seriously folks, it is like that.

I am now regulated by the legal profession. I spent 9 years at medical school, doing my basic degrees for medicine and surgery, and my PhD in the early diagnosis of frontal dementia. As a junior in the medical profession, walking around as the most junior member pushing the Consultant’s trolley and writing in the notes, the thought that you might be ill did seem an alien one.

And yet I was extremely ill. For all people in addiction, there becomes a time when you are in complete denial and lack complete insight. That’s when it is impossible for you to be regulated.

I also have a lot of sympathy for the regulators who regulate people who I think can be best be described as a “dry drunk patients” – i.e. they spend months or even years dry before relapsing. They are, I feel, “living by the seat of their pants”, or “whiteknuckling” it.

The alternative is recovery – where you are not merely abstinent, but where you embrace a life which is utterly content, but in the absence of your addiction of choice.

I indeed find this hard to explain to people who have never experienced addiction. I do not wish to compete with ‘patient leaders’, or think tanks who go on and on and on and on about patient involvement.

But I do wish to recommend to you, if you are in their catchment area, the Practitioners Health Programme (PHP). An incredible ambition of Prof Clare Gerada, the programme is a lifeline to doctors who are ill.  It’s been shown in numerous numerous surveys that an ill doctor under-functions as much ‘use’ as a doctor who is completely out of the service. I would simply say to anyone who is ill in the medical profession, put your own health ahead of your career. Your patients deserve that too. Do not be blinded by your own career. I am proud to attend regularly PHP.

I don’t do much apart from hundreds of blogs for the SHA, or campaigning for people living with dementia. But I am at least at last content.

 

 

 

Update: I (Dr Shibley Rahman) was returned to the GMC Register for the UK 26 August 2014. I had been in recovery from alcohol since the onset of my coma due to meningitis in June 2007.

 

“Think like a multinational corporate leader. Act like the chief of the NHS.”

 

Simon Stevens’ catchphrase is: “Think like a patient, act like a taxpayer.”

In 2013, the US and EU decided to start negotiations on a new free trade agreement, the Transatlantic Trade and Investment Partnership (TTIP).

In a recent piece for the New Statesman, the most notable comments by Andy Burnham MP in George Eaton’s interview concerned TTIP and its implications for the NHS (apart from he was spitting bullets at aspects of HS2).

Many Labour activists and MPs had been concerned, according to George, “at how the deal, officially known as the Transatlantic Trade and Investment Partnership (TTIP), could give permanent legal backing to the competition-based regime introduced by the coalition.”

And here was Andy again at the start of the European elections (not reported by the media who were much more interested in Nigel Farage, Roger Helmer, and their ilk.)

As Benedict Cooper wrote recently on The Staggers for the New Statesman:

“A key part of the TTIP is ‘harmonisation’ between EU and US regulation, especially for regulation in the process of being formulated. In Britain, the coalition government’s Health and Social Care Act has been prepared in the same vein – to ‘harmonise’ the UK with the US health system.

“This will open the floodgates for private healthcare providers that have made dizzying levels of profits from healthcare in the United States, while lobbying furiously against any attempts by President Obama to provide free care for people living in poverty. With the help of the Conservative government and soon the EU, these companies will soon be let loose, freed to do the same in Britain …

… The agreement will provide a legal heavy hand to the corporations seeking to grind down the health service. It will act as a transatlantic bridge between the Health and Social Care Act in the UK, which forces the NHS to compete for contracts, and the private companies in the US eager to take it on for their own gain.”

So fast forward a few months.

Ed Miliband asked David Cameron today specifically how TTIP would impact on the NHS.

Cameron reported today that there had been five good meetings on progressing it, and continued thus:

“We are pushing very hard and trying to set some deadlines for the work. No specific deadline was agreed, but it was agreed at the G7 that further impetus needed to be given to the talks and, specifically, that domestic politicians needed to answer any specific questions or concerns from non-governmental organisations, or indeed public services, that can sometimes be raised and that do not always, when we look at the detail, bear up to examination.”

And the attack on NGOs continued:

“I do think this is important because all of us in the House feel—I would say instinctively—that free trade agreements will help to boost growth, but we are all going to get a lot of letters from non-governmental organisations and others who have misgivings about particular parts of a free trade agreement. It is really important that we try to address these in detail, and I would rather do that than give an answer across the Dispatch Box.”

So the upshot was Cameron agreed to write to Miliband in detail to provide an update on TTIP and the NHS at last.

And this is not a moment too soon – it’s almost a year to the day since @Debbie_Abrahams asked about this on 19 June 2013 (see here).

Cameron tried also to advance the rather bizarre argument that TTIP would lift people out of poverty, trying to link up in a very Conservative approach to the free trade arrangements and the social determinants of health.

The most helpful exchange, perhaps however, was between Andrew Gwynne and the Prime Minister this afternoon:

From the late 1980s, a narrative surrounding the ethics  and economics of human gene patents has been taking shape into a ‘perfect storm’.

The discussion included impact of gene patents on basic and clinical research, on health care delivery, and on the ability of public health care systems to provide equitable access when faced with costly patented genetic diagnostic tests.

Scientists at institutions around the world discovered and sequenced a series of genes linked to breast and ovarian cancer in the early 1990s.

Mutations in these genes prevent the body from producing tumor suppressing proteins, which in turn increases an individual’s risk of contracting breast or ovarian cancer.

A key discovery, for example, was that individuals with these mutations have a cumulative lifetime risk of ~40–85% of developing breast cancer and ~16–40% chance of developing ovarian cancer, compared with 12.7% and 1.4% risk for the general population of developing breast or ovarian cancer, respectively.

So with these cutting edge findings in research, ‘translationary’ laboratories developed diagnostic tests for these mutations, which opened up the possibility of preventive management for breast and ovarian cancer, including prophylactic surgery and the use of certain medications.

There are countless other examples.

There also has been talk about doing a genomic screen with a view to identifying genetic risk factors for the dementias.

And Simon Stevens lovebombed the idea last week at the NHS Confederation:

“First, personalisation. A decade and a half on from the Human Genome Project, we’re still in the early days of the clinical payoff. But as biology becomes an information science, we’re going to see the wholesale reclassification of disease aetiologies. As we’re discovering with cancer, what we once thought of as a single condition may be dozens of distinct conditions. So common diseases may in fact be extended families of quite rare diseases. That’ll require much greater stratification in individualised diagnosis and treatment. From carpet-bombing to precision targeting. From one-size-fits many, to one-size-fits-one.”

So a more appropriate catchphrase for Simon Stevens might be:

“Think like a multinational corporate leader. Act like the chief of the NHS.”

One concern has been that TTIP powers would jeopardise well entrenched national laws and regulations.

Frances O’Grady of the UK’s Trade Union Congress for example, is publicly concerned that deregulation and bolstering of corporate rights could mean an accelerated privatisation of the UK’s National Health Service. 

“The clauses [of ISDS] could thwart attempts by a future government to bring our health service back towards public ownership”.

A “socialist planned economy” combines public ownership and management of the means of production with centralised state planning, and can refer to a broad range of economic systems from the centralised Soviet-style command economy to participatory planning via workplace democracy.

In a centrally-planned economy, decisions regarding the quantity of goods and services to be produced as well as the allocation of output (distribution of goods and services) are planned in advanced by a planning agency.

According to Linda Kaucher, quoted in the New Statesman:

“[The Health and Social Care Act] effectively enforces competitive tendering, and thus privatisation and liberalisation i.e. opening to transnational bidders – a shift to US-style profit-prioritised health provision.”

Cooper continues:

“The TTIP ensures that the Health and Social Care Act has influence beyond UK borders. It gives the act international legal backing and sets the whole shift to privatisation in stone because once it is made law, it will be irreversible. Investor State Dispute Settlement (ISDS) laws, fundamentals of the agreement, allow corporations legal protection for their profits regardless of patient care performance, with the power to sue any public sector organisation or government that threatens their interest.”

“Once these ISDS tools are in place, lucrative contracts will be underwritten, even where a private provider is failing patients and the CCG wants a contract cancelled. In this case, the provider will be able to sue a CCG for future loss of earnings, thanks to the agreement, causing the loss of vast sums of taxpayer money on legal and administrative costs.”

Given also Andy Burnham’s reported opposition to TTIP, it would be absolutely ludicrous for the Socialist Health Association to adopt any position other than to oppose the parts of TTIP which are clearly to the detriment of the NHS. This situation, I feel, has arisen because “leaders” who’ve never set foot on a ward in a clinical capacity have little understanding of the social capital of its workforce: doctors, nurses, healthcare assistants, and all allied health professionals. It will be painful for members of the Socialist Health Association if they wish to collude knowingly with this non-socialist agenda. This is all the more telling as the Socialist Health Association seem bizarrely silent concerning the pay freeze for much of the nursing workforce.

And so the NHS strategy is beginning to take shape – parallel worlds of grassroots clinical service delivery (the unprofitable bit which costs money), and the more lucrative bit (where the State can use patient data taken from the general public on the basis of presumed con set to develop diagnostic tests and treatments, with the help of investment from venture capitalists and large charities, to export to the rest of the world under free trade agreements).

It is time for the Socialist Health Association to work out who exactly they represent?

TTIP makes intellectual asset stripping look like taking candy from a baby.

And the jury is out on Simon Stevens and the think tanks, many people will also say. But this is possibly a lost cause.

So we wait with baited breath for Ed Miliband’s reaction to David Cameron’s note about TTIP. Hopefully they will not simply agree to this agenda, ever increasing the democratic deficit.

@legalaware

Why are English policy wonks fixated on the dangerous wrong policy of competition for their NHS?

A series of different amendments are coming from various sources to ask Andy Burnham to scrap the market in the NHS.

And indeed Andy Burnham claims to be well aware of the dangers of the introduction of a sort of-market to the NHS:

In recent years, there has been clear unease at policy wonks ‘doing’ the traditional circuits in think tanks, known to feather each other’s nests, with no clinical backgrounds (including no basic qualifications in medicine or nursing), pontificating at others for a cost and price how to run the NHS in England.

Think tanks have been part of the discussion, with blurred lines between marketing and shill and academic research, exasperating the real research community.

The King’s Fund boasts that, “Providing patients with choice about their care has been an explicit goal of the NHS in recent years. Competition is viewed by the government as a way of both providing that choice and giving providers an incentive to improve. The Health and Social Care Act set out Monitor’s role as the sector regulator with a specific role of preventing anti-competitive behaviour in health care.”

Chris Ham, who has previously marvelled voluptuously at the US provider Kaiser Permanente in the British Medical Journal, goes hammer and tong at it on an article on competition here.

The theme or meme comes up as a recurrent bad smell in the impact assessment for the Health and Social Care Bill here, citing in the need to consider equality concerns in competition the reference Gaynor M, Moreno-Serra R, Propper C, (July 2010) Death by Market Power Reform, Competition and Patient Outcomes in the National Health Service. NBER Working Paper No. 16164, July 2010.

The authors of that impact assessment nonetheless reassuringly observe that “Gaynor et al (2010) found competition impacted differently across certain areas with possible negative impacts on transgender and black and minority ethnic (BME) people. However, further evidence implies that these risks, associated with increasing competition, should not be overstated and may not impact upon equality issues.”

Andy Burnham – and Labour – have pledged many times that the repeal of the failed Health and Social Care Act (2012) will be in the first Queen’s Speech of a Labour government.

Policy wonks are human beings, and can fail.

It is well-known that many errors in anesthesiology are human in nature. It’s argued that because equipment failure is an infrequent explanation for mishaps in the hospital, clinicians should be aware of the human factors that can precipitate adverse events.

While there are various types of human errors that can lead to complications, “fixation errors” are relatively common and deserve particular attention. Fixation errors occur when clinicians concentrate exclusively on a single aspect of a case to the detriment of other more important features. This is exactly what has happened with the undue prominence of the benefits of competition in the NHS.

Put simply, without any of the bullshit, competition is simply the crow bar which puts private providers into the NHS.

Milburn and Hewitt have been reading from this narrative from ages, and it threatens to engulf Labour yet again. Burnham is fighting a battle for the soul of the party now, and one can only speculate how successful he will be. He has said on many occasions that collaboration is the key to running the NHS in England, not competition; integration not fragmentation; people before profit.

But if you look beyond the lobbying – you can find the evidence right before your eyes. Jonathon Tomlinson through an excellent blogpost of his refers to a large body of literature from Professor Don Berwick which has been in the literature. This is clearly worth revisiting now.

The New Statesman published last week an article which should make senior healthcare policy wonks in England weep.

Martin Bromiley is neither a doctor, or a health professional of any kind. He is not even a member of the revolving door policy wonks in English healthcare policy. Bromiley is an airline pilot.

“Early on the morning of 29 March 2005, Martin Bromiley kissed his wife goodbye. Along with their two children, Victoria, then six, and Adam, five, he waved as she was wheeled into the operating theatre and she waved back.”

A room full of experts were fixated on intubating her, instead of doing a tracheostomy, which indeed Bromiley indeed asked for. A tracheotomy is  a cut to the throat to allow air in.

What happened next was incredible.

“If the severity of Elaine’s condition in those crucial minutes wasn’t registered by the doctors, it was noticed by others in the room. The nurses saw Elaine’s erratic breathing; the blueness of her face; the swings in her blood pressure; the lowness of her oxygen levels and the convulsions of her body. They later said that they had been surprised when the doctors didn’t attempt to gain access to the trachea, but felt unable to broach the subject. Not directly, anyway: one nurse located a tracheotomy set and presented it to the doctors, who didn’t even acknowledge her. Another nurse phoned the intensive-care unit and told them to prepare a bed immediately. When she informed the doctors of her action they looked at her, she said later, as if she was overreacting.”

This is not the first time that a ‘fixation error’ has had disastrous consequences.

Another example happened on 28 December 1978, the United Airlines Flight 173.

A flight simulator instructor Captain allowed his Douglas DC-8 to run out of fuel while investigating a landing gear problem.

It’s a miracle that only ten people were killed after Flight 173 crashed into an area of woodland in Portland; but the crash needn’t have happened at all.

In a crisis, the brain’s perceptual field narrows and shortens. We become seized by a tremendous compulsion to fix on the problem we think we can solve, and quickly lose awareness of almost everything else. It’s an affliction to which even the most skilled and experienced professionals are prone.

In March 2012, Professor Allyson Pollock wrote an article in the Guardian, stating ‘Bad science should not be used to justify NHS shakeup’.

In this article, Pollock argued that pro-competition arguments from economists Julian Le Grand and Zack Cooper at the London School of Economics had produced an incredibly distorting effect on what was an important discussion and, “[raised] serious questions about the independence and academic rigour of research by academics seeking to reassure government of the benefits of market competition in healthcare.”

Pollock argues that such colleagues had been sufficiently successful for David Cameron to declare “Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.”

It is reported in one case, the previous chief of NHS England, Sir David Nicholson KCB CBE “said a foundation trust chief executive had been told he could not “buddy” with a nearby trust ? under plans announced last week to help struggling providers ? because “it was anti-competitive”.

He continued: “I’ve been somewhere [where] a trust has used competition law to protect themselves from having to stop doing cancer surgery, even though they don’t meet any of the guidelines [for the service].”

“Trusts have said to me they have organised, they have been through a consultation, they were centralising a particular service and have been stopped by competition law. And I’ve heard a federated group of general practices have been stopped from coming together because of the threat of competition law.”

“All of these [proposed changes] make perfect sense from the point of view of quality for patients, yet that is what has happened.”

Meanwhile, there was more product placement for providers including Kaiser Permanente yesterday by Jeremy Hunt in parliament:

“From next year, CCGs will have the ability to co-commission primary care alongside the secondary and community care they already commission. When combined with the joint commissioning of social care through the better care fund, we will have, for the first time in this country, one local organisation responsible for commissioning nearly all care, following best practice seen in other parts of the world, whether Ribera Salud Grupo in Spain, or Kaiser Permanente and Group Health in the US..”

Everyone appears to be fixated apart from the most junior in the room, or people like me who wouldn’t want to touch these jobs in think tanks with a barge pole.

It is indeed a badge of honour for me that the feeling is likely to be mutual.

Competition does not explain whether a person who has had chest pains due to a clogging heart should have a physical stent to open up the pipes of blood in his heart, or whether he needs tablets he can take. That is down to clinical professional acumen.

Competition with few big providers can lead to massive rip offs in prices, because of the way these markets work (these markets are called ‘oligopolies‘).

And all too easily providers can be in a race to the bottom on quality, cutting costs to maximise profits.

Remember Carol Propper’s research being used to bolster up the failed plank of competition in the Health and Social Care Act impact assessment?

Wow.

Here she is again in the speech by Simon Stevens, the new NHS England chief, being used in a slightly new context for his speech before the NHS Confederation last week: of the “sensible use” of competition in the NHS (somewhat reminiscent of the use of the words “sensible use” in the context of another potentially disastrous area of policy – targets):

“If we want to be evidence-informed in our policy making and commissioning lets pay heed to research from Martin Gaynor, Mauro Laudicella and Carol Propper at Bristol University. They’ve spotted the striking fact that between 1997 and 2006 around half of the acute hospitals in England were involved in a merger. Their peer-reviewed results found little in the way of gains.”

These fixation errors are causing damage to the English NHS.

It’s time some people got out of the cockpit.

 

Care at the crossroads. Burnham has something big, and you may be quite pleased to see him

Social care funding is on its knees.

Andy Burnham MP, Shadow Secretary of State for Health, addressed a sympathetic audience at the #NHSConfed2014 yesterday, talking about unlocking resources for general medicine.

We live in crazy times. Newark saw the christening of the Conservative Party as the protest party you should vote if you wanted to STOP UKIP. But let me take you back to an era when the Labour Party had principles (!)  In August 1945, Aneurin Bevan was made Minster for Health following the 1945 General Election. The National Health Service (NHS) was one of the major achievements of Clement Attlee’s Labour government. By July 1948, Minister for Health, Aneurin Bevan had helped guide the National Health Service Act through Parliament.

A full day has been allocated to the Opposition health on Monday in parliament in part of their discussions on her Majesty’s Gracious Speech. Simon Stevens – NHS England’s new chief – has asked for solutions for well rehearsed issues, and Andy Burnham is clear that this is no time for another apprentice like Jeremy Hunt. Whilst being upbeat about the future of the health and social care system, he wants to move away from a “malnourished system”, with carers employed on zero hours contracts and less than the minimum wage. Indeed, this is a serious issue which has caused me some considerably anxiety too. A “product of [my] time in Government”, clearly this framework has also benefited from a parliamentary term in opposition.

Burnham crucially identifies not an inefficiency in which money is spent (although the ongoing Nicholson savings rumble on). But he does identify an inefficiency in outcomes (such as the near-inevitable fractured neck of the femur in the leg for a seemingly-trivial cost-saving in not purchasing a grab handrail). Labour, inevitably, though has an uphill battle now. The system appears to encourage the medical model of care, according to Burnham, encourages hospitalisation of people, so it is not simply a question of throwing money at the service. People are more than aware that an ‘unsustainable NHS’ is in a nutshell code for a NHS starved of adequate fundings.

Burnham feels that you can’t half-believe in ‘integration’, and is mollified about the consensus about a need for integration across all main political parties.

“I am really worried that the ‘Better Care Fund‘ might give integration a bad name”, comments Burnham.

People who have watching Burnham’s comments will note how Burnham has openly commented how he feels he has been misled by certain think-tanks in the past. A period of opposition has enabled Burnham conversely to obtain a crisis of insight. And yet he talks about his “precious moment” in order “to build a consensus of shared endeavour, which I intend to use to the full and very carefully.” Intriguingly, he does not wish to ‘foist a grand plan’ on voters after the next general election. This is of course is political speak for his ‘shared agenda’, driving a cultural change by stakeholders within the system. This is precisely what Burnham feels he has achieved through the commission on whole person care by Sir John Oldham.

“Not a medical or a treatment model, but a truly preventative service, that can at last aspire to give people a state of physical, mental and social wellbeing.”

Burnham wants to put a stop to the ‘random set of disconnected meetings with individuals within the service.’

An exercise was carried out at the start of the NHS.

This is the famous leaflet.

Burnham desires a new leaflet from an incoming Labour government to introduce how social care can become under the umbrella of the National Health Service.

“Going forward, you should expect to receive much more support in your home. The NHS will work to assemble one team to look after you covering all the needs you have. We want to build a personal solution that works for you, for your family, and for your carers, because if we get right at the very outset and the very beginning it’s more likely to work for you and give you what you want, and cost us all much less. We want you to have one point of contact for the co-ordination of your care. We know you are fed up with telling the same story to everyone who comes through the door. It’s frustrating for you, and wasteful for us. To get the care that you’re entitled to, when and where you want it, you will have powerful new rights set out in the NHS Constitution such as the right to a single point of contact for the coordination of all of your care and a personalised care plan that you have signed off. But – and there is a big but – to make of all this happen, you will changes in your local NHS, and, in particular, you will changes in your local hospital. We can do a better job of supporting you where you want to be, we won’t need to carry out as much treatment in hospitals, or have as many hospital beds. It is only by allowing the NHS to make this kind of change to move from hospital to home that we will all secure it for the rest of this century.”

Burnham feels that the NHS must be the ‘preferred provider’ and the DGH should be allowed to reinvent itself – building the notion of one team around the person. I personally have formed the opinion: “close smaller hospitals at haste, and repent at leisure“. Critics of marketisation will inevitably point out the blindingly obvious: that even with a NHS preferred provider, there’s still a market, and nothing short of abolition of the purchaser-provider split will remedy the faultlines. There could be a one person tariff or one person budget for a person for a year. It would give an acute trust a much more stable platform, according to Burnham, in contradistinction to the activity based tariff. This does require some rejigging of how we have the proper financial performance management system in place: there should be a drive, I feel, for rewarding behaviours in the system that promote good health rather than rewarding disproportionately the work necessary to deal with failures of good control, such as dialysis, amputations or laser treatment.

Burnham is clearly inspired by the ‘Future Hospitals’ soundings from the Royal Colleges of Physicians, focused on a new generation of generalist doctors working across boundaries of primary and secondary care:

“Since its inception, the NHS has had to adapt to reconcile the changing needs of patients with advances in medical science. Change and the evolution of services is the backbone of the NHS. Hospitals need to meet the requirements of their local population, while providing specialised services to a much larger geographical catchment area.”

Burnham even talks about possibly reviewing the “independent contractor” status of GPs.

Centralised care is mooted for people in life threatening situations. But Burnham has found that barriers to service reconfiguration exist through the current competition régime and market, with integration encouraging in contrast to collaboration, people before profit, and merge “without the nonsense of competition lawyers looking over their shoulders”. Therefore, Burnham repeats his pledge to remove the Health and Social Care Act (2012), which has driven “fragmentation, complexity and greater cost”. Under this construct, section 75 and its associated Regulations is disabling rather than enabling for health policy. There is clearly much work to be done here to make the legislation fit for purpose, as indeed I have discussed previously. Wider dangers are at play, as Burnham well knows, however. Here he is speaking about his opposition to TTIP (the EU-US Free Trade Treaty) which the BBC News did not seed fit to cover despite their Charter requirements for public broadcasting. And here is George Eaton writing about his opposition to TTIP in the New Statesman.

Burnham is clearly, to me, positioning himself to the left, distancing himself from previous Labour administrations. There are clearly budgets in the system somewhere, and while Burnham talks about unified budgets he does not put the emphasis on personal budgets. There is no doubt to me that personal budgets can never be ‘compulsory’, and each person group (e.g. people living with dementia) presents with unique challenges. It’s clear to me that deep down Andy Burnham is still in principle keen on something like the ‘National Care Service’, in preference to any gimmicks from the Cabinet Office. Burnham in the Q/A session with Anita Anand indeed describes how this had been thrown into the long grass at the time of Labour losing the general election in 2010, but how paying for social care in 2014 is as fundamentally unfair as paying for medicine had been pre-NHS according to Burnham. This would take some time to put in place, such as a mechanism for a mandatory insurance system, and a proper care coordinator infrastructure. And these are not without their own controversies. But, with Miliband playing safe one unintended consequence for neoliberal fanatics has been that it has not been possible to impose a strong neoliberal thrust to whole person care; and whatever Miliband’s personal preferences, the pendulum to me is definitely swinging to the left. Burnham talks specifically about a well planned social care system as part of the NHS.

And so Burnham looks genuinely burnt by previous administrations, and, whilst certain key players will want personal budgets and competition to be playing a greater part in policy, it appears to me that the current mood music is for Labour not appearing to promote privatisation of the NHS in any form.  The ultimate success of the next Labour administration will be determined by the clout of the Chancellor of Exchequer, whoever that is. It could yet be Ed Balls. For matters such as ‘purse strings’ on the social impact value bond or the private finance initiative, Burnham may have to slog out painful issues with Balls in the way that Aneurin Bevan once did with Ernie Bevin in a previous Labour existence. Burnham’s problem is ensuring continuity with the current system where services have been proactively pimped out to the private sector, but ultimately it is the general public who call the shots. Burnham knows he’s onto something big, and, for once, some people may be quite pleased to see him.

 

@legalaware