A Better NHS

From Spinwatch where there is more about Lansley’s private healthcare industry backers including 2020Health and Reform

Some clues as to how the NHS was converted from a public service to a free market. A 15min look at international health corps lobbying the UK department of health.

GP Commissioning is a consequence of the ‘purchaser-provider split’. In simple terms this defines GPs as purchasers (of health care) and hospitals as providers.

This is an artificial distinction. It doesn’t reflect what actually happens.

GPs provide at least as much care as hospitals. For example, in the last 3 months of last year I saw 807 patients and referred 51. Less than 7%. Of the referrals I made, many were for diagnostic or management advice and the patient will be sent back to me (and my practice team) to continue looking after them ourselves. Very often, hospital specialists ask me to perform investigations, trial or administer treatments, test for alternative diagnoses and so on. Both GPs and Hospitals are providers of health care. In actual fact, the whole array of health professionals and patients themselves work together as co-producers of health care.

The distinction between purchasers and providers is artificial. It has been introduced to create a health care market.

This artificial split has created new problems that weren’t there before. One is that hospitals have ‘perverse incentives’ to perform excessive investigations and procedures which they can bill to GPs. See this previous post for details.

Another problem is that hospitals have no incentive to work with GPs to reduce referrals. Recently I worked with a local neurologist to teach other GPs about the management of migraine. An audit of PCT referrals suggested that up to 40% of referrals could have been avoided and the patients managed effectively in primary care. The ‘purchaser-provider split’ has destroyed any incentives for hospitals to reduce the numbers of referrals because that would reduce their income. The pressure is unprecedented for at least 3 reasons.

• One is that the hospitals have to become foundation trusts and make an operating profit or go to the wall.
• The second is that they have to do this at a time of £20bn worth of cuts which is has never been done before in the NHS. (Excellent analysis from Richardblogger here)
• Thirdly, they are now operating in a competitive market where new entrants (referred to by the government as ‘any willing providers’) will be able to pick off the easy, profitable work that hospitals do and offer it to GP purchasers (GP Commissioning Consortia, GPCC) who will be under pressure to save money and under threat of EU competition law if they choose their local hospital rather than a cheaper competitor.

GPs on the other hand have enforce the £20bn cuts by ‘purchasing’ less care which means referring less patients and/or referring to cheaper ‘providers’. Certainly there are good grounds for referring less, as my audit of headache referrals showed, and my colleagues’ audit of gynaecology referrals showed (also 40% unnecessary). But, GPs who over-refer need support and training, and cooperation with the local hospital (provider) to work out careful clinical protocols and pathways. Without this, there is a serious risk that patients who actually need to be referred, will not, because of the need to save money.The purchaser-provider split is not just bad for hospitals and GPs, but bad for patients, stuck between purchasers and providers each with different financial incentives rather than their patients’ best interests. More worrying for patients is that the risk of medical errors is significantly higher when GPs and hospitals are not communicating and collaborating closely.

With the proposed changes the incentive for the hospital to help safely reduce referrals has gone, because they’re now trying to encourage more referrals to generate income and avoid going to the wall.

No hospital doctor wants to over-investigate or operate when it is not clinically indicated. No GP wants to hang on to a patient they’re worried about when they ought to be referring. But to introduce financial competition at the time of severe financial cuts forces clinical decision making to be compromised by financial considerations.

It doesn’t have to be this way. One of the first articles I wrote was about the Mayo clinic.

The Mayo Clinic in Northern Minnesota offers exemplary care at costs within in the lowest 15% of costs for the whole US.  It does this by removing financial incentives from clinical decision making, by paying staff salaries or fixed fees instead of linking pay to procedures and by significantly improving the level of teamwork by facilitating communication and collaboration between all the professionals involved in patient care. Costs were reduced and there were less unnecessary investigations and less clinical errors.

If Lansley was interested in improving efficiency, quality and safety he wouldn’t be introducing via GP commissioning an artificial split that will do exactly the opposite.

He should be facilitating collaboration between public health, social, primary and secondary care. This will give the much lauded increased clinical involvement in management with the added bonus of a range of clinical perspectives.

He should remove financial incentives to over-treat or under-refer.

He should give responsibility for these multidisciplinary teams to look after geographical areas and decide between them who is best placed to provide the care patients need.

And he should wholly reject the purchaser-provider split.

Now read: The colossal waste in commissioning costs by Wendy Savage published in the Guardian on 20.01.2011

Now that the NHS is going to be run along business lines to improve efficiency I’ve been thinking about the role of my patients. Policy bods think about the role of systems. It’s my job to think about the role of patients.

Health is distributed according to socio-economic status so that my patients, who are on the whole severely deprived, are also pretty sick and in need of a lot of care. So under an NHS that plans and delivers care according to need, they would get more care than patients who are better off and more healthy.

But under the new NHS that doesn’t plan care, but delivers it according to business principles, I’m worried that my inefficient patients will get less care.

Why are they inefficient?

1. Many of them cannot read or write so they have trouble understanding appointments, diseases, treatment regimes etc.

2. Many have mental illnesses including severe anxiety, depression, schizophrenia, dementia so that they are forgetful and chaotic.

3. Many are addicted to drugs and alcohol, so they are unpredictable and chaotic and frequently present to hospitals at a point of crisis.

4. Many are socially isolated, especially the people described above, the elderly, single mums, immigrants and so on. They present very frequently for company and reassurance.

5. Many have complicated mixes of different chronic diseases such as diabetes, heart disease, arthritis, renal disease, and so on, frequently compounded by mental illness, so they need a lot of care.

6. Many are very poor, over 50% do not have a car and many struggle to pay to travel to appointments, so often don’t attend, or don’t collect prescriptions if they have to pay.

7. Many of them don’t attend appointments for all the reasons above, so we cannot look after them effectively or perform all  the checks for which we are paid.

8. Lots of them don’t take their medications, and so we struggle to get their diseases under control and then don’t get paid when their blood pressure (for example) is too high.

9. Many have very unhealthy lifestyles for which there are medical consequences, but little in the way of medical solutions, so they don’t get better no matter what we do.

10. A lot don’t trust doctors. And stay well away or ignore whatever we suggest.

These patients need looking after. They need a lot more care than patients who are better educated, wealthier, and more secure. Because they do not, cannot behave ‘efficiently’, their GPs and hospitals will appear to be inefficient. And the market solution for inefficiency is, either to become more efficient, or be closed down or taken over. Lansley has said for the NHS market to work, inefficient providers must not be bailed out.

The Inverse Care Law, coined in 1971 by Julian Tudor Hart is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served, This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

Doctors and patients work together as ‘co-producers’ of health. Efficiency in health care is therefore a joint effort. This is most clearly explained in Tudor Hart’s latest book published in September last year: The Political Economy of Health Care. It is absolutely essential reading.

The risk that these reforms pose to vulnerable patients is particularly grave.

To preserve an NHS where patients, not profits come first:

• send your views to info.whitepaper@bma.org.uk
• join Keep Our NHS Public
• find out more from the NHS Support Federation

I’ve just had a look at the 51 referrals I made to secondary care for the last 3 months of 2010. There were 51 referrals out of 807 appointments.

None of these patients were interested in provider choice. In almost every case they had to go through a time-wasting, complicated process called choose and book, and in almost every case they chose the local service.

The government are betting the future of the NHS on patients and doctors being sufficiently picky about their secondary care providers, that the providers are forced to compete on price and quality, driving prices down and quality up. They are betting the future of the NHS on this.

If patients are not picky and GPs choose their local services, there will be no competition, and the fundamental basis of Lansley’s  £3bn total reorganisation of the NHS will have failed.

They’ve got less than a week before the Health White Paper goes to Parliament. This would appear to be a fatal flaw.

Ten choices I‘ve made with my patients this year.

1. Sidney is 97 and has dementia and chronic lung disease. He was in hospital for nearly a month before Christmas with a chest infection and has come home feeling very weak. He has taken to his bed. I was called to see him and he has another chest infection. The choice we have to make is whether he should go back to hospital or whether I should treat him at home, knowing he might well die. He decides to stay at home.
2. Anna is 66, she has severe bronchiectasis which affects her lungs and makes it very difficult to breath. She has been on the intensive care unit (ICU) 3 times in the last year because of infections. She came to see me with flu-like symptoms and deteriorating breathlessness, she knows another ICU admission is likely. We discuss whether she would like to be resuscitated in the event of a cardiac arrest. She says, to me and her husband, “there is almost nothing left to resuscitate, no thank you doc.”
3. Beryl has throat cancer. She has had surgery, radiotherapy and chemotherapy over the last 18 months. A CT scan last month showed the cancer had spread to her right lung. The oncologist has recommend surgery to remove the affected part of the lung. She doesn’t think she can cope with more surgery. We discuss the options. She decides to go ahead. See the excellent Atul Gawande for more on these dilemmas http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande
4. Cheryl has poorly controlled diabetes and is severely obese. She is also very anxious and rarely leaves home because of panic attacks. She is terrified of needles. Without insulin it’s very likely her kidneys will fail and she will go blind. We discuss the options. In spite of her needle phobia she agrees to see the surgeons to discuss a gastric bypass operation which might improve her diabetes sufficiently to avoid the need for insulin.
5. Mohammed has severe pain in his knees due to osteoarthritis. His family have encouraged him to see a surgeon to consider a knee replacement. He comes to see me to discuss the options. With physiotherapy he could reduce the pain and have a few more years before needing surgery. He decides to see the physiotherapists.
6. Maisy is 4. Her mother is keen for her to have a flu vaccine; she’s very worried about all the flu going around at school. We discuss the risks and benefits in detail. She decides it is not necessary.
7. Smantha is 36, she’s had a coil in for the last 4 months for contraception but the irregular bleeding is distressing her. She comes in to discuss the options. I reassure that this often settles down and we decide to try something to reduce the bleeding in the meantime.
8. Lucy has become increasingly psychotic over the Christmas break and her family are worried about her. I visited her at home with a psychiatrist and social worker to perform a section assessment to consider compulsory admission to a psychiatric unit. After careful consideration of all the options, we agree that the home care team, with my support will look after her at home.
9. James has had a relapse and started drinking heavily again. He comes to see me for another detox. We discuss the previous attempts and present options. Previous detoxifications haven’t been successful. We agree that he will see the alcohol counsellor this week and make a plan with the specialist alcohol team.
10. Eric has motor neurone disease. He is becoming gradually paralysed and can only manage soft or pureed foods. At a multidisciplinary meeting we discuss placement of a feeding tube that will be placed directly into his stomach through the abdominal wall. This is to prevent him choking on is food as his swallowing muscles become weaker. He wants to continue eating by mouth for as long as possible in spite of the risks.

These are the kind of choices that patients make with their doctors and nurses every day. They depend on a relationship of trust and mutual understanding which develops from continuity of care.

We know that overwhelmingly patients choose to see their own doctor and have treatment in their local hospital. By converting the NHS from a public service into a competitive business the choices that really matter to patients will come secondary to business interests.

The only choice the government are interested in is ‘provider choice’, which is a mechanism for stimulating markets and undermining the principles of a public NHS provided according to need.

To preserve an NHS where patients choices come first:

• send your views to info.whitepaper@bma.org.uk
• join Keep Our NHS Public
• find out more from the NHS Support Federation

I completed the DH consultation on greater choice and control yesterday. It is available here

It says the target audience is (from the top) GPs, nurses, health visitors, clinicians, managers… and way down at the bottom, at number 16, patients, then carers and finally, ‘service users’

The consultation has 57 questions, and about 100 pages, not including supplementary documentation, a glossary and related links. It took me about 2 hours to complete without reading any supplementary information.

Questions 1 to 56 were variations on the following:

Choosey patients like to choose and are choosey about their choices. If you could choose, what would you choose to ensure choicey patients have choosier choices?

Question 57 said (more or less)

Can you forsee any problems with our obesession with choice?

I’ve written about the problems with choice before, the problem with patient choice, more problems with patient choice, and yet more problems with patient choice

But the problem with I’m concerned about here is the problem with consultations. I’ve committed myself to campaigning for a fair, equitable, public NHS which means doing everything I can to stop governments of any political persuasion from transforming a public service into a private business, and consequently made time to fill in this consultation.

But I know that none of my GP colleagues, most of whom feel as strongly as I do about the NHS will have time. I cannot imagine many nurses, health visitors or patients completing it either. Every day amongst my pile of post as thick as a telephone directory and about 50 emails, I am sent a few questionairres. Most of these promise that it won’t take more than 10 minutes.  Commercial organisations sometimes offer a cash incentive if I complete them promptly. I ignore all the commercial ones but usually I fill in ones that are relevant to my patients or research we are involved in, but it really helps that they promise it won’t take more than 10 minutes. Nevertheless I rarely leave work before 8.30pm.

No way are GPs going to fill in this consultation. In the balance between our patients and our families, there simply is not enough time.

There are other reasons.

Firstly, I only heard about it on Twitter. Most GP’s don’t check Twitter.

Secondly it is a sham. 56 questions start with the stated assumption that the only thing better than choice is more choice.

Thirdly it is patronising. A lot of questions imply that doctors have never offered patients choice before, but only now, thanks to the governement they will be forced to start.

Fourthly it is ahistorical. Before the internal market was introduced in 1990 a GP could refer their patients to any consultant within the NHS. Now that the NHS has an internal market that is impossible because of the crazily complex financial arrangements. In this respect it can only get worse

My guess is that less than 0.01% (roughly 300) of GPs will complete this. Thanks again to Twitter I believe that parliament will be asked after the consultation how many GPs have responded.

We should all ask how much money is being spent on these sham consultations, who is responding and what difference they make. My impression is that they make no difference at all, and like my colleagues I should have spent more time with my family.

Update 25.01.2011

Only 200 GPs responded out of approximately 33000 (unofficial communication) If the govt tries to justify any consultation in future remember to ask who responded.

An essay I wrote in 2006 when avian flu was all the rage. A lot of it seems relevant to the problems we’re faced with now. Just think pigs instead of chickens.

Several times a day the BBC RSS news feed adds headline stories about newly discovered cases of the deadly H5N1 strain of avian flu to my Internet browser, so that in order to keep my essay up to date I continually monitor the latest statistics about the numbers of countries and individuals affected. Weekly the numbers increase by a handful. Meanwhile a program on Radio 4 informs me that every day on Britain’s roads there are 9 fatalities, and a newsletter arrives from a medical charity asking for donations to help save some of the one million lives a year lost due to malaria. I check the RSS news feed, there is nothing about malaria even though by my crude reckoning, another 114 people must have died in the hour since I last checked. According to the World Health Organisation (WHO) on Feb 20^th 2006 there have been 170 confirmed cases and 92 deaths from the H5N1 strain of avian flu since February 2003. (1)

When governments claim there is no need for panic, they are stimulating panic, bringing up comparisons with the 1918-1919 Spanish flu pandemic.  Research in October 2005 concluded that the strain of flu at that time was ‘entirely avian and bore some similarities with the H5N1 virus’ (WHO). This resulted in up to a third of the world’s human population becoming infected and of these, 20-100 million died. The reason for the very wide range of estimates of deaths was due to a paucity of data from the African and Asian subcontinents. Mortality data for the USA and Western Europe was extrapolated to estimate the effect in other continents. At that time the infection spread rapidly around the world, helped in part by the mobilisation of troops for war. Its spread was truly global; 5% of the population of Ghana died in just 2 months and nearly 20% of the population of western Samoa died. Entire Inuit villages in very remote areas of Alaska were wiped out. As is often pointed out, more people were killed by the flu epidemic than by the fighting in the first world war. Unlike most strains of flu, in which people die from secondary bacterial infections, the Spanish flu caused death directly and affected the young in particular, especially pregnant women, in whom mortality was more than 70%.

Since H5N1 was first discovered in Hong Kong in 1997 it has undergone various mutations, each increasingly virulent and capable of killing a wider range of species and becoming resistant to one of the two classes of anti-flu drugs; amantadines. The effectiveness of the other class of antiviral drugs, neuraminidase inhibitors which includes oseltamivir (tamiflu) is in doubt. Nevertheless, vitally,  there is still no evidence of a mutation resulting in a form of the virus that can be spread between humans and so the current WHO phase of pandemic alert is 3, a ‘pandemic phase’, where there is ‘no, or very limited human to human transmission’. In contrast, phase 6, a ‘pandemic’, refers to the stage where there is ‘efficient and sustained human to human transmission’. Far more frequently, epidemics of avian flu like this, affect poultry without effecting humans such as in 1983 when an H5N2 virus infection in the United States caused 13 million poultry deaths either as a result of infection or because of the poultry cull instituted to control it. (3)

An unfair global burden.

As with all infectious diseases, including tuberculosis, HIV/AIDS and malaria, poor people in underdeveloped countries are bearing the burden of avian flu. Since the disease affects only those people who are in close contact with infected birds, almost all the deaths so far have been in peasant poultry farmers in Vietnam, Indonesia, Thailand, China and Turkey. It is farmers in these countries who bare not only the risks of succumbing from the disease themselves, but also of having their chickens killed by infection or by culling. The H5N1 virus is particularly virulent, killing up to 100% of young chickens (DEFRA) More than 150 million birds have been culled so far in an attempt to prevent the spread of the disease and tens of thousands more are being culled daily. In poor countries such as these, compensation for loss of animals and loss of business is either none or negligible.

This leads to a serious disincentive to report suspicious illnesses among their flocks. Though a poor farmer’s family may face starvation and financial ruin because of the uncompensated loss of livelihood, wealthier farmers may also be tempted to sell birds or hide suspicious deaths to avoid the financial consequences. The moral obligation is based on the public good, the assumption being that the measure of culling and quarantine are intended to reduce the spread of avian flu locally, nationally and internationally in both bird and human populations. This calls for the farmers to act altruistically, sacrificing their livelihoods for the public good. They have to face a choice that farmers in wealthier countries do not. In July 2005 the U.S. poultry and egg industries drew up a plan authorizing the U.S. Department of Agriculture to “pay for 100 percent of the cost of purchase, destruction, [and] disposal of poultry infected with or exposed to H5/H7” viruses (PoultryUSA, July 2005). Compensation measures are very costly, how should they be funded, -to what extent should farmers, insurance companies, governments -tax payers- or international organisations be responsible? Should there be a global fund for compensating farmers for culled birds, birds that die as a direct result of the virus, or loss of business? Although the government of a poor country may be morally obliged to reduce the risk of avian flu to its citizens, lacking the funds for compensation, it may have to rely on a combination of authoritarian coercion and peasant altruism to do so.

Compensating the farmers may help prevent the spread of avian flu, but there are other problems of compensation common to both poor and wealthy countries. After the discovery of H5N1 in Italy, the Italian Farmers Confederation said eight out of ten consumers had stopped buying chicken. The Federation said since October the poultry sector has lost some 600m euros (£410m) and 30,000 workers have been temporarily laid off. (4) Paying farmers compensation for their culled stock may be sufficient incentive to prevent the spread of avian flu, but it doesn’t compensate associated businesses. Even if some compensation should be forthcoming, the networks of people employed and affected by the industry are too wide-ranging to be adequately or fully compensated. Hence the question of whether obligations are relative to means. The ethical delineation of how much compensation can be afforded would be limited minimally according to the minimal cost of restricting the spread of avian flu in the human population, partially in fully compensating all those affected by measures imposed on the poultry industry and fully in making sure the costs of poultry farming additionally encompass the costs necessary for revolutionising the poultry industry to ensure that the conditions that contribute to the development and spread of infection are eliminated.

Those who are not in the poultry business share responsibility for its methods because they expect cheap poultry. The price of tax increases required to compensate those affected, even in the maximal case described above, if any, are likely to be negligible. The main costs would be reflected in the price of poultry, yet there is no intrinsic right to cheap chicken. The measures imposed are in anticipation of a more infectious strain of avian flu, yet farmers who are expected to bear the costs of draconian measures designed to protect the urban consumers who face the risk of a pandemic that may never happen.

An appetite for flesh.

The global scale of intensive farming is mind-boggling. China produces 13 billion chickens annually, 60 percent of them on small farms. In the US more than 9 billion chickens are raised every year in factory farms. As people become wealthier and food is produced more cheaply, the appetite for meat increases and so the market in the world’s largest nations, China and India, can be expected to rise massively to meet the demand. Basic market forces and economies of scale force the production costs down as low as possible to satisfy consumer demand. Animal welfare takes second place to economic concerns so that the vast majority of chickens no longer roam the yard, but are manufactured in factories. The rise in demand for organic meat, whilst an encouraging reflection of concern for animal welfare, is insignificant in scale by comparison. That animals are capable of suffering, and that they do so particularly in conditions of intensive farming is self evident and does not need expansion here, except in relation to avian flu. At the time of writing, evidence points away from wild birds and towards domestic birds as the cause of the H5N1 variety of avian flu.

Because intensively farmed animals are in such close proximity to each other the risks of diseases spreading rapidly between them are very high. As a result, prophylactic antibiotics are routinely used in animal feeds. Antibiotics are also added to animal feeds to promote growth, independently of their use to prevent disease. Disease resistance to antibiotics increases with the amount and range of antibiotics used and is higher in more intensively bred livestock (DEFRA) so that industrial farming presents new and significant opportunities for emerging diseases. Unlike antibiotics, which are relatively cheap to produce and are varied in type, there are only two groups of antiviral drugs that may be of use in avian flu. The first strains of H5N1 found in China were sensitive to the antiviral amantadine, representing one of the antiviral groups, but since then resistance has developed, prompting speculation that resistance developed as a result of widespread and innapropriate use of prophylactic amantadine in poultry in China (WHO). The result is that now only the remaining, significantly more expensive drug, oseltamivir (Tamiflu) is effective in humans, and as I discuss below, only partially. WHO has called for the use of antiviral agents to be banned in poultry because of the risk of resistant organisms developing which could then effect humans. If there is an acceptable level of risk of developing new infectious diseases as a result of antimicrobials, then how should it be measured, and when do we decide that it has been exceeded? Animals suffer from the effects of antimicrobial treatment when they grow unnaturally fast and suffer from disease and humans are susceptible to the same diseases and rely on the same antibiotics.

The SARS outbreak in 2002-2003 led to 8,437 cases and 813 deaths. Eventually the virus was traced to a small mammal called a palm civet and the spread initially occurred through markets where wild mammals were traded in China’s Guandong region. In H5N1 avian flu was detected in 2 mountain hawk-eagles that were smuggled from Thailand into Belgium in hand luggage. The annual trade in wild animals is estimated to be 4 million birds, 640 000 reptiles, and 40, 000 primates. In May 2003 a prairie-dog trader in Wisconsin let his animals mix with other mammals imported from Ghana and within a month, 71 cases of monkey-pox in humans had been reported in 6 states. (5) In the UK, mad cow disease (BSE) led to new variant CJD in humans with tragic consequences for those effected. The disease only spread into cattle because farmers started feeding infected sheep byproducts to their cows. In all these cases human treatment of animals lead not only to the development and or spread of new diseases, but to animal suffering. The Kantian principle, that humans ought never to be used merely as means, but should be ends in themselves, ought to apply to animals, that are capable of suffering, as well.

In the UK, the measures for control set out by DEFRA are for the “culling of all susceptible birds on affected premises together with dangerous contacts on other premises.” Globally more than 150 million birds have been culled and the numbers are increasing by tens of thousands daily. The methods for culling birds are significantly less humane that those supposedly humane methods used for slaughter in developed countries and in less developed countries there have been reports of birds buried and burned alive (6). How many millions of healthy birds can be killed in order prevent the spread of a disease or to save a single human life? Can the destruction of wild birds and natural habitats be justified in order to control the spread of avian flu, and if so, what level of evidence is required? Can endangered species be culled if they are thought to be carriers? The traditional precautionary principle would accept the destruction of all these on the basis of flimsy and uncertain evidence. An alternative precautionary principle that values animals and the natural environment more highly would aim to tackle the problem with far less destruction.

A global response.

Pandemics do not respect national borders and the international spread of the disease and the international response headed by the WHO demonstrate the global scale of the problem. Since the response needs to be international, a number of dilemmas arise, such as the extent to which a global organisation should be able to dictate measures to control avian flu in different countries and to what extent should those countries be able to make their own contingency plans. A joint FAO/OIE/WHO joint statement released in November 2005 urged member states not to use antiviral drugs in animals in order to preserve their effectiveness for humans. Guidelines have also been drawn up for countries to prepare for a human pandemic. In January 2006, $1.8bn from World Bank, EU, US, and other countries was pledged to stop the spread of avian influenza from bird to human populations in affected countries (7). A pandemic involving human to human spread would put everyone at almost all nations at a similar level of risk. Trans-national, internationally funded bodies such as the WHO have reciprocal duties to their member states as well as shared duties and duties which extend beyond those states. In one respect their duties extend beyond their member states because a pandemic virus is not confined to any association of states, and so in order for their duties to their members to be fulfilled they need to act outside their borders. As members of a global community, by virtue of their shared humanity, as well as their privileged position of wealth, power and expertise, they also have duties to act in order to protect people in other countries irrespective of their duties to their own members. Likewise, governments have to decide whether their duty is to protect their citizens only within the jurisdiction of their own borders such as by the use of vaccinations and antiviral treatments, or whether they are able to dictate measures outside their borders to other countries in an attempt to protect their own citizens, such as import and immigration restrictions; whether they can dictate measures to prevent the global spread of disease, such as compulsory quarantine, culls and restrictions on trade in other countries, or whether they can reduce, by positive measures such as scientific, economic and logistical support, the spread and impact of avian flu. If a country refuses to impose measures agreed by international bodies, the degree to which its autonomy is respected has to be balanced with the risk it poses to other countries.

If international travel contributes to the spread of avian flu, should passengers there be quarantine periods to ensure symptoms did not develop before travel? Should passengers only be able to travel if they had proof of effective vaccination or immunity? If one country in particular has a very high incidence of avian flu, should the international community be able to impose conditions of quarantine and compulsory vaccination on all its citizens in order to try to prevent spread of the virus? In the event of a global pandemic should all international travel be stopped?

A vaccine cannot be manufactured until the virus for which it is being developed has been identified. Since the present H5N1 avian influenza does not have the potential for human to human transmission, a vaccine cannot yet be developed until a mutation occurs that has this potential. Once this variant with human to human transmission is identified it would take at least 6 months to develop a vaccine. All drugs are subject to clinical trials to determine their effectiveness and safety. In the event of a pandemic there would be enormous pressure to reduce this time to the minimum possible. A vaccine produced now, in anticipation of a pandemic strain, to cover part, say the H5 part of the virus, would be unlikely to be specific enough to be effective and so it would be exceedingly risky for companies to produce vast quantities of a vaccine that may never be used; there may not be a pandemic even if the virus mutates into a more infectious form, and there may not be a market for the drugs. Should governments / taxpayers subsidise the costs of research, development and testing of drugs manufactured by private companies for private profit? Should a company be forced to forfeit their patent for a drug that is needed to vaccinate the worlds population? Bitter experience regarding antiretroviral drugs for HIV/AIDS demonstrates that even in cases of diseases that threaten millions, drug companies and governments do not give up patents, rather they seek to tighten property rights (8) No single company has the resources to produce the quantities required in a short time, so should all technologically capable companies be given license to produce the vaccine? If there are limited quantities of the vaccine, it will have to be rationed. If it is to be distributed according to need there would be different ways of assessing need. One approach would to be to prioritise the most vulnerable, the very young and old, pregnant women and the immuno-compromised, healthcare workers and their administrative staff. Poultry workers, veterinarians, and others allied to the poultry industry would be at increased risk. Politicians and other important public sector workers would claim their stake as well. Underdeveloped countries, particularly those with rural populations in close contact with poultry and high incidences of malnutrition and HIV/AIDS would be able to claim that their populations ought to be prioritised according to clinical need because their citizens were particularly vulnerable. It these countries are unable to afford the vaccines, and if supply is limited, then ought they to be protected and funded by organisations such as the WHO?  If a vaccine is developed in sufficient quantities to vaccinate a large proportion of the worlds population many people would nevertheless refuse vaccination. Should they be forced to accept the vaccination in order to prevent them catching and spreading the infection to others or should their autonomy be respected? If there are adverse reactions and side effects to a vaccine produced in massive quantities in a short time, should the manufacturers be expected to bear the costs of litigation? In 1976, fearing a potential swine-flu epidemic, US Congress agreed to cover the liability costs when 40 million people were vaccinated. They paid over $90 million in damages and said they would never again assume the liability of pharmaceutical companies during a potential epidemic (9). If governments expect pharmaceutical companies to take these kind of enormous risks, can they also expect them to assume liability and forfeit their profits by resigning their patent rights?

Since resources are limited, if companies concentrate their efforts on drugs to prevent and treat avian flu, a disease that may never occur, it would be at the expense of research and development into diseases such as malaria, HIV/AIDS and tuberculosis which already kill millions every year in developing countries. The Africa Report (10) estimated that $1bn a year, just over half the amount pledged to combat avian flu so far this year, would significantly reduce the more than one million deaths from malaria that occur every year. Global funds for malaria, a disease that is known to kill, and for which cheap, effective preventive methods and treatments are available, are seriously lacking, and yet, for a disease that does not yet exist, billions are being spent on highly expensive, ineffective treatments. Given that there are limited global funds for tackling diseases, those diseases that are known to kill and for which cost-effective treatments are available ought to be prioritised.

The antiviral, oseltamivir (Tamiflu) manufactured by Roche has attracted the most attention in the hope for a treatment for avian flu because it appears that it may reduce the severity and duration of the illness marginally, although it  probably does not reduce mortality. Not surprisingly, given that there have been so few cases of H5N1 infection in humans, there are very few published reports of the use of tamiflu. The New England Journal of Medicine reported in December 2005 that treatment with the recommended dose of oseltamivir, did not completely suppress the virus and, even more worrying, led to oseltamivir resistance during treatment. (11) Antiviral drugs are very rarely used because of their high cost and relative ineffectiveness and yet vast amounts of money are being spent stockpiling tamiflu, including nearly 15 million doses for the UK. (12)

This in itself is alarming despite being in line with WHO guidance. It may also come from democratically elected governments feeling pressure from their electorate to be doing something in preparation. The evidence for the electorate’s demand for tamiflu comes at least in part from the enormous demand for the drug on the black market. On October 31^st 2005, Fortune magazine reported that, “Tamiflu is the most sought after drug in the world and that avian flu is “very good news” for investors”

Tamiflu is available to the NHS at a cost of £16.36 for a course of 10 capsules. It is widely available online  for £99 for 10 capsules (13). Since tamiflu is being sold legally from sites such as these, then it is being rationed according to the market and not according to need. It is being stockpiled by individuals to be used in the absence of medical supervision, on low risk situations, as and when they perceive the need. This raises a new concern that, inappropriately administered, it is quite possible that it could lead to the development of other tamiflu-resistant viruses that may present quite unexpected epidemics unrelated to H5N1. Responsibility for the use inappropriate use of these drugs ought to be shared between the manufacturers, distributors and purchasers as well as the government authorities responsible for controlling the pharmaceutical industry.

Despite negligible evidence for its efficacy, tamiflu remains the only drug with any evidence of effectiveness. Yet, as with vaccinations, should infected people be quarantined and/or forced to take tamiflu or other drugs to treat the infection to prevent its spread?

Summary

Pandemic avian flu presents a number of interesting ethical challenges since it does not yet exist, yet if it was to occur it would be devastating. National and individual autonomy is challenged by a disease that could infect us all. The necessary ethical responses are limited by economic factors and highlight inequalities in global wealth. Industrial animal production continues to threaten animals and humans, and the limitations of a capitalist system that profits from healthcare are highlighted.

1.   http://www.who.int/csr/disease/avian_influenza/country/cases_table_2006_02_20/en/index.html

2.   http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

3.   http://bmj.bmjjournals.com/cgi/content/full/331/7524/1066

4.   http://news.bbc.co.uk/1/hi/world/europe/4714574.stm

5.   Cook, Robert A and Karesh, William B, The Human-Animal link. Foreign Affairs, Vol 84, No. 4, p.46

6.   http://www.upc-online.org/slaughter/22805karenflu.htm.

7.   http://news.bbc.co.uk/1/hi/world/asia-pacific/4622982.stm

8.   http://www.accessmed-msf.org

9.   Laurie Garrett, The Next Pandemic? Foreign Affairs, Vol 84, No. 4 p.10

10. http://news.nationalgeographic.com/news/2003/06/0612_030612_malaria_2.html

11. http://content.nejm.org/cgi/content/full/353/25/2667?ijkey=a09c5bdd2d7c7acd1ff6048c550b1fb1fd2a9eec

12. http://www.dh.gov.uk/pandemicflu

13. http://www.ukmedixplus.co.uk.

You can now respond to this by clicking on the link here and then clicking on ‘submit a rapid response’. You don’t need a subscription or BMA membership

Signed by 119 Doctors

Published on BMJ online:

Clive Peedell and more than 100 co-signatories ask why the BMA is not representing its membership and has acted as though the proposed health reforms are a done deal

Open letter to the Chair of BMA Council, Chair of the BMA General Practitioners Committee (GPC), and all members of the BMA GPC

Dear Dr Meldrum, Dr Buckman and members of the BMA General Practitioners Committee (GPC)

Following the publication of the health White Paper earlier this year, Dr Meldrum wrote to the profession to let us know how the BMA was going to respond to the consultation process [1]. As you know, BMA Council agreed only to “critical engagement with the consultation process”.

The consultation period is now over and it is clear from the Department of Health’s response to the consultation [2], that the BMA’s policy of “critical engagement” has failed to persuade the Government to slow down or change its approach. The BMA quite rightly responded with a damning press statement:

“There is little evidence in this response that the government is genuinely prepared to engage with constructive criticism of its plans for the NHS. Most of the major concerns that doctors and many others have raised about the White Paper seem, for the most part, to have been disregarded.”

In fact, Andrew Lansley’s plans are now even more market based. Within the new Operational Framework for the NHS in England, [3] he is introducing “price competition” into the NHS, which fundamentally changes the NHS from being a “quasi-market” system of fixed prices (tariffs) to a much more open market system. Hospitals will be allowed to charge rates lower than the national tariff, which sets the prices for thousands of NHS procedures and covers roughly half of hospital income. According to Zack Cooper from the London School of Economics, “Every shred of evidence suggests that price competition in healthcare makes things worse, not better.” [4]

The NHS Confederation also share this analysis [5]: “Economic theory predicts that price competition is likely to lead to declining quality where (as in healthcare) quality is harder to observe than price. Evidence from price competition in the 1990s internal market and in cost-constrained markets in the US confirms this, with falling prices and reduced quality, particularly in harder-to-observe measures”.

Moreover the BMA have stated that it has “concerns over the use of ‘best practice’ or deregulated tariffs in the NHS, as the system brings with it price competition, which can risk basing decisions on price rather than on clinical need.” [6]

The White Paper has not even been published as a Health Bill as yet. It will then need to be read in Parliament and then go through the legislative process. We are therefore very concerned that the BMA and more specifically the BMA General Practitioners Committee (GPC) is treating proposed policy (i.e a White Paper) as if it is policy. For example, on the17^th December 2010, the GPC Chair, Dr Buckman wrote a letter to all GPs stating that [7]:

“Practices should now be working with other practices to make progress in setting up their embryonic consortia and electing and appointing a transitional leadership”

In addition, the BMA recently published a briefing paper called “Shaping change: BMA’s position on the future development of the proposed NHS reforms” [6]

On the topic of GP Consortia and commissioning, the paper stated that:

“The pace of change in developing commissioning must allow the vanguard to develop swiftly”

So, despite explicit reassurances from Dr Meldrum and BMA Council that the BMA would only “critically engage” with the consultation, this does not appear to be in keeping with what the BMA is actually doing. The fact that market based policies have actually been strengthened by Mr Lansley, goes completely against the BMA’s stated policy from numerous Annual Representative Meetings (ARMs). It is therefore clearly time for the BMA to withdraw its “critical engagement” policy with the coalition government and start to engage properly with the membership. It is remarkable that despite “the most radical restructuring of the NHS since its inception” [8], BMA Council recently voted against holding a Special Representative Meeting (SRM) of the BMA to allow its membership to debate the current proposals. This is in contrast with the BMA’s stance against the other most significant NHS White paper reforms, Working for Patients in 1989, where two SRMs were held to debate the issues. Whilst the BMA has also failed to formally survey the profession on the White Paper, surveys conducted by the King’s Fund and the Royal College of General Practitioners (RCGP) have both revealed major concerns from the profession, with fewer than one in four doctors believing that that the proposed reforms will improve the quality the patient care provided by their organisation or practice. [9]

We believe that the BMA and more specifically the BMA GPC currently has no mandate from the BMA membership to continue with the “critical engagement” policy that it is still clearly employing. Mr Lansley’s reform agenda has been widely criticised across the health policy and political spectrum as moving too fast. These critics include one of the Coalition Government’s own Cabinet minsters, Mr Vince Cable. Yet, the current approach from the BMA only serves to increase the pace of reform because the BMA has effectively sent a message to the profession that the White Paper is a “done deal”.

We have serious concerns that the White Paper reforms will fundamentally undermine the founding principles of the NHS by creating a more much expensive and inequitable market based healthcare system. The “Curate’s Egg” is a rotten egg. However, we also believe that it is not too late to save the NHS by derailing the White Paper reforms. The Health Service Journal placed Dr Meldrum at number 3 and Dr Buckman at number 8 of the top 100 most influential people in the NHS this year (up from number 35 last year) and stated [10]:

“From an influence point of view the BMA is critical because it could derail the coalition’s white paper reforms, which propose a clinically led system. If the BMA were to say no, then the whole initiative could grind to a halt”

Thus the NHS really is in your hands. We understand the great pressures you are under, but it is now time to mobilize the power of the profession and stop these damaging reforms which will destroy not only the NHS, but also profoundly impact upon the social fabric of our nation.

This is a great opportunity for the BMA to achieve redemption for its opposition to the inception of the NHS in 1948. We urge you to take it and will support you 100% of the way.

Yours Sincerely

Dr Clive Peedell

Consultant Clinical Oncologist

BMA Council

BMA Political Board

Co-chair NHS Consultants Association

The following 118 doctors are co-signatories to the open letter: Charlotte Abson, consultant oncologist, Maidstone; J Mark Aitken, consultant physician (retired), Leavenheath, Suffolk; Amina Aitsi-Selmi, Wellcome Trust PhD Research Fellow, London; Ian Banks, president of the European Men’s Health Forum, London; Christopher Bem, consultant surgeon (ear, nose, and throat, and neck), Bradford; Morris Bernadt, consultant psychiatrist, London; Crispin Best, Chair, BMA Scottish Local Negotiating Committee Forum; John Beynon, consultant gynaecologist, Chichester; Kambiz Boomla, chair, City and East London Local Medical Committee, London; David Bramble, consultant child and adolescent psychiatrist, Shrewsbury; David Broughton, clinical director (older people), Middlesbrough; Peter Bruggen, retired consultant psychiatrist, London; Christopher Burns Cox, consultant physician, Bristol; Nicholas Burns-Cox, consultant urologist, Taunton; Penelope Burton, general practitioner (retired), Hampshire; Ruth Caudwell, consultant community paediatrician, London; Iain Chalmers, editor, James Lind Library, Oxford; Anne Chamberlain, consultant in rehabilitation medicine (retired), Leeds; Peter Crome, consultant geriatrician, Keele; Robert Cumming, retired consultant haematologist, Glasgow; David Cundall, consultant in community paediatrics, Leeds; S Dar, specialty registrar, Essex; Jonathan Dare, emeritus consultant in child psychiatry, London; Jacky Davis, co-chair of the NHS Consultants Association and founding member of Keep Our NHS Public; Nicholas Dennis, consultant in clinical genetics, Southampton; John Dickinson, general physician (retired), Sheffield; Paola Domizio, histopathologist, London; Joanna Downton, consultant in rehabilitation medicine, Stockport; Christopher Dowrick, professor of primary medical care, Liverpool; Gary Drybala, consultant psychiatrist, Leicester; Robert Elkeles, professor of diabetic medicine and consultant physician, London; David Elliman, consultant paediatrician, London; Nina Essex, consultant physician (retired), London; Barry Fairbrother, consultant surgeon, Sutton, Ashfield; Henry Fell, consultant microbiologist (retired), Bury St Edmunds; Jacqueline Ferguson, consultant in psychotherapy, Oxford; Peter Fisher, president of the NHS Consultants Association and consultant physician (retired), Banbury; Peter Fleming, paediatrician, Bristol; Andrea Franks, consultant dermatologist, Chester; Roger Franks, consultant cardiothoracic surgeon, Liverpool; Robert Galloway, specialty registrar in emergency medicine, Tunbridge Wells; Zahid Ghufoor, general practitioner, London; John Gibbs, consultant paediatrician, Chester; Geoffrey Gill, consultant physician, Liverpool; Colin Godber, consultant in old age psychiatry (retired), Winchester; Niru Goenka, consultant physician in diabetes and endocrinology, Chester; Steve Goodacre, accident and emergency clinician, Sheffield; Paul Goulden, consultant anaesthetist, Dewsbury; Hilary Graver, general practitioner (retired), London; Richard Grunewald, consultant neurologist, Sheffield; Mary Harrington, consultant physician, Keighley; Evan Harris, former Liberal Democrat MP for Oxford West and Abingdon and Liberal Democrat science spokesman; David Hawkins, consultant physician in HIV and genitourinary medicine, London; Roger Hayter, consultant physician, Machynlleth; Graham Hitman, consultant physician and diabetologist, London; Allan House, director of Leeds Institute of Health Sciences and professor of liaison psychiatry, Leeds; William Irving, consultant virologist, Nottingham; Alex James, registrar in anaesthesia; John Jarrett, emeritus professor of clinical epidemiology (retired), London; David Jobson, general practitioner (retired); Frank Joseph, consultant physician in diabetes and endocrinology, Chester; Harry Keen, professor and consultant physician emeritus, London; Jessica Kirker, psychoanalyst and consultant psychiatrist in psychotherapy, London; Sebastian Kraemer, consultant child psychiatrist, London; David Lawrence, consultant in public health and honorary senior lecturer, London; Andrew Leach, consultant anaesthetist, Hastings; Dianne LeFevre, consultant psychotherapist, Basildon; D G Lewis, consultant anaesthetist emeritus, Leicester; Karen Leyden, consultant anaesthetist, Northampton; Graeme Little, general practitioner, Stockton-on-Tees; Anna Eleri Livingstone, general practice principal and trainer, London; Catherine McGrother, consultant in public health medicine, Leicester; Robert MacGibbon, retired general practitioner, London; Anthony Macklon, consultant physician, Durham; Krishnaswamy Madhavan, consultant oncologist, Southend; Alasdair Miller, clinical teaching fellow, Lincoln; Stephen Moore, consultant in emergency medicine, Chester; Patrick Mullen, consultant in anaesthesia, Chester; Patricia Munday, consultant in genitourinary medicine, Watford; Brendan O’Reilly, general practitioner (retired), South Wales; Ragnar O’Reilly, general practice partner, Colchester; David Paintin, consultant gynaecologist (retired), Great Missenden; Janet Porter, consultant in accident and emergency medicine (retired), Southend; John Puntis, consultant paediatrician, Leeds; Paul Revell, consultant haematologist, Stafford; Alexander Robertson, consultant psychiatrist (retired), Ludlow; Trefor Roscoe, general practitioner, Sheffield; Wendy Savage, obstetrician and gynaecologist, London; Brian Scott, consultant physician, Lincoln; Robert Scott-Jupp, consultant paediatrician, Salisbury; Alex Scott-Samuel, consultant in public health medicine, Liverpool; A G Shaper, emeritus professor, London; Francis Sheehy-Skeffington, consultant paediatrician (retired), Cambridge; Brian Silk, retired consultant paediatrician; Alan Smyth, senior lecturer in paediatric respiratory medicine, Nottingham; Gabriel Steer, general practice principal, Kingston; Fiona Subotsky, consultant child and adolescent psychiatrist, London; John Sweeney, consultant in genitourinary medicine, Blackpool; C Mark Taylor, consultant in paediatric nephrology, Birmingham; David Taylor-Robinson, Medical Research Council population health scientist, Liverpool; Katherine Teale, consultant anaesthetist, Salford; Kathrin Thomas, consultant in public health, general practitioner, and honorary lecturer, Cardiff; Jonathan Tomlinson, general practitioner, London; Gill Turner, consultant in community paediatrics, Hexham; Helen Venning, consultant paediatrician, Nottingham; John Ward, general medicine physician (retired), Sheffield; Anthony Waterston, consultant in community paediatrics (retired), Newcastle; Eric Watts, consultant haematologist, Basildon; Malcolm Weller, emeritus consultant psychiatrist, London; Diane Wellesley, associate specialist in clinical genetics, Southampton; Catharine White, consultant in paediatric neurology, Swansea; Steven White, consultant in clinical neurophysiology, London; Chris Williams, locum staff and specialty grade doctor (haematology), Bangor; Michael Williams, consultant in haematology, Birmingham; Barrie Woodcock, consultant haematologist, Liverpool; Robert Wood-Walker, consultant paediatrician (retired), Colchester; Luke Zander, senior lecturer (retired), London; and Patrick Zentler-Munro, consultant physician, Inverness.

References:

[1] Letter to the profession from Dr Hamish Meldrum. 30^th July 2010 available @

http://web2.bma.org.uk/pressrel.nsf/wlu/SGOY-87UCEG?OpenDocument&vw=wfmms

Accessed on 22/12/10

[2] Liberating the NHS: Legislative framework and next steps. Department of Health. 15^th December 2010

Click to access dh_122707.pdf

[3] The Operating Framework for the NHS in England 2011/12. Department of Health. Available @

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122738

Accessed 23/12/10

[4] Price competition could raise death rates, experts warn. Health Service Journal. 17^th December 2010. Available @  http://www.hsj.co.uk/news/finance/price-competition-could-raise-death-rates-experts-warn/5023349.article

Accessed on 22/12/10

[5] NHS Confederation response to the White Paper: Regulating healthcare providers. October 11^th 2010   http://www.nhsconfed.org/Documents/Response%20to%20Regulating%20healthcare%20providers%20FINAL.pdf

Accessed on 22/12/10

[6] BMA briefing: Shaping change: BMA’s position on the future development of the proposed NHS reforms. Available @ http://www.bma.org.uk/images/whitepaperbmabriefingdec2010_tcm41-202540.pdf

Accessed on 22/12/10

[7] Dr Laurence Buckman’s letter to GPs. Avavilable @ http://www.bma.org.uk/wa/representation/branch_committees/general_prac/letternhswhitepaperdec10.jsp

Accessed on 22/12/10

[8] Liberating the NHS. The right prescription in a cold climate? King’s Fund. 2010. Available @ www.kingsfund.org.uk/document.rm?id=8780

Accessed on 22/12/10

[9] Impact of the Health White paper. What do doctors think? King’s Fund 2010

http://www.kingsfund.org.uk/current_projects/the_nhs_white_paper/impact_of_the_health.html

Accessed 23/12/10

[10] 003 – Dr Hamish Meldrum. Health Service Journal.  17^th November 2010. Available @

http://www.hsj.co.uk/home/hsj-100/003-dr-hamish-meldrum/5021931.article

Accessed 23/12/10

From David Loxterkamp

Those of us who sit each day with the dying, bereft, lonely, and disillusioned, those who suffer chronic pain or struggle to buy their medications, know clearly what George Bailey [It’s A Wonderful Life] learned from his fateful jump: “Strange, isn’t it? Each man’s life touches so many other lives, and when he isn’t around he leaves an awful hole, doesn’t he?” I hope we will not let primary care become an awful hole. Will we be the voice that speaks for the lives we touch and touch us in return?

Together we must demand a broader, more-farsighted, and compassionate view of the business of medicine. I am reminded here of another Christmas classic, and words uttered equally to the point:

“Business!” cried the ghost, wringing its hands again. “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business.”

Dickens, C. A Christmas Carol.

NHS efficiency savings may be possible thanks to radical plans for medical education.

The latest white paper, “Training Today’s Doctors Tomorrow” outlines policy (surely ‘plans’? ed.) that will allow medical students and businesses to do NHS work before they’ve gone through the expensive business of a university medical education.

In a joint statement released today, Secretary of State, Andrew Lansley and Secretary for Education Michael Gove said, “Under this system students will pay for their education up front by doing essential front line work like NHS direct, swine-flu hot-lines and general practice in poor areas where patients are least likely to notice. The NHS will be liberated from the economic tyranny of over-qualified, over-paid doctors and universities will save money at the same time. Everyone’s a winner”

Turkey twizzler Bernard Matthews is one of the first Business Partnership entrants to the new scheme. A minister explained, “Following the success of the graduate entry program in which people with a degree in something skip all the boring theoretical bits in a medical degree and get straight on to the fun stuff like trying out treatments on real patients, we’ve started a new Business Partnership program. This will allow businessmen to cream off NHS work for 5 years before doing a 6 week certificate in doctoring which will allow them to become consultants in whatever they like and earn absolutely loads.”

“Honorary Professor Matthews will be running the new Freedom orthopaedic hospitals using techniques imported from his famous poultry business. Instead of a full anaesthetic with all the expensive tubes and bleeping machines, patients will be given a quick electric bath and then their painful joints replaced by a big machine. A number of BOGOF (buy one get one free) deals have been set up so that patients with a dodgy knee or hip can get the other one done at the same time before it gets arthritic, as they inevitably do.”

Steven Dorrell, chair of the Commons Health Select Committee was unable to comment because he’d spent the previous day shouting at the rest of the committee. Another 6 white papers are expected before Christmas.

Facing overwhelming opposition from the public and medical professionals, including the head of the British Medical Association Hamish Meldrum and the Chair of the Royal College of General Practitioners Clare Gerada, Secretary of State Andrew Lansley is pressing on with NHS reforms which a senior NHS manager said will cause a ‘bloody awful train crash’ in the short term and and many senior doctors believe will lead to the end of the NHS.

Public support for the NHS is at an all time high and appetite for an overhaul is at an all time low and yet Lansley, like the most bullish of orthopaedic surgeons, presses on regardless.

What does this mean for my patients and colleagues?

Put simply, Primary Care Trusts (PCTs) the 151 organisations that organise and plan the delivery of NHS services and control over 80% of the NHS budget will be scrapped over the next 3 years and replaced with GP consortia. The GP consortia will have to do what the PCT’s did. The main difference is that they will also have to make 4% year on year ‘efficiency savings’. Which is a political speak for cuts, in other words, less care and less staff. Lansley’s spin is that GP consortia will be better than PCTs because doctors are better at amputations than managers and will there for manage the cuts in a way that actually benefits their patients. This has never been tried before anywhere, ever. Nobody believes its possible to make savings of this degree without cutting services. Every GP practice will have to have a consortia representative, so that means when City and Hackney PCT combines with Tower Hamlets and Newham there will be roughly 200 representatives. GPs are notoriously difficult to organise (one reason why we’re not protesting) and on the whole they’re far more interested in looking after their practices than local politics, so most likely a handful will take on the representative role and then attempt to do what PCTs have struggled to do with experienced managers for years.

The other important thing to come out today is an analysis by the chief economist at the King’s Fund, Professor John Appleby, published on Health Policy Insight.

The Operating Framework has another surprise on tariffs: they are no longer to be fixed.

Trusts, including independent sector providers of NHS care will be free next year to offer their services at below the tariff price. Let me repeat that: there will now be competition on price.

This may help PCT budgets go further, but, as the Operating Framework notes rather blandly, ‘Commissioners will want to be sure that there is no detrimental impact on quality, choice or competition as a result …’.

I think this is the biggest shock. It means that there will be a race to the bottom, with providers competing to provide the cheapest possible services. Hospitals which have a complicated case-mix depend on cross-subsidising so that money raised from relatively straight-forward care such as outpatients, elective surgery or radiology ensures that the intensive care, A&E and rehabilitation units stay open. Lansley wants a free market in health services. What this means is that there will be a bun-fight to provide the profitable easy stuff and hospitals will be left to do the complicated, messy stuff. That means the old and vulnerable, the people with multiple chronic disease, people with dementia and other serious mental illnesses who cannot be looked after profitably will suffer the greatest deterioration in care.

It will be impossible for a consortia to pay hospitals above the ‘market rate’ even if they think its necessary to keep them from going bust because the government has set up Monitor to ensure competitiveness and stop price fixing.

It doesn’t have to be like this. The letter signed by over 250 senior doctors on Monday says,

Andrew Lansley’s aims of putting patients at the heart of care, involving clinicians in decisions about the provision of services and reducing managerial costs could be achieved without the massive structural upheavals of abolishing PCTs and SHAs. PCT Boards could be restructured, to give much better representation of clinicians,. members of the public and accountable members of Local Government. The present, costly healthcare ‘market’ could be abolished, saving billions in transaction costs and achieving the £20 billion ‘efficiency savings’ demanded by Sir David Nicholson.

So why is Lansley pushing ahead with reforms we cannot afford and do not want?

Because commercial health companies have been lobbying and advising the Department of Health (and Andrew Lansley) for the last 30 years in order to get their hands on the £100bn+ NHS budget. A free market in health care provision will ramp up demand, drive down quality, deprive staff of rights and force salaries down to the lowest level the market can sustain. It will create a postcode lottery in quality and range of services. Hospitals and surgeries will be forced to close becasue of being bankrupt even when patients lives depend on them and people will be forced to take out insurance to cover the gaps in provision. Business minded GPs will sell their practices to the private sector and the NHS will become nothing more than a brand, three letters to be stuck on to the front of a private equity firms latest aquisition.

If you care about the NHS it’s time to follow the students and get on to the streets.

“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Health Service Journal

The government is proposing to abandon practice boundaries. To do so will destroy personal care, destablise practices and pose great risks to patients.

Almost every new patient that registers with me asks the question, “Are you going to be my GP?”

Its not just the young American woman with cancer, the elderly man who has had a stroke, the couple expecting their first baby or the postman with depression. The overwhelming majority of people still want a doctor who knows them, their medical history and their personal story. This personal care and relationship between patients and doctors is the heart of general practice in this country, and in-spite of all the changes that have undermined this in the last 20 years or so, it remains universally popular.

Practice boundaries exist so that GPs can make a committment to, and take responsibility for a population within a specified geographical area. If you are sick they commit to take care of you and that care extends to your home. Practice boundaries guarantee that your own personal doctor can visit you in your own home when you’re too sick to get to the surgery and that you can see a GP close to where you live. If practice boundaries are removed and our patients come from miles away, their home care will have to be provided by doctors or nurses they do not know, or you may find that you have to travel further to register with a GP.

Young, mobile patients who consult infrequently generate income for GP’s because the fee we earn from registering them exceeds the cost of care. It is because of our patients who need little care that we can look after patients who need a lot of care. If young patients who want a quick, convenient service choose to register with a Virgin or Sainsubury’s surgery because it’s quick and convenient, then established practices will be left with increasingly complex and costly patients and they will soon be bankrupt.

Suburban practices will be particularly worried about the changes because their commuter patients will register in the cities, leaving them with the elderly, housebound, the unemployed, young mums and children. All of whom consult more and have greater health needs that average.

There is a dark side to the changes that the government should pay close attention to. Child abuse is high on the media and political agenda. If practice boundaries are removed then child abusers will make sure that their children are registered at different practices. At our weekly meetings with the health visitors we will no longer have the level of knowledge about families we have at present. No amount of government meddling with IT can make up for this.

Every practice that cares about their patients and every patient that cares about continuity of care with their own doctor should strongly protest about this absurd proposal.

See also Iona Heath, The Perversion of Choice,

your freedom to choose any practice, qualifiesmy freedom to choose continuity of care when I am old and frail.The age old conflict between liberty and justice lives on wheneverchoice is exercised, in the NHS as elsewhere, and it is bothnaive and futile to pretend that it could ever be otherwise.

Update: 26.01.2011

Every GP practice in England needs to save £2,500 a day over the next three years to hit NHS efficiency targets, according to a senior DoH adviser

The easiest way to save this amount of money is to stop looking after anybody who is really sick. Last year one of my patients, a young man with epilepsy and Crohn’s colitis had to go into hospital to have his abdominal wall repaired. For the third time. After emergency surgery to remove large amounts of his bowel he was left with a colostomy. When this was repaired the wall of his abdomen: the muscle, skin and connective tissue, refused to heal. He spent several weeks in hospital following an infection which caused the wound to break down and then came to see our practice nurse twice weekly for dressing changes for several months before eventually being referred for an experimental treatment involving a large graft. He was very sick after the graft operation and spent several weeks in hospital including time on the ICU. Six months on his wound has still not healed. He has become depressed and his epilepsy has deteriorated and so he is seeing the psychologist and the neurologist.

Because of the purchaser-provider split we pay for all the care he gets in hospitals and for all the specialist referrals. At present the cost is paid by the PCT and they tell us what our costs are as a practice.

Once we have our own budget, someone like this will knock an enormous hole in our finances. If we could find a way of getting him, and a few other patients with similarly complex medical needs to register somewhere else, we might, just, be able to get near the £2500 a day ‘efficiency savings’ demanded by the Department of Health.

We’re not going to do this. And I don’t know of any GPs who would consider doing such a thing. But until now GPs haven’t had the threat of insolvency hanging over them just for doing what they are trained to do, looking after people who really need it.

We still have the absurd situation described by the Inverse Care Law where those GPs who work in areas with the least health needs i.e. the wealthiest areas, earn the most money for the least work. The Inverse Care Law states that The availability of good medical care tends to vary inversely with the need for the population served.  This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.  The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.

Update 19.11.2013

Any GP you want, so long as you’re healthy. Jeremy Hunt wants to scrap GPs’ catchment areas to give patients more choice. Sounds great – until you think it through. Guardian CIF

17.1.2012

A GP writes about her experience of caring for a patient outside her practice boundary

I was slightly dissapointed when 7/8 of my first year medical students showed up for their last day of teaching at my practice on thursday December 9th. The eighth student was ill, so not one of them was protesting. When I asked them why not they said that in their first week as medical students they were told not to get involved in any protests because even a police caution would mean they might be thrown off the course and almost certainly they wouldn’t get a job. Images of Fascist Spain or Nazi Germany came immediately to mind (I have just read Alone in Berlin: “…everyone ought to be interested in politics. If we all had been, then maybe the Nazis wouldn’t have got their hands on power.”

Protesting doctors do exist. I asked 3 of my GP partners if they ever protested. They are between 50 and 60 years old and all of them spent considerable time as students and junior doctors marching and protesting on a whole range of issues. Dr Jane Grubb is in her 80s and has spent her life as a peace protestor and campaigner. Professor Wendy Savage (in her 70s) still campaigns for womens’s rights to control their own fertility and have access to abortions as well as chairing the Keep Our NHS Public campaign. Professor Harry Keen CBE a highly distinguished endocrinologist is a founder member of the NHS support federation. Dr Jacky Davis has been speaking at public events about the cuts and the threats to the NHS for the last couple of years.

I spent lots of time as a medical student on marches and protests about road building. It never occured to me that it might jeopardise my future career. I marched around Aldermaston marking the 50th anniversary of the first Aldermaston CND march with an enormous anarchist flag in 2008 without the slightest concern about what the BMA might think.

Organisations like MEDACT which campaigns for global public health are full of protesting doctors as the pictures on their website show. Doctors who volunteer with organisations like Medcins sans Frontieres/Doctors without Borders, and Merlin are involved with political protest and campaigning well beyond the emergency provision of medical care. One of the most common concerns medical students have when I talk about my experience working as a volunteer in Afghanistan and Nepal is that their career will be ruined by taking time out to do what I did.

The philosopher Hannah Arendt is best known for alerting us to the danger that evil is banal, rather than being something that only the pathologically derranged are capable of, it’s possible simply because people ignore the bigger picture and concentrate on their own lives and careers

“…careerism, as Arendt noted in her book on Eichmann, is seldom conducive to thinking.” Corey Robin, Dragon Slayers London Review of Books

We shouldn’t forget the words of another doctor, Rudolf Virkow,

“Medicine is a social science and politics is nothing more than medicine on a large scale”

We cannot allow our medical students to be intimidated and forcibly depoliticised at such an early stage in their career. A modern tick-box medical education seems to be about narrowing young minds rather than broadening them and its rare to find a student who actually reads for the purpose of expanding their intellectual horizons rather than getting through their exams.

What good can it possibly be to society if its doctors are so removed from the concerns of their patients, the needs of society or the history of freedom?

Fabulous essay from 1968: Why do I demonstrate?

Please send stories of more inspirational doctors to echothx@gmail.com

Edited on 18.7.2011. Now reduced to 8 things, but more serious than before, especially number 6.

1. The cost. The NHS reorganisations are estimated to be between £1.9bn and £3bn. Not only will the reorganisation be hugely expensive but the administration and transaction costs of running a market are vast. The last Health Select Committee reported that 20 years of commissioning in the NHS was a failure and had only led to increased transaction costs estimated to be 14% of the total NHS budget. It would have been far cheaper to increase clinical representation on existing PCTs than to completely scrap them and then set up GP commissioning consortia to do the same thing.

2. The numbers. There are not limits on the size of commissioning consortia. Historically PCTs have covered a geographical area and have been responsible for care of all the people in that area. PCTs are to be replaced with commissioning consortia. The Royal College of General Practitioners, based on international studies of similar organisations said that they should have a minimum of 300 000 patients in order to have a sufficient economy of scale to effectively commission the range of services their patient’s need. Many doctors warned that they should be co-terminous with local authorities and responsible for a geographically defined area. The government have allowed anyone to set up a consortia. There is a list of consortia here. In london they range from 7 to 67 practices in size. They are not obliged to cover a geographic area.This allows GPs to select the most efficient practices and avoid the least efficient. There is a serious risk of having an inadequate risk pool with a small consortia so that a few very expensive patients threaten the ability of the consortia to pay for other patient’s care.

3. The brain drain and the brains remaining. PCTs perform between 140 and 300 functions and have a broad range of analytical and managerial skills to do this. The proposed abolishment is leading to many of the best staff leaving already to work for private companies or to do something completely different. They are already falling apart. It remains to be seen how many experienced staff will be left to support GP commissioning consortia. Many consortia are already forming partnerships with the private sector, hastening the demise of a public NHS.

WThe majority of GPs don’t have any business or public health qualifications and we have barely any training for this. Our ‘business skills’ are learned ‘on the job’. We’re experts about dealing with our practice population, but don’t know very much about the needs of hospital or community services, or how to assess to the needs of large populations. We will have to re-employ PCT staff or involve the private and voluntary sector to perform the managerial, needs analysis, cost effectiveness, etc. work.

A report in the HSJ on 14.7.2011 showed that more than a quarter of those leaving PCTs had more than 15 years experience, 21% were clinicians and 21% worked in the most senior roles.

King’s Fund chief executive Chris Ham warned the NHS was “asset stripping the commissioning function, removing the very people and skills it needs to retain”.

There was a “serious risk” that the lost expertise would result in the NHS losing financial control, he said.

4. The conflicts of interest. If I think I am the best person to provide a musculo-skeletal assessment service and commission myself, there is a conflict of interest. How am I to separate my commissioning and providing functions? How are we to stop groups of GPs commissioning themselves and making Daily Mail headline salaries? There is a perception that we GPs are paid far too much (based on cases of individual GPs rather than any serious analysis). Converting the NHS into a business will see some GP entrepreneurs making absolutely whopping profits out of commissioning, as they did out of fundholding. Most, especially those looking after the most vulnerable populations will see their salaries fall significantly because there’s less money to be made looking after patients who behave inefficiently. I have written a post about conflicts of interest here.

5. The purchaser provider split. Commissioning reinforces, indeed depends on the split between GP purchasers and hospital and community providers competing for our patients and money. It makes effective collaboration desperately difficult, pits one hospital against another, and in a cash strapped environment forces decisions to be made about individual services without considering the wider health economy. Hospitals are loathe to work with GPs to reduce referrals because their income depends on more referrals, and GPs are desperate to reduce referrals to save money. Because of erverse incentives, gaming is rife with providers seeing to over investigate and operate and excessively review patients in order to earn more. Here a post about how it operates in a local hospital.

6. Patient choice. Before 1990 a GP could refer their patients anywhere in the NHS without having to set up a contract, or worry about gaming. Now GPs will most likely only have the resources to commission services from their local hospital but patients will be able to choose any ‘qualified provider’ in the NHS. In order to have effective market forces, patients will have to be tempted away from the services their GPs have commissioned.

In a speech health secretary Andrew Lansley made in 2005 (quoted in LeftFootForward):

“The statutory formula should make clear that choice should be exercised by patients or as close to the patient as possible, thereby maximising the number of purchasers and enhancing the prospects of competition.”

This explains why the government is transferring power and financial decisions to GP commissioners and ultimately to patients themselves with personal budgets. Providers will then be able to bypass GPs -who have vested interests in their patients using the services they have commissioned- by advertising directly to patients. The last thing the government and the private providers want is for GPs to be choosing where their patients go. The route to competition will be direct to consultant access even though we know it is extraordinarily expensive as they have discovered in France.  

7. The postcode lottery. Each consortia will choose to commission services for their own population which may have advantages, Tower Hamlets has very high rates of diabetes and City and Hackney has very high rates of drug and alcohol abuse so we might want more services for these problems than Totnes (for example) But if we want more of one thing we’ll have to spend less on something else (like fertility treatment)  There will be widespread differences in provision. Drug and alcohol services whilst necessary, don’t do much to increase satisfaction with the NHS or win votes (not compared to fertility treatment) There will be high profile media hysteria once the differences become wider and clearer.

8.  The bottom line. Tarifs, the set price for a medical service, are to be abolished, in order to encourage competing providers to provide the cheapest service. Not the best service or the most appropriate, but the cheapest. Quality is extraordinarily difficult (though not impossible) to measure. Price is easy. The government has set up an organisation called Monitor to ensure competition. There is a separate Care Quality Commission but there will be considerable tension between cost and quality, with the weight towards cost because we have to make such enormous (£20bn) savings. The government’s reassurance that there will be no competition on price has been investigated by blogger Dr No who has found it to be already rampant.

“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Price Competition could raise death rates… Health Service Journal

GP commissioning is unaffordable, will damage relationships between GPs and hospitals and will drive down patient choice. It needs to go.

On radio 4 early on Sunday morning I heard reported that 40% of the British population think people with disablities are ‘work-shy’. The figure comes from a recent survey of public attitudes to disablity called Access all areas. It doesn’t use the phrase ‘work-shy’ on the report, it says, “40% felt disabled people turned down job offers even when they were physically capable of doing them.” I was shocked. Obviously people turn down work they’re capable of for all sorts of reasons, but the figure shocked me because I think our attitudes to disability are symbolic of our attitudes to ourselves. I’m a GP in an inner-city practice with exceptionally high levels of deprivation looking after a lot of people with disabilities. Work-shy isn’t something that comes to mind when they struggle down the corridor on their crutches or sit at home all night after a stroke waiting to call me rather than bother the ambulance, or when they come in to see me for a review of their depression and apologise for their dishevellment – a consequence of being too depressed to eat, sleep or wash properly for the last month.

The answer to the question, “Who is the NHS for?” seems obvious, but most people reading this will have had little contact with the NHS and little experience of serious illness or disability. Illness doesn’t affect everyone equally. By far the unhealthiest years of our lives are at the end, and we’re pretty vulnerable at the beginning. In between, during our most productive years we are on the whole, pretty ignorant of illness and disability.

Conditions that affect us in our prime such as depression, learning disabilities, drug and alcoholism, epilepsy and so on are under-represented in our media saturated world of idealised conceptions of healthy people. The vicious cycle of illness, disability and poverty further alienates them, ‘the unhealthy poor’ from us, ‘the healthy’.

Combined with a historically unparalleled rise in prosperity over the lifetime of most people in this country, it is very easy to avoid thinking about vulnerability, including our own.

David Bell, president of the Institute of Psychoanalysis and a consultant psychiatrist, warns of the dangers:

Our relationship with awareness of our own vulnerability is far from comfortable – we have a natural tendency to locate it in other people – it is he, not me, who is in need, it is she, not me, who is vulnerable.

We maintain this attitude towards our future risks as well. Even if we’ve been fortunate enough to enjoy good health for most of our lives, we’ll all need medical attention in our latter years. On a few occasions this year I’ve spoken publicly about the incidence of disease and disability in old age, some of the uncomfortable statistics are as follows:

1 in 3 of you will spend your last years with some form of dementia

1 in 4 of you will experience mental health problems and 1 in 4 of you with 2 or more chronic diseases will also be depressed

1 in 10 of you will have cancer once you’re over the age of 60

Almost 1 in 4 men and 1 in 6 women over the age of 75 will have some form of heart disease.

About 1 in 7 men and 1 in 9 women over the age of 75 will have diabetes. If you are from a SE Asian background the chance will be up to 6 times higher.

1 in 5 men and 1 in 6 women will have some form of painful arthritis

Almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85.

Not only will you be diseased up to the earlobes you’ll also be drugged up to the eyeballs:

On average people over 60 received more than 42 prescription items in 2007. In 1997 they received on average only 21.

1 in 16 hospital admissions are due to adverse drug reactions and 2% of people admitted die as a result of these reactions

If any readers want to try reading these statistics out to their friends I expect you’ll have the same response that I had: people beg you to spare them the depressing details or they stick their fingers in their ears. When I debated with Civitas (the think-tank dedicated to seeking intellectual justification for the conversion of the NHS from a public service to a free market) one of the audience members said that GPs are no longer necessary because you can just put your symptoms into Google to get a diagnosis and then choose your specialist for treatment. What he means of course, is not that ‘people’ will have no need of a GP, but that he will not need a GP. His response is a real world example of what philosopher Slavoj Zizek describes as ‘a drive not to know’,

Another lesson of psychoanalysis is that, contrary to the notion that curiosity is innate, that there is deep inside each one of us a Wissenstrieb, a ‘drive to know’, there is, in fact, the opposite. Every advance in knowledge has to be earned by a painful struggle against our spontaneous propensity for ignorance. If there’s a history of Huntington’s chorea in my family, should I take the test which will tell me whether or not (and when) I will inexorably get it? If I can’t bear the prospect of knowing when I will die, the (not very realistic) solution may appear to be to authorise another person or institution whom I trust completely to test me and not tell me the result, but, if the result is positive, to kill me unexpectedly and painlessly in my sleep just before the disease’s onset. The problem with this solution is that I know that the Other knows the answer, and this ruins everything, exposing me to gnawing suspicion. Slavoj Zizek Bring me my Philips Mental Jacket

For David Bell, this ‘gnawing suspicion’ can be revealed in his patients who present with conditions such as schizophrenia and narcissistic disorders and also at the societal level where,

this projective system has a drive of its own: as it gathers momentum it acquires contempt, providing the psychological soil for destructive social processes such as racism or homophobia to germinate.

In a remarkably foresighted paper he wrote in 1999 in the journal of Psychoanalytic Psyochotherapy, titled Primative State of Mind, he explains the social implications:

But, Reich argued, [in his book The Mass Psychology of Fascism], fascism also reflects man’s deep aspirations and it cannot be fully understood without appreciation of the fascist mentality and its deep
roots in the unconscious. Reich explored how, through identification with a tyrannical (Nazi) figure, masses of the oppressed population were supported in their wish to project their own hated vulnerability elsewhere. The Nazi propaganda machine provided objects for this projection, namely Jews, gypsies, homosexuals and blacks. It is thus their own hated vulnerability and helplessness which they then sought to annihilate through extermination of these people. This is, of course, not meant to be a total explanation of fascism, but if it is not included in the broader social and political understanding of fascism, something essential is lost.

Like the ancient Greeks we have made a virtue of health and ability and infused them with moral status, so that when we ourselves are ill, disabled or vulnerable whether due to cancer, poverty or loneliness, our natural inclination is to ask, “why me? what did I do to deserve this? I never thought it would happen to me!” We project this perceived moral weakness on others in order to make ourselves feel better. I’ve explored this idea in a previous post: Is Socialised Medicine Evil? which discusses various right wing trends that link wealth and health with moral good, “We deserve to be wealthy and healthy because we are good, they deserve to suffer because they are bad.” Bell predicts our present state of affairs,

The cuts express an ideological assault on the concept of welfare – originating with Margaret Thatcher and now escalating violently. This ideological position can be characterised as follows: the welfare state does not provide people with the basic necessities of life as part of a duty of state but instead is a mechanism by which people are disempowered, creating in them a helpless state of invalidism. The “have-nots”, instead of “getting on their bikes” and competing in the marketplace, stay at home and whinge for the nanny state to do something for them. Namely, to have one’s basic needs met is to be treated as if suffering from a state of infantile dependence and to be dominated by a delusion of an inexhaustible supply of provision.

In this kind of thinking, or more properly non-thinking, the world collapses into simple binary categories – “us and them” – and all complexity is lost.

Those on welfare become just “scroungers”. Worst of all, many who are legitimately entitled to benefit identify with this propaganda and collapse into despair. The nanny state slogan expresses this perverse logic and hatred of vulnerability.

The propaganda is most effective when it is internalised, sentiments echoed by the Archbishop of Canterbury last month, talking about government plans to force pople on welfare to do voluntary work,

people who start feeling vulnerable feel even more vulnerable as time goes on, that’s the kind of unfairness that I feel. People often are in this starting place, not because they’re wicked or stupid or lazy, but because circumstances have been against them, they’ve failed to break through into something and to drive that spiral deeper, as I say, does seem a great problem.

I see this in my patients every day, they really are driven to despair, believing that others see and treat them as a burden on society, they internalise this as guilt and shame which leads to misery and anxiety and in the worse cases, suicide. Returning to the BBC survey of attitudes to disablity,

People in lower income groups were found to be less compassionate on the issue of disability than skilled people, with older people sometimes more intolerant than the young.

The shocking conclusion is that the ideological assault on the welfare state, including the NHS is made likely to succeed because in doing away with the institutions designed to protect us when we are most vulnerable we are both denying and symbolically doing away with our own vulnerablity.

What’s needed is a renewed compassion for others and ourselves.

See also

Today’s Britain: where the poor are forced to steal or beg from food banks. Guardian 27/10/2014

Language is a weapon used to make ‘others’ of people in poverty. Joseph Rowntree Foundation. April 2013

The ‘scounger’ myth is causing real suffering to many in society. LSE blog. April 2013

Owen Jones, Independent 13.12.2011:

We don’t even really talk about the unemployed anymore; they’re more likely to be “people on benefits” defining them not by lack of work, but by reliance on taxpayers’ money.

John Harris, Guardian 01.04.2013 :

We have to talk about why some people agree with benefit cuts

Truth and Lies about Poverty. Pocket Guide

Scroungers, Scumbags and Soaring Welfare Costs: excellent analysis about where the money is going by FlipchartFairytales

Benefits in Britain. Separating the Facts from the Fiction. Guardian

Letters in The Times and Financial Times today 13.12.2010

BMA policy is to uphold the founding principles of the NHS (which are held dear by British citizens) and states that “health care should be on the basis of public provision not private ownership, co-operation not competition, integration not fragmentation and public service, not private profits”.

With health professionals and the concerned public so opposed to reforms, it would be folly for the Government to impose them.

Times letter signed by over 150 doctors.

Financial Times:

For a letter in a similar vein see

this Letter to Lansley

I completely agree with other writers linked below so I won’t report too much, but in case you were wondering:

This public health White Paper takes the piss more thoroughly than a phalanx of urinals. Health Policy Insight

The Independent [yesterday] confirmed the dominance of multinational companies on a Whitehall project setting health policy. Eighteen representatives of Mars, Unilever, Diageo and other commercial interests attended the first meeting of the Public Health Responsibility Deal in September – three times the number from health and consumer groups. The group will propose policy on diet, drinking, tobacco, exercise and behaviour change.

It’s a bit like handing responsibility for drug policy to the mafia. So we have junk food manufacturers whose profits depend on us eating more junk, being given the green (traffic light) to gently nudge us into making the kind of consumer choices that will make us more healthy. If you were in any doubt about the dumbness of the government’s plans for public health there is detailed analysis from blogger Dr Aust and Andy Cowper, Health Policy Insight.

If you’re still curious and want to understand how the international food trade works read Stuffed and Starved by Raj Patel.

Originally posted on Health Policy Insight yesterday. Thanks to Richardblooger for the tip off.

Letter from Healy J to Cameron D about Letwin O’s review of Lansley A’s liberation theology

Note that it still dodges the elephantine business of the enormous transfer of state assets to the private sector, probably because Labour have been the principle architects of NHS privatisation and are STILL not arguing against it.

Rt Hon David Cameron MP
Prime Minister
10 Downing Street
London SW1A 2AA

01 December 2010

Dear Prime Minister

I welcome the review of the Health Secretary‟s plans for the NHS that you have asked Oliver Letwin to undertake, confirmed by No10 and the Treasury to the Financial Times and reported today.

This is the right time for the review, before the Government gets any deeper into the high-cost, high-risk internal reorganisation that Andrew Lansley set out in his White Paper in July.

My concern is for the future of the NHS, and this is entrusted to you and your Health Secretary for now.

This is set to be a period of severe financial squeeze for the NHS. Despite your promise to protect the NHS and to protect NHS funding, the health service is already showing signs of strain. This time next year, when the NHS will be operating on funding from the first year of your Spending Review, rather than the last year of ours, these strains will be much clearer to patients and the public.

This is a period during which the efforts of all in the NHS should be dedicated to making sound efficiencies and improving patient care. It is therefore exactly the wrong time to be forcing the NHS through what the King‟s Fund Chief Executive describes as “the biggest organisational upheaval in the health service, probably, since its inception”.

There are questions which the Health Secretary has been unable yet to answer, and on which you and Oliver Letwin will want to be fully satisfied if you are to allow him to press ahead with his plans. The ten must-answer questions for the Health Secretary are:

1. How does the Health Secretary justify breaking the promise you and the Deputy Prime Minister made to the Country in the Coalition Agreement, as your programme for Government?

2. How does the Health Secretary justify to the public and to patients, the £3 billion cost of internal reorganisation, especially within the financial pressures on the NHS over this Parliament?

3. To what extent will the Health Secretary‟s internal reorganisation distract from and make more difficult the action needed to meet the immediate challenge of sound financial efficiencies, whilst improving patient care?

4. Why have the Health Secretary‟s plans attracted universal concern from health experts, professional bodies and patients‟ groups about the risks, and why do fewer than 1 in 4 of GPs – who all other NHS professionals see as the “winners‟ in his new system – believe the reorganisation will improve patient care?

5. Why will there be more state (statutory) organisations in the NHS after the Health Secretary‟s changes than there are now, and why will there be more civil servants in the DoH than there are now?

6. How can the Health Secretary claim that his plans will lead to a “patient-led” NHS, when decisions on commissioning which will drive the provision of services will be made not by patients, or with the direct involvement of patients, but by “GP consortia”?

7. What financial risk assessment and due diligence has been done on the Health Secretary‟s plans which in 2 years‟ time will see £80 billion a year of taxpayers‟ money spent by organisations that do not yet exist?

8. What Parliamentary and public accountability will there be for failures in patient safety or services and for failures in financial management or probity under the Health Secretary‟s plans?

9. Is your Government prepared to see trust in the patient-GP relationship put at risk because GPs will make rationing as well as referral decisions on treatment, so that patients will question whether their GP is doing what is best for them or best for the GP‟s own budget and consortia business?

10. Is your Government prepared to see a two-tier health service as patients find important services will be commissioned and available in some areas but not in others?

I trust that you will ensure that the answers the Health Secretary provides to these essential questions will be fully tested.

If you feel able to share with me the conclusions you come to on these points, I would be grateful. Otherwise I look forward to seeing your conclusions reflected in future Government policy announcements and developments.

Yours sincerely.

As ever

John Healey MP
Shadow Health Secretary

cc: Rt Hon Andrew Lansley CBE MP
Rt Hon Oliver Letwin MP