The healthmatters blog; commentary, observation and review
Most of us have read the claim that the introduction of the internal market increased NHS administration costs from 5% to 14%, with many variations on the theme claiming for example that this means £10bn could be saved by ending the internal market.
The source for the claims about 5% and 14% is the 4th Report of the Health Committee, Session 09/10 on Commissioning. The following extracts are from the report…
According to the official historian of the NHS, Dr Charles Webster, the service:
has traditionally scored highly on account of its low cost of administration, which until the 1980s amounted to about 5% of health-service expenditure. After 1981 administrative costs soared; in 1997 they stood at about 12%
An estimate of administrative costs since 1997 has been made by a team at York University, in a study commissioned by the DH but never published. This concluded that:
In the English NHS, the purchaser-provider split, private finance, national tariffs and other policies aiming to stimulate efficiency in the system and create a mix of public and private finance and provision mean almost unavoidably that the more information is needed to make contracts, hence transactions costs of providing care have increased, and may continue to increase.
The Health Committee concluded that …..
Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; and the Department of Health was unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts.
Two things should immediately be pointed out. The quote about 5% is from an excellent book, A Political History of the NHS by Charles Webster, but the passage in the book does not itself have any references to where the 5% came from or what it actually contained. It is almost certain that in the era pre 1980 many tasks which might now be characterised as “administration” or “management” were only done as part of a wider job and so would not have been recorded in any way.
And the York University Report – NHS Management and Administration Staffing and Expenditure in a National and International Context, from March 2005, time and again sets out that comparison of costs between countries and between periods in our own NHS are beset with many issues around classification, so for example the 14% contains an “estimate” of consultants time which might be classed as management. It stated:-
There are no agreed definitions of ‘administration’ and ‘management’ in health care between (and sometimes even within) countries’ health care systems. Substantial ambiguity exists around any comparisons, particularly as definitions shift as groups of workers are recategorised. Consequently, all cross-national and cross-sectoral figures must be viewed with extreme caution.
The York Report also has these key passages:-
Before reviewing the data we have accessed, it is useful to emphasise the particular nature of the political debate about NHS ‘bureaucracy’. Expenditure on management in other public sector organisations (e.g. schools) is rarely measured systematically, and it is not denigrated in the way that the alleged ‘excesses’ of health sector management are. Yet in all service industries and organisations, management and administration is essential for the efficient delivery of services. Furthermore, as the complexities of health care delivery have increased, and there has been increased recognition of system failures such as practice variations, clinical errors and inappropriate or untimely treatment, the need for effective management and administration has increased in all health care systems, public and private.
Expenditure on management and administration, in the NHS and in all other health care systems, is a means to an end: its purpose is to improve patient care. The relatively ill informed and superficial debates around whole system ‘bureaucracy’ make little attempt to assess the value of management and administration in particular activities, or accept that some such expenditure is essential to ensure the appropriate and efficient delivery of care. The primary policy issue should not be overall management staffing levels or costs, but how investments of this type affect the performance of the health care system and its component parts.
The figures relate to the total estimated cost of administration and management not just the cost of commissioning.
The comparison of 5% to 14% is pointless as we have no comparable basis.
There was an increase in administration costs (probably quite significant) due to the late 1980s early 1990s changes as many new organisations came into being and transaction costs grew but this has not been quantified.
But there are argued to have been compensating benefits from the changes, such as in information technology, but no study has set out what these actually contributed to the 5% v 14% issue.
Whilst reference is repeatedly made as if the cost of commissioning (or of the Purchaser Provider split) is 14% this is not the case. Our own work has estimated the cost at far less, as does the Impact Assessment for the H&SC Bill.
If, perhaps when, the H&SC Act is repealed and the competitive market is removed then there will be scope for savings but not of the order of £10bn.
Further savings could come from reducing the number of NHS organisations through consolidation, but merges and other transactions have a bad track record.
We can only “guesstimate” but this might over time be of the order of 1 – 2% of total English NHS expenditure, but there would be considerable transition costs to be met and neither change would be easy and consolidation would be contested!
Richard Bourne, October 2013
Universal Health Coverage (UHC) is defined by the World Health Organisation as ensuring “that all people obtain the health services they need without suffering financial hardship when paying for them”. It is fast gaining global political momentum as a key health priority for the post-2015 development framework which will replace the current UN Millennium Development Goals.
From the perspective of an organization that works to achieve universal access to HIV prevention, treatment, care and support, shouldn’t we give our full support to a principle that promises to deliver 100% coverage of services for everyone who needs to access them? At the International HIV/AIDS Alliance, we would answer yes – so long as the approach is grounded in reality.
There is no getting around the fact that we live in a world where significant barriers exist to the realization of Universal Health Coverage. These include insufficient funding for health leading to reduced availability and quality of services; stigma and discrimination; human rights violations; criminalizing laws such as those against homosexual behaviour or drug use which drive people underground and away from health services; and inadequate legal protection for women who are confronted with gender-based violence. Our support for UHC must depend on the extent to which its definition and implementation directly addresses all of these barriers.
The Framework Convention on Global Health (FCGH) and the post-2015 development agenda, produced by the Joint Action and Learning Initiative on National and Global Responsibilities for Health, makes a very strong case that improving health outcomes requires more than UHC. It needs a broader focus that goes beyond strengthening public health care and addresses the economic and social determinants of health, including equity and the right to health. Human rights lawyer Gorik Ooms explains in a recent blog that if UHC is not anchored in the right to health, it could look like “selective” primary health care, excluding antiretroviral treatment for example, as is the case in Ghana.
The sobering picture is that even if we get the financing for health right, this in itself does not guarantee sufficient quality of services or universal access. A recent Oxfam paper describes how many health insurance schemes which are promoted by the World Bank and other donors to finance UHC invariably disadvantage the poorest and most marginalized, and how those countries that have made the most progress to date have prioritised equity from the outset.
We need to redirect our attention towards populations and interventions excluded from current UHC models which are not tackling the barriers to universal coverage adequately enough. Addressing the stigma, discrimination, marginalization and human rights violations that prevent individuals or groups of people from accessing the health services they need requires:
Reform of legal frameworks to end criminalizing and discriminatory laws, including the criminalization of groups such as men who have sex with men, sex workers, drug users, and criminalization of HIV transmission.
Accurate context-specific disaggregated data about the needs, vulnerability and discrimination faced by marginalized populations and their level of access to services.
Appropriate demand creation to ensure improved access to health services by marginalized populations, including through strengthening community service delivery systems alongside sensitizing, training and awareness-raising among public health workers.
Addressing the underlying social and economic determinants of health beyond service delivery and extending the focus on UHC to a more comprehensive set of measures required to create healthy living conditions, reflected in an overarching outcome-focused post-2015 health goal.
- A strong and inclusive accountability mechanism which enables people, including from marginalized groups, to effectively claim their rights.
UHC as a key instrument to achieve improved health outcomes for all only has real meaning when it is translated into concrete and measurable targets related to universal access and financial risk protection alongside additional targets on health outcomes and enabling healthy behaviour.
From the Alliance’s perspective, UHC will be a success if it serves the marginalized populations we work with across the world. Any gay man, irrespective of the country he lives in, should be able to go to his nearest health clinic to get tested and receive user-friendly information and services on how to protect himself against HIV. If he tests positive he should be able to get the necessary support for treatment initiation, adherence and be able to pick up his anti-retroviral therapy free of charge without fear of being denied treatment, arrested or murdered. Strong community-based organisations – that provide care and support as well as helping to uphold rights – have a critical role to play in making this possible and sustainable.
The time has come to stop idealizing Universal Health Coverage and to become realistic about how it should be delivered so as to make it work for all.
Click here to read the International HIV/AIDS Alliance’s discussion paper on Health in the Post-2015 Sustainable Development Framework.
By Marielle Hart, International HIV/AIDS Alliance
A study published in the New England Journal of Medicine, shows that bowel cancer screening with faecal occult blood testing reduces the risk of dying from bowel cancer, and this effect lasts as long as 30 years. However, such screening does not influence the all cause mortality, so screened patients won’t necessarily live longer.
The study is a long term follow-up to the Minnesota Colon Cancer Control Study, which began in 1975 and included 46,551 participants aged between 50 and 80 years. Participants were randomly assigned to be screened with faecal occult blood testing every year or two years or to a control group . Screening was carried out in two six year periods, and the patients were then followed over the next 30 years.
More than 7 in 10 people died during the study, and whether they had been screened made no difference to when they died. However, in the annual screening group the risk of death from colorectal cancer was 32% lower than in the control group, and in the biennial group it was 22% lower than in the controls.
The magnitude of the screening benefits was similar to what was originally reported after 13 years of the trial, indicating that the effects of faecal occult blood testing persisted even after screening had stopped.
Men between 60 and 69 benefited the most from screening. Women over 70 also had a significant benefit from annual screening, but little benefit was seen among women under 60.
No studies have directly compared colonoscopy and faecal occult blood testing, although randomised trials are ongoing. The UK bowel cancer screening programme offers a faecal occult blood test every two years to men and women aged over 60.
BMJ 2013; 347:f5773
In the run up to the 2015 general election, the NHS is likely to have a large part of its community health services (and some hospital services) provided or managed by the private sector. Mental health services, 30% of which are currently provided by commercial or third sector organisations, may be the shape (although not necessarily the size) of things to come.
Clinical Commissioning Groups (CCGs) will be struggling to balance rising demand and expectations and shrinking budgets, with limited powers. Some CCGs will manage these pressures better than others, perhaps changing general practice as they do so, but others will fail to develop new services or balance their budgets. There will be increased effort by NHS England to manage (and micro-manage) the health service, and promote service integration. The instability of NHS Trusts and unachievable targets will undermine these efforts, and top-down management will fail more often.
There will be more public engagement with the NHS, through both official channels (Healthwatch, the Health & Wellbeing Boards) and unofficial ones (campaigns to preserve existing NHS resources & services). The conflict between bottom-up accountability to vociferous local interests and central accountability to NHS England will increase tensions within the NHS.
Further shrinkage of publicly-funded social care will occur. Individuals trying to manage their own social care by using the benefits system will be challenged by benefits cuts and restrictions, even as political rhetoric emphasises ‘personalisation’ and ‘personal budgets’.
Financial instability in the hospital sector will increase, particularly where there is Public Finance Initiative (PFI) debt. This instability will also arise because of the inability of the hospital sector to respond to social and demographic changes (more very old people, fewer carers), inherent inefficiencies in hospital organisation, and declining staff engagement, motivation and confidence. The divide between District General Hospitals (DGHs) and teaching hospitals will widen, and 50 or so Hospital Trusts will not achieve Foundation status.
Variability in the quality of general practice will persist, despite the modernising forces within clinical commissioning and the ambitions of NHS England. The low skill base and poor organisation will remain widespread.
Public debate will express growing interest in the importance of individual responsibility for health, while family and friends will be seen as essential support for those in hospital, acting as advocates and also as direct providers of care.
The Health Matters seminars identified ten problems that a Labour government elected in 2015 will need to address (but not necessarily solve), over a ten year period.
- Funding constraints should prompt both ‘smarter working’ (as advocated by NHS England) but also reclassification of PFI and other historic debt as “toxic”, so that they can be managed separately from NHS cash-flows, or renegotiated.
- Generic challenges (common to all health services in industrialised societies) include social and demographic changes, system obsolescence, unwarranted variability in service performance and outcomes, increasing expectations and intolerance of poor quality, and resistance to innovation. The NHS is good at co-ordinated care for specific time-limited activities (maternity care, surgery, rehabilitation, palliative care) but less good when care coordination is needed for high volume, complex, long-term conditions. General practice and DGHs are no longer capable, as currently organised, to deal with these challenges. For example, there is a need to incentivise pro-active work, particularly in primary care, and a need to change incentives for hospitals to admit and discharge patients.
- The separation of mental health services from other services and their fragmentation by out-sourcing adds to the challenges facing the NHS, rather than reducing them. Joined up care is needed in the NHS, and between the NHS and social care, and because patient experiences of care are so often poor, it may make financial trade-offs possible and generate efficiency savings. Investment will be needed in the processes that are known to achieve collaborative working-such as shared budgets & professionals in services that are able to cross organisational boundaries
- The variability of quality of care in general practice, its limited skill set and poor level of organisation, make general practice a weak link in the NHS chain. The limited influence of the NHS over it cannot be allowed to persist. Although general practitioners (GPs) are in theory well positioned to provide coordinated care, the discipline is unable to do so under its present contract. A new GP contract is needed which will, for example, restore responsibilities for 24 hour care to general practice.
- The fragile means tested/privatised economy of social care, and the sometimes weak working relationships between the largely commercial care home sector and the NHS, can result in variable quality of care for care home residents and avoidable costs for NHS hospitals. Free social care could be funded by an Estates (Death) tax, or through hypothecated compulsory social care insurance. Free social care could be introduced in stages. One early stage could involve drawing the care home sector further into the public domain, through an NHS franchise. The different funding regimes in social care and the NHS are unhelpful, but providing social care for free will not in itself deliver more harmoniously functioning services.
- A historically weak political culture exists around the NHS, in which change is seen as a threat, and a deep democratic deficit, in which the public is excluded from NHS decision-making. There is a need for a mature political dialogue, but the mechanisms for it need to be established first, and then used systematically.
- Public health has been marginalised just as the social determinants of health and illness become clearer than ever. Community development (to increase social capital) generates early benefits for health and wellbeing, so closer working between CCGs and Health & Wellbeing Boards should be promoted.
- NHS management has been re-organised too often, and has lost a great deal of experience and its collective memory. The decay of leadership means that the cadre of management needed not only to stabilise the NHS but also to promote organic growth within it, is weak. Recovery of memory is an urgent task, and debate is needed on how to achieve it.
- Quality of care in the NHS is undermined by rapid and repeated organisational changes, a narrow focus on targets and the decay of leadership (amongst clinicians as well as managers). Perceptions of the poor quality of care are currently being manufactured by those hostile to the NHS. Their dominance can be undermined by adopting a person-centred approach to change. The debate about ‘integration’ of services is an opportunity to do this. ‘Integrated care’ is an unhelpful term because it starts from the perspective of existing services, not from the needs of people. It would be better framed as ‘joined up care’ or ‘whole person care’, or ‘co-ordinated care’. National Voice has a useful working definition of joined-up care which is very patient centred. http://www.nationalvoices.org.uk/30-charities-call-david-nicholson-endorse-new-principles-integrated-care
- Power in the NHS is dispersed across the health economy, without commensurate accountability across different centres of power, as seems to have happened in mid-Staffordshire according to the Francis Report. This is especially the case in the commercial sector, as the Winterbourne View private hospital scandal demonstrated. Citizens have little influence over the health services available to them, professionals may be disempowered by local management, local services are also resistant to ‘command and control’ management from the centre, whilst the commercial sector hides its activities behind a screen of ‘business secrets’. Community development offers participatory accountability with effective involvement in planning, usually around geographic areas.
An incoming Labour government in 2015 could base its policy towards the NHS on a response to the generic challenges, from two angles.
First, a balanced economy of health care should contain incentives that promote prevention, health promotion and a strategic role for public health, reinforce holistic care, and reduce reliance on hospitals. This will probably require some organisational combination of hospital and community services with lead commissioners and shared or programme budgets as possible funding mechanisms, but in most situations these combination will not be best achieved by merger. This change is likely to require the abolition of the Quality & Outcomes Framework in general practice, and of Payment by Results in hospitals.
Second, the key attributes of a service that meets needs can be defined in terms of:
- The forward deployment of expertise (the most experienced in the frontline, in hospitals and community services – including out-of-hours services).
- Training in the management of uncertainty at all levels of the NHS to reduce patient referral/hand-on and ‘buck passing’.
- Engagement of the public in NHS decision-making, and the NHS in community development, as a precondition for continued funding, with emphasis on increasing the power of ‘voice’ through use of social media and other mechanisms.
- The promotion of generalism (a holistic approach) in community and hospital services.
- Making the maintenance of collaborative, trusting working relationships between disciplines the primary task of NHS management.
- Deepening relationships and encouraging effective and efficient working between local authorities and the NHS. The NHS can then evolve towards a situation in which local government Health & Wellbeing Boards sign off CCG plans, giving local government increasing responsibility for healthcare commissioning.
- Reducing the intellectual and practical gulf between services for mental and physical health.
- Establishing single budgets and shared financial accountability as the norm across community and hospital services, along with a single outcomes framework, communication systems for sharing of information between services, and funding mechanisms aligned to desired outcomes.
In 2015 a Labour government could begin to promote local services spanning community and hospital practices, similar to Kaiser Permanente-type health maintenance organisations, but without driving their growth using market mechanisms. The exact mechanisms for governing these local services should be the subject of natural experiments (because we do not yet know the optimal mechanism). Changes can occur slowly and the new services can evolve over time. Such changes could occur within existing legislation, once section 3 of the Health & Social Care Act (HASCA) 2012 has been repealed. Planning for the repeal of Section 3 of HASCA needs to start soon, including a realistic appraisal of what can be unravelled and what cannot. Legally watertight ways of avoiding the privatisation elements of EU law need to be finalised.
Engagement of the NHS with community development, the wider public involvement in the NHS that seems likely to occur, and the evolution of local co-ordinated services will push the NHS towards becoming part of local rather than national government. This shift in accountability and governance will also be slow and incremental, with no system wide re-organisation occurring by decree.
Steve Iliffe & Richard Bourne, for the Health Matters seminar group
The Health Matters seminars included: Richard Bourne, Professor Peter Crome, Professor Ilana Crome, Dr Brian Fisher, Professor Claire Goodman, Professor Steve Iliffe, Professor Jill Manthorpe, Dr Linda Patterson, Martin Rathfelder, Professor Aubrey Sheiham.
This book comprises reflections from medical practitioners, academics and educationalists, on factors which they deem to be affecting the evolution of the role of doctors. These include, among others, the changing working environment, regulation and revalidation and the changing demographics of the profession.
As one of the guinea pig doctors who took on District General Manager posts in the wake of the Griffiths Report of 1983 I was particularly interested in the chapter on doctors in management. I have no doubt that people with clinical experience make more effective managers than those from a purely administrative background and that more doctors, nurses and paramedical staff should be actively encouraged to take on management roles after appropriate training of course – I had the great good fortune to be sent to Harvard for health systems management training. I do wonder however whether it is sensible for clinicians to retain a clinical responsibility after they have taken up a management role. It seems to me that the potential conflict in interest between the greater good of the institution in question and its patients and that of the particular clinician’s patients is just too great. In my own case a public health background and perspective meshed in very well with my management role. This being so it rather surprised me that only a handful of my fellow public health doctors chose to become managers.
Having witnessed what has happened to doctors and medical practice over my own 50 year medical career, to me the key influences have been the development and implementation of evidence based practice, the empowerment of patients through the information revolution, the expanding role of other healthcare professions and the increasing salience of management in trying to control spiralling costs. The effect of these influences has been the transformation of medicine from a judgement based profession to an evidence based, checklist/computer aided technology with increasingly blurred boundaries in relation to other healthcare professions, particularly nurses.
It is significant I believe that my own speciality of public health has opened its doors to non-medical graduates. Is this, I wonder, a harbinger of things to come in the clinical specialities? As a budding obstetrician I had no doubt that midwives with suitable training could do all the things I did; and I recall a general surgeon contemporary of mine telling me in all seriousness that training as a seamstress would have been a good basis for his surgical technique. The position of the medical specialities may be different, but I doubt it.
This is not to say that there is not a place for a cadre of medical scientists and epidemiologists to develop the healthcare evidence base. But the future of healthcare delivery surely must lie with a cadre of generic healthcare practitioners applying the knowledge base developed by the scientists with the help of appropriate checklists and computer programs.
Looking more strategically at the country’s needs in an increasingly competitive global environment, one has to wonder whether we can continue to divert so much of our academic/intellectual capital into healthcare rather than into science and technology. It is the case, I am told, that one of the medical schools in Israel rejects applicants with good exam results for this very reason.
If I could turn back the clock would I choose medicine as a career now? The profession has changed out of recognition since I decided to become a doctor at the age of 10 years. The idea of being a professional with all that this meant in terms of status and independence appealed greatly then. But medicine is no longer a profession and today it would be the challenge of being an entrepreneur, living on one’s wits and hard work, that would attract.
So an important book with interesting contents that has also stimulated some thinking about where medicine is going. Billed as being aimed at doctors and medical students seeking new strategies for understanding and managing change; and at sociologists and policy makers, it fulfils, I believe, a useful purpose.
Paul Walker, June 2013
Publisher Radcliffe. ISBN – 1 3: 978 184619 991 2
A safe and sustainable solution to the long standing problems confronting care in Staffordshire must be found. Problems at Mid Staffordshire Foundation Trust (MSFT) have led to the instigation of the Trust Special Administration process (TSA) but there are also serious doubts about the sustainability of University Hospital of North Staffordshire (UHNS), and other issues around the quality of care across the county. A solution is needed for the whole health economy.
It is accepted that the organisational form of MSFT must change – it is not “sustainable” as a stand alone Foundation Trust – but this applies to 50 or more provider organisations within the NHS. The promoted solution of (in effect) allowing UHNS to take over MSFT (or just the Stafford component) is likely to convert two failing trusts into one larger failing trust.
There is no magic solution: you would not start from where we are – solutions are messy, take time, cost money and require effective management – and there will be unintended consequences and unexpected issues along the way. The management consultant approach which assumes we can predict flows and levels of demand and then meet that demand in some optimal cost effective fashion through inspired managers is laughable.
In simple terms there must be a solution to the organisation arrangements of MSFT and a safe and sustainable solution for the use of Stafford Hospital, but simply trying to address these without a much wider whole system programme will inevitably fail.
A whole system solution should be an NHS solution, where the best of the knowledge and experience of the NHS is applied to finding solutions – not a market and failure approach where support from other parts of the NHS might be ruled anti-competitive or indeed resisted by NHS organisations looking to benefit from any failure of competitors. It should draw on NHS expertise not pay further millions to management consultants.
A whole system approach requires a shared vision and a long term strategy. It needs to be based on the Joint Strategic Needs Assessment and the commissioning intentions for health (unknown) and social care (vague). It must be acknowledged that with an unstable provider landscape and a raft of weak new health organisations (especially the two CCGs and the HWB) some system level leadership is necessary.
This is an opportunity for finding more imaginative and comprehensive solutions, learning lessons which could be applied across the country, based on the realisation being reached across the NHS that integration is the essential component of long term stability. This requires a wide consensus and support from the community, but the TSA approach in South London has led to confrontation and legal challenge and a proposed solution with little or no support. In Staffordshire there has to be a solution which is supported by the community, the wider stakeholders and the workforce. The community has shown that they will actively resist unsupported change, and delays, costs and energy will be expended on conflict not progress.
The route to sustainable solution has to be through better service integration across health and social care and across the all various NHS organisations. Delivering such a solution will take 3 – 5 years, will require some investment, subsidies (debt write offs) and changes to standard payment mechanisms and an overarching Programme Management structure. System leadership must come through a strategic board (or programme board) with representation from the various organisations, key clinicians and community and workforce representatives overseeing the transformation programme. It all begins with a coherent clinically informed vision for the desired end point.
Control over what will need to be a significant stream of additional funding will give the board its power. As is being acknowledged elsewhere, the system leadership must have flexibility, for example to opt out of key policy levers such as tariff and procurement rigidity, with ability to pool budgets and share posts and bend governance arrangements (eg FT status).
The (disputed) history of Stafford Hospital is largely irrelevant to possible solutions; the broadest consensus asserts that clinical quality issues are not the imperative for change and so far as anyone can judge the quality of care at Stafford is good. There is no doubt about the need for a clear focus on quality of care but as the Frances Report demonstrates cutting staff, failing to listen to staff and having a staff that are disengaged and demoralised will lead to poor care.
The concern of the community in Stafford is that the current services delivered from Stafford Hospital should be made safe and sustainable; the proposals so far are to cut services significantly, to only deliver an arbitrary set of services. The assumption is that for other services patients can go elsewhere as there are “competitors” nearby willing to accept the patients as they get the tariff payment for them. This is again the management consultant approach. If a facility is shut all that happens is the patients will go somewhere else leading to economies of scale. But patients may not respond as the management consultants predict1.
The alternative argument is that safe care can be provided from Stafford Hospital if the costs are met! These costs may be marginally greater than some arbitrary average but this is still cheaper than other solutions. It is both affordable and value for money. Crucial to this however is that clinicians see that there is a future in which they wish to participate and so Stafford can attract and retain the necessary highly skilled staff. To meet ongoing professional development requirements some of these staff will need to “rotate” across a larger organisational entity than just Stafford – in an NHS based on values like cooperation that is possible. A combination of use of modern communications technologies and of clinical networking can minimise “isolation” and allow local staff to obtain specialist advice and support 24/7 services, making a smaller facility safe and viable.
The key to protecting services at Stafford is 24/7 Emergency Care and the Intensive Care Units (ICU) this requires. ICU deals with patients with the most severe and life-threatening illnesses and injuries that require constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialise in caring for seriously ill patients. The lights stay on and they operate 24/7.
The proposal being strongly promoted is to downgrade the facility at Stafford to just a High Dependency Unit (HDU). HDU is for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed.
But if there is no ITU then others services cannot be supported leading to the domino effect of first halving the range of services as proposed and then inevitably the next stage of closure of the whole hospital. The community knows this instinctively.
In terms of finances great caution is required. Projecting finances, levels of demand, workforce requirements and costs are notoriously difficult and many PFI projects based on overoptimistic assumptions (everyone signed up to!) stand as testament. In simple terms the current MSFT has had expenditure in excess of income of around £15m (around 10%) for some years; allowed to continue thanks to subsidies from the wider NHS system. There is some analysis to suggest that under some reasonable assumptions this gap might be reduced perhaps to £5m but obviously continuing subsidies are required and so MSFT is “unsustainable”.
However it takes little to show on equally plausible assumptions (guesses) how that residual gap could be closed if a wider system approach took out more of the overhead and management costs, and activity/income was rebalanced across various settings.
What nobody has worked out is what the alternatives will cost, although it could well be more. Other local facilities are not meeting access targets so obviously they cannot just absorb additional patient flows without implications – which may require investment or entail additional costs.
And what of the need for local services – the human cost of more travel and greater uncertainty. The CCG commissioners appear to have been told they must say they will not pay over tariff – they will not subsidise local services as people can travel a bit further and get treatment at the same tariff cost – so why pay more? But “local” has wider value in terms of health equality, reducing anxiety, increasing access and these and other compensatory benefits have to be factored into the cost/benefit analysis. One view is that there is a subsidy the other view is that the cost is worth the benefit.
As regards the other loose end which is Cannock Chase Hospital the solution is to transfer ownership to an organisation which will best be able to use the potential of the large but heavily under utilised site to best advantage – leaving a few valued health services to be provided from part.
So the approach to Stafford and Mid Staffs must be:-
- patience and honesty
- an NHS solution
- a whole system solution managed as such over 3 – 5 years
- built on consensus
- whole system cost benefit analysis
- strategic oversight and collaboration not mergers and acquisitions
- suspending some system rules (around tariff, competition and procurement)
- rebuilding the reputation of Stafford and ending the disputes
- retaining ITU at Stafford (using clinical networking to support)
- having 24/7 emergency and acute care from Stafford
- keeping all other services at Stafford (reconfiguration 3 – 5 years later)
- adopting a 5 year plan to bring Stafford into financial balance
- with some element of subsidy during the transition.
1 The Newark example is a classic. The local “A&E” which had a long history of issues around optimum staffing levels was shut based on the entirely correct assumption that better emergency care could be provided if instead everyone went to a proper A&E at a local hospital some miles distant. The result was higher death rates in Newark not lower.
Richard Bourne, May 2013
In recent years, general attitudes towards smoking have changed a great deal. Increased awareness of smoking’s effects on your health and government legislation have seen cigarettes and accompanying advertising messages all but eradicated from public sight. This has cast the smoker in an unfavourable light – now they carry with them a habit that is deemed not only detrimental to their own health but anti-social too.
Within this environment, there is a lot more pressure upon the smoker to give up and, it seems, an increased inclination to do so. Of those that remain addicted to smoking in the UK, 63% possess the desire to quit. Unsurprisingly, the main reason given for this disposition is concern over health and the gloomy prospect of premature death.
Kicking the Habit
Despite nearly two-thirds of smokers having a desire to quit, the vast majority remain addicted as relapse rates for those that attempt to give up are very high. Many smokers have tried to give up at least once but have failed because their dependence on cigarettes is so hard to kick.
The addictive element is nicotine, and all smokers have built up a physical dependence to this drug, such that abstinence from it will cause a multitude of unpleasant withdrawal symptoms. These include nausea, headaches, anxiety and extreme cravings that are at their worst within the first 12-24 hours of quitting, making this the most common period for relapse.
Think of Your Health
For those who bite the bullet and endure that difficult first day, there are so many statistics borne from reliable sources that suggest quitting smoking will make your life much better. Within three days you should already start feeling better.
Within just 20 minutes of stubbing out your final cigarette, your body’s blood pressure and pulse rate will return to normal. Inside 48 hours the nicotine in your body will have disappeared and your quest to escape the drug’s vice-like grip will become that much easier. The 72 hour mark will see your breathing improve significantly as the bronchial tubes start to clear, so your energy levels should improve and physical exertion will become easier.
The long-term benefitsare even more note-worthy. By your ten-year mark as a non-smoker the risk of developing lung cancer will drop by half and the risk of you having a heart attack will be at the same level as someone who has never smoked.
Okay, so the fact that giving up smoking will improve your health is hardly a revelation. However, if you don’t mind having heavy lungs, perhaps you have grown tired of having a lighter wallet.
Cigarettes have increased massively in price, especially in the last ten years. The government have hiked up tax exponentially not just as a measure to line their own pockets, but as a tool to incentivise people to quit.
If you pay for your cigarettes as and when you need them, the deficit that your habit is inflicting on your finances might not be as obvious. However, if you take just a few moments to ponder the cumulative sums of cash squandered upon the habit it can become mind-boggling. If you think of quitting smoking in terms of what you can spend with the money saved then you can provide yourself with quantifiable inspiration– this quit smoking calculator tells you exactly how much you’ve spent, and what luxuries you could have treated yourself to instead!
Smoking severely depletes your health and your wallet. Considered in combination and alongside the increasing perception of smoking as an anti-social habit, surely there is no better time to send your habit ‘up in smoke
Gavin Harvey is a personal trainer who loves to blog on all things fitness and health related.
Health activism was not on the curriculum when I did my postgraduate public health training in the early 1970s; but then nor were inequalities in health nor communications. But, it did not really matter because as a practising public health physician in the pre and post 1974 NHS, I quickly learned that using the conventional routes for getting things done and effecting change led nowhere, or, at best, led somewhere but very slowly; and that a key role, as one ambitious for change, was to support and even promote at local and national levels what today would be called health activism. It seemed to me that one had to use all possible avenues for effecting change and I never felt there was any ethical problem in both trying to influence my health authority directly, ex officio as it were, and indirectly through some outside agency such as, in the early days of the post 1974 NHS, the newly created Community Health Councils some of which were very much in the health activism business. Whether my various employing authorities had concerns about this dual role – being both inside and outside the metaphorical tent – I never found out.
So, I assiduously cultivated my relationship with the local CHC which happened to be one of the activist ones; and later became an active member of Action on Smoking and Health at local and national levels; and an early and active member of the Public Health Alliance, later to become the UK Public Health Association.
Laverack believes that the need for health activism to tackle dominant public health issues, including particularly inequalities in health, is greater than ever; and that the key to success is “ working together for change,” involving the combination of activism, a strong professional lobby and credible scientific evidence that has the best chance of influencing social and political change. For me the acid test of any book about public health is what it has to offer on the major public health challenge of the age, namely, obesity. Disappointingly, on this measure this book scores poorly (only one mention in the index) even though the “working together for change” injunction is paramount in this area.
Perhaps the most important section of the book is that dealing with the current and potential future impact of the internet and social media on the effectiveness and scope of health activism. This is foreign territory for me but from my experience as editor/administrator of this health matters website, I am persuaded of their potentially revolutionary impact.
As a long time practising public health practitioner I worry that the discipline is much more about analysis than activism – paralysis through analysis as the saying goes. So I approached this book – all 175 pages of it – with some reservations expecting an undermining of the energy and excitement of the concept of health activism by a lot of philosophising and theorising. There is indeed a lot of analysis of the concept of health activism and of other related concepts but for me the saving grace of the book is the wealth of examples given. Would, I wonder, my effectiveness as a public health activist have been improved had I been able to read this book early in my career. I think the answer is probably yes because of the lessons to be learnt from the many case studies.
Rudolf Virchow has always been a hero of mine for his landmark work in microbiology. But now I know that he was an early example of what Laverack calls the individual as activist. The story of his activism on behalf of the miners of Silesia during and after an epidemic of typhoid fever in 1847 is truly inspiring. Virchow, in Laverack’s view, is one of the many enlightened health professionals who have played an important role in bridging the gap between the state and civil society and who have demonstrated that the “professional should always be political,” a phrase that should be the motto of the public health discipline, though from my own brief experience as a City Councillor it is easy to become nominally political but much more difficult to become effectively political.
Paul Walker, May, 2013
Published by Sage ISBN 978 -1- 4462 – 4964 -2
It has a lot of competition, so seeks to differentiate itself by relating understanding of biological systems, subsystems and elements to human health. This is what drew me to the book. To a large extent, it achieved this aim, providing a real world (macroscopic) consequence to failings at lower levels. By doing this, understanding is deepened and learning is more secure.
But the book suffered from over-ambition in my view. The pace after the first 50 or so pages increased rapidly, with a much greater tendency to supply facts and terminology with decreasing room for explanations. This is a shame as the initial style adopted made for effortless reading. I was able to understand cellular biology, and the fundamentals of chemistry more clearly than ever before. The shape and nature of the periodic table is no longer a mystery to me. The genetic code is now crystal clear in my mind. Her explanations assumed no prior knowledge, and communicated ideas with great clarity, albeit with some occasional repetitions.
For example, soon after explaining molecular chemistry basis so lucidly, large molecular diagrams appear, starting on page 53 with ATP (Adenine Triphosphate). The transition was too large without intermediate explanations. So her writing style started to suffer as a result, I would guess, from the sheer scale of the undertaking. The pace she had adopted was not sustainable.
Every once in a while, we just have to give in to our sweet tooth. Well, there is nothing wrong in having some meringue or ice cream for dessert, right? Absolutely. The problem actually starts when we consume more than we should. Perhaps we are all aware about diabetes and its effects, but what causes diabetes really?
“Type 1 diabetes is caused by the immune system destroying the cells in the pancreas that make insulin. This causes diabetes by leaving the body without enough insulin to function normally. This is called an autoimmune reaction, or autoimmune cause, because the body is attacking itself,” according to Diabetes.co.uk.
Meanwhile, Type 2 diabetes is often caused by lack of exercise, unhealthy diet, old age, and obesity. Although there are generic factors that can heighten one’s risk, it is imperative for an individual to take the necessary steps to keep himself healthy. Pediatric Endocrinologist Dr. Robert H. Lustig tells us how sugar can affect our health in his video Sugar: The Bitter Truth. It pays to have a reliable insurance coverage like Aviva Health of course, but then again, who wants to suffer the consequences of diabetes?
Below are some tips on how you can avoid diabetes:
1. Don’t skip breakfast.
“What we suspect is that the consistency of eating a daily breakfast helps control appetite and caloric intake for the rest of the day, which helps prevent weight gain,” says lead author Andrew Odegaard, a research associate at the University of Minnesota.
2. Get at least six to eight hours of sleep at night.
According to a pre-diabetes study done by the Boston Area Community Health, “Sleeping less than six hours a night is associated with a 60 percent higher rate of diabetes.”
3. Exercise regularly.
Exercise not only keeps you fit, but it also helps control your cholesterol level and regulates the production of insulin.
If you’re going to look at the list above, none of them actually cost a lot of money. You don’t really need to join a prestigious gym club or buy ridiculously priced “diet” drinks; there’s only one thing you need to keep yourself fit: discipline.