May 24, 2015

Responding to Monitor’s 2014/15 report on the Performance of the NHS Foundation Trust sector

 Rob Webster, chief executive of the NHS Confederation, said:

“This report provides a clear indication of the pressures faced by the NHS today, with the Foundation Trust (FT) sector posting a year-end deficit for the first time. The financial issues within providers are well-documented and these figures further highlight the impact from an FT perspective. Sustainability in the NHS is a challenge that must be met by the whole system and we will need to see strong leadership over the next five years to meet it.

“Following the debate around the NHS during the general election, we welcome the Prime Minister’s commitment made earlier this week to find at least £8 billion extra investment in the NHS by 2019/20. We look forward to working with the Government as it develops its spending plans for health and care. A clear signal from the Government that it will increase funding each and every year of this Parliament will allow the NHS to focus on the tough efficiency savings required and achieve the vision set out in the Five Year Forward View.

“The figures published today demonstrate that the NHS has a fragile settlement and that this will remain over the coming years. We will need to count on transformation funding delivered up-front and action to prevent social care from being cut, in order to prevent NHS organisations from being knocked off course.

“Local leaders continue to work with their teams to deliver great care in the NHS each and every day. We now need to change the way care is delivered in many parts of the NHS, with new models of care, backed by strong support from national bodies and politicians over this full Parliament. This looks within our grasp if we align behind the Five Year Forward View, secure sufficient funding and back the NHS to deliver.”


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May 24, 2015

The NHS after the Election

When forced to choose between saving the nation from the marauding Scots and saving the NHS from the Tories, middle England opted to face down the Jacobite rebellion. Labour’s warnings about the effect on the health service of another term for Cameron fell flat, as did the National Health Action Party’s call to turn the clock back to the good old days before purchasers and providers split (although two of their candidates did save their deposits). It all seems so difficult to understand, so perhaps we have to go back into history to see more clearly what is unfolding around us.

IN THE BEGINNING At the foundation of the NHS in July 1948 male life expectancy was around 65, the growing middle class was relieved it could access the free public health services that were available to the working class, and living standards were low. The new National Health Service had, from the outset, two features that have shaped its subsequent development; central allocation of funds (wrongly called a ‘command economy’), and contracting out of many services.

Central allocation of funds, from the Ministry down through regional bodes to local services, was not a form of planning, although attempts at planning were grafted onto it as the NHS grew. Central allocation always involved negotiation about what local services needed, and always provoked competition for resources. Competition was an inevitable consequence of need (or demand) exceeding supply. Added to this constant negotiation and competition was the problem of bottlenecks. Bottlenecks occurred when there were resource mismatches – enough surgeons to operate on those needing surgery but not enough theatre staff, or even enough theatres. Bottlenecks were removed by allocating resources to them. Most recently the Blair administrations bought operating time and space from the private sector to reduce waiting lists.

Contracting out was a dominant feature of the NHS from its first day, because most community-based NHS services – general practice, dentistry, opticians and pharmacists – were provided by for-profit subcontractors to the NHS, functioning as franchisees. The nature of the franchises varied – general practice functions as a network of small doctor co-operatives that reinvest profits in their organisations and charge patients nothing, whilst dentists operate public and private services in parallel, and charge patients using the public option.

New ways of contracting out have developed as the NHS has grown; voluntary pharmaceutical price regulation that guarantees profits whilst also capping them, hospice development through the charitable sector, the Private Finance Initiative for new hospital building and Foundation Status for hospital (which makes them into franchisees).

The important point is that from the beginning the NHS has had a public sector (the nationalised hospitals) and a public domain occupied by sub-contractors. The public sector took 80% of the NHS budget, but to this day 90% of citizens’ contacts with the NHS take place in the public domain. So if we want the NHS to stay public, what are we asking for, a bigger public domain or a bigger public sector? The Conservative government can live with the former, and is anyone calling for the nationalisation of dentistry?

THE END OF THE BEGINNING Although the Conservatives were hostile to the NHS for some time after its foundation, this attitude changed to one of bipartisan support; the first large scale hospital building programme was initiated in the early 1960s by the then Conservative health minister, Enoch Powell.

In 1983 a group of health policy analysts, heads of teaching hospitals and Conservative politicians met at the Carlton Club for a private discussion about the future of the NHS. The meeting came up with two over-arching objectives; the NHS needed to be ‘fully costed’, and its financial basis should shift from general taxation to a form of compulsory health insurance, based on National Insurance.

Fully costed’ means knowing the price of every part of every treatment, from the cost of cashing a prescription to the price of a major operation. This has been largely achieved (although there are some details of costing that remain unclear, and these are now discussed in terms of “unbundling”). The advantage of having services ‘fully costed’ is obvious – prices are central to markets, and so help the extension of contracting-out that we have seen since the middle of the Blair/Brown administrations.

However, having prices does not necessarily mean that contracting out will spread quickly. The NHS is a difficult industry to extract profits from, on the scale that shareholders require, and the market has failed as much as it has succeeded – the Circle debacle with Hinchingbrooke Hospital being an example. The Kings Fund’s judgement before the 2015 election is right. Most contracting out has been small-scale and marginal, except in mental health services. The over-excited advocates of market mechanisms hoped that market forces would sweep through the NHS like a whirlwind; they have been proved wrong and now look silly. Some of their opponents prophesied the end of the NHS as predatory for-profit companies swooped in; they got that very wrong, at least so far, and now sound histrionic. Of course privatisation attempts will still continue, and will demand local responses.

The second objective seems distant. The NHS is more efficient in its use of resources than European compulsory social insurance systems, and more socially just than the chaotic system of funding that has grown up in the USA. Nevertheless, if a crisis were to develop in the NHS, it could provide the opportunity for vested interests – the insurance industry that would welcome 60 million more customers, and the wealthy who could top up with personal insurance and so jump any queues – to propose a fundamental change.

Such a crisis could occur because of the cost containment being applied to the NHS. The NHS budget needs to grow by 4 to 5% per year to allow the application of new treatments and technologies, but at present it is growing by less than 1%. We are already beginning to see the consequences of this squeeze with lengthening waits in A&E departments and longer delays in starting cancer treatments. If it continues over five or so years the NHS budget will be 20% lower than it needs to be. To contain the impact of this, the current government is likely to press on with market solutions, despite their poor record, because they intensify the competition for resources that has always been a feature of the NHS, reduce job security and (in theory) increase productivity.

Productivity may not increase, and services will slow down and fail to meet demand. Key performance indicators, like time to investigation for potential cancer symptoms, will slip and treatment outcomes will not improve. The mid-Staffordshire hospital scandal shows what this could be like. On the other hand productivity might increase, but at the expense of the quality of care; when resources are tight ‘relational expertise’ – the ability to be with the ill person as a source of both information and of comfort – gives way to ‘technical expertise’ – the right treatment is given, even if the recipient does not understand its’ rationale and effects.

WHAT NEXT? The NHS has high levels of public support, and (perhaps surprisingly) support is growing. This support, even if relatively passive, will be a problem for a government hostile to the NHS. Passive support may not be enough, however. The Wanless long-term review of the NHS in 2002 argued that the health service would not survive in its current form without the “active engagement” of the population in staying healthy.

Increased funding for the NHS is needed to cope with rising technology costs, and this need will become more urgent the longer this administration survives. The decisions about containing NHS funding are political, not economic. Britain can afford to increase the NHS budget, which could have the twin benefits of improving the quality of medical care whilst also increasing consumer demand and tax income. We are a long way from the point where growth in the NHS budget could undermine other economic investment and damage the economy; this seems unlikely to occur even with an NHS budget of 14 to 16% of GDP (it is currently less than 8%).

Imminent wide-scale privatisation seems unlikely, despite the best efforts of the current administration, for the reasons given above. Reconfiguration of the NHS, on the other hand, is highly likely. One option would be for local government to become the natural home of NHS and social services combined into a single entity; this is underway in Manchester with the active involvement of Labour-led councils. Another option would be the formation of integrated services like the US Kaiser Permanente system, which contains general practitioners, specialist hospitals and social care in a single management structure; the first nine hospitals wanting to do this in England were given the green light in March 2015.

The achievement of the second Carlton Club objective, the shift to social insurance, seems unlikely in the short term. Even if this prediction is wrong, the outcome would probably be more European than American and more like a hypothecated health tax than a true insurance system that matches premiums to healthiness. A European-style compulsory health insurance plan would offer its enrolees a range of services within a prescribed tariff. Although politicians dislike hypothecated taxes because they reduce flexibility in allocating funds, some citizens might welcome the new freedom to ‘shop around’ with their new found personal health budget. Given their long lives, disposable income and high standard of living, these citizens might want to reshape a health service designed for a past society.

Steve Iliffe 23/5/15




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May 20, 2015

The fear of dying in misery in a hospital is driving the assisted dying debate, says medical ethics expert

 The fear of a miserable death in a hospital bed rather than at home is driving public support for mercy-killing law in the UK, a Birmingham City University academic has warned.

Responding to a report published today by The Parliamentary and Health Service Ombudsman, listing some of the worst cases in recent years of terminally ill patients dying without dignity, Timothy James, senior lecturer in Medical Law and Ethics at Birmingham City University, said: “For most people, dying at home isn’t about autonomy, it’s about dealing with the fear of dying in a hospital with poor end of life care. The fear of dying in misery in a hospital is what is driving the assisted dying debate.”

“We’ve known for a long time now that the option should be available for terminally ill patients to die at home. We are seeing too many cases where proper pain control is not being given.“

Referring to care in the English NHS, the ombudsman’s report details some of the cases investigated over the last four years, including that of a 29-year-old male dying of cancer who was admitted to hospital and left without pain relief for 11 hours.

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May 19, 2015

Cholesterol drugs associated with 30% lower stroke risk in healthy older adults

Findings suggest drugs might be considered for preventing stroke in older populations
Use of cholesterol lowering drugs is associated with a one third lower risk of stroke in older adults without previous disease, finds a study published in The BMJ this week.
In high income countries, a growing proportion of heart disease and stroke occur in the oldest people. In France, for instance, people aged 85 years and over accounted for 43% of deaths from coronary heart disease and 49% of deaths from stroke in 2010.
Yet very few people over the age of 70 take part in trials testing cardiovascular drugs, so their benefit in the oldest people remains uncertain. However, lipid lowering drugs are widely used to prevent heart disease and stroke in older age groups. This is known as primary prevention.
So a research team based in France set out to determine the association between use of lipid lowering drugs (statins or fibrates) in healthy older people and long term risk of coronary heart disease and stroke.
They tracked 7,484 men and women (average age 74 years) with no known history of vascular events, such as heart attacks and strokes, living in three French cities (Bordeaux, Dijon, Montpellier).
Face to face examinations took place every two years. Trained nurses and psychologists also performed interviews and took various physical and cognitive measurements. Factors such as education, occupation, income and lifestyle were also taken into account.
After an average follow-up time of nine years, the researchers found that use of lipid lowering drug (statins or fibrates) was associated with a one third lower risk of stroke compared with non-users. But no association was found between lipid lowering drug use and coronary heart disease.
Further analyses, taking account of age, sex, body mass index, blood pressure and blood cholesterol levels, did not show any effect modification, either for stroke or for coronary heart disease.
In a population of community-dwelling older people with no history of vascular events, use of statins or fibrates was associated with a 30% decrease in the incidence of stroke, say the authors.
This is an observational study, so no definitive conclusions can be drawn about cause and effect. Nevertheless, if replicated, the study results suggest that lipid lowering drugs might be considered for the prevention of stroke in older populations, say the researchers.
Despite some limitations, they say their data “raise the hypothesis of protection against stroke related to long term use of lipid lowering drugs for primary prevention in older people, with no difference between statins and fibrates.”
They point out that, in their population, the incidence of stroke was low (overall, 0.47 per 100 person years) so a 30% reduction in stroke risk results in a limited number of avoided cases. However, “in other populations more exposed to the risk of stroke, a one third reduction in stroke risk, if confirmed, could have an important effect on public health,” says Christophe Tzourio, Professor of Epidemiology at University of Bordeaux and Inserm.
This study will not change guidelines, but the results “are sufficiently compelling to justify further research testing the hypothesis that lipid lowering may be effective in the primary prevention of stroke in older people,” says Graeme Hankey, Professor of Neurology at the University of Western Australia, in an accompanying editorial.
Meanwhile, for clinicians and patients, he says the decision to start statins for primary prevention of vascular disease in people over 75 “continues to be based on sound clinical judgment” after considering each person’s predicted vascular risk with and without statins, their predicted risk of adverse effects, and the patient’s own priorities and preferences for treatment.
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May 19, 2015

Alzheimer’s Research UK calls for new dementia research strategy as part of 100-day plan

On day one of the new Parliament, Alzheimer’s Research UK has called for the creation of a new dementia research strategy and a commitment to year-on-year increases in Government funding for research into the condition. As MPs meet in Parliament for the first time since the general election, the UK’s leading dementia research charity has outlined actions that should be taken in the first 100 days of Government to capitalise on research progress and help deliver new treatments sooner.

Dementia currently affects 850,000 people in the UK, costing the economy a staggering £24bn a year, with those numbers set to rise as the population ages. With no treatments yet able to tackle the diseases that causes dementia, the condition is the biggest killer of women and the third biggest killer of men in the UK. In recent years politicians have begun to recognise the need for research into dementia, but while funding for research has increased to £66m in 2015, a rise spending is still needed to bring it in line with other health conditions.

The Prime Minister’s Challenge on Dementia 2020, which was launched in February, included an aim for significant progress to be made towards developing a cure or disease-modifying treatment over the next five years. Alzheimer’s Research UK believes that to lay the ground to help achieve these aims, four key steps must be taken within the new Government’s first 100 days:

  • Support for the creation of a dementia research strategy, to maximise investment for research
  • Action to raise public awareness of lifestyle changes that can help lower dementia risk
  • A commitment to implementing recommendations from the Innovative Medicines and Medical Technologies Review, set up to speed up delivery of new treatments and  medical innovations
  • A commitment to year-on-year increases in funding for dementia research

For every six researchers working on cancer in the UK, just one works on dementia, with a significant funding boost still needed to attract more scientists to the dementia research field. Alzheimer’s Research UK argues that a doubling of government funding is needed over the next five years, to take spending to £132m by 2020.

Hilary Evans, Director of External Affairs at Alzheimer’s Research UK, the UK’s leading dementia research charity, said:
“In recent years we’ve seen a global movement to take up the fight against dementia, and this is a crucial moment for the UK to ensure that this momentum continues. If we are to achieve the Prime Minister’s vision for tackling dementia and deliver on the G7’s ambition for new treatments by 2025, a new strategy for research is vital. Dementia destroys countless lives across the UK, and we owe it to those affected to keep up the fight against the condition. Alzheimer’s Research UK is leading the way with an ambitious drive to increase our own investment, and government action is also vital if we are to make real progress and transform lives.”


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