Thursday, 28 March 2013

BMA and RCN call on government to take urgent action on competition regulations for NHS services.

As the NHS in England faces the biggest shake-up for a generation, and with only days to go until new commissioning arrangements for NHS services come into force, doctors’ and nurses’ leaders are today (28 March 2013) calling on the Government to amend controversial regulations to make it absolutely clear how competition will be managed amidst continued confusion and anxiety about the changes. There are increasing concerns from doctors and nurses that competition will be enforced. The BMA and RCN say clarity in the legal framework is crucial, placing beyond doubt the limits of competition.

Regulations laid before Parliament last month provided greater details about how aspects of patient choice and competition would operate under the Health and Social Care Act, which takes effect on 1 April. They were intended to ensure good procurement practice, but prompted widespread concern and uncertainty about the apparent requirement for competitive tendering for most health services.

Although the regulations have since been revised to acknowledge some of these concerns, there remains a lack of clarity around when commissioners will be required to tender all services. The BMA and RCN are concerned that competition risks fragmentation of services, creates unnecessary transaction costs and increases scope for legal challenge, making it harder for the NHS to deliver high-quality, cost-effective and integrated care to patients.

During the passage of the Act, the Government stated on a number of occasions that commissioners would have the freedom to decide which services they would tender. Monitor has the task of producing guidance for commissioners on procurement and competition which is expected to provide clarity on what will be expected of commissioners and how Monitor will discharge its functions in this area. However this guidance has still not been published, causing further uncertainty for commissioners.

The BMA and RCN are asking the Government for:
Immediate and definitive assurances on whether commissioners could legitimately seek to limit competition in all circumstances where it is in patients’ best overall interests
Assurances to be clearly reflected in the legal framework
A firm commitment that commissioners could prioritise patient services over competition and choice, thereby avoiding fragmentation.

Dr Mark Porter, Chair of BMA Council, said: “Although the revised regulations improved the original wording, we stressed the need for this to be supported by clear guidance to provide the assurance and clarity that is needed to ensure that competition does not undermine integration, innovation, or clinical autonomy.

“With major NHS changes coming into force on 1 April, that guidance has still not been published. This has created great uncertainty and anxiety for clinicians and patients, and left commissioners in a potentially vulnerable state. We have not received satisfactory assurances from the Government that would alleviate the considerable fear that commissioners are facing.

“Until we see how the regulations work in practice we cannot be sure that commissioners will have the freedom to act in the best interests of patients. The stakes are too high to take such risks in what is untested territory.

“We urge the Government to give immediate and absolute assurances about the limits of competition, changing the wording of the regulations if this is what it takes, to ensure that its prior commitments match the reality on the ground. Commissioners need to be completely clear about the rules governing commissioning and to know that they will be allowed to make the best decisions for their patients.”

Dr Peter Carter, Chief Executive & General Secretary of the RCN, said: “Even with the recent revisions to the regulations there is still a worrying lack of clarity over how much freedom commissioners will have to provide the best possible care for patients. There is a very urgent need for Monitor and NHS England to publish the promised guidance for commissioners.

“We remain concerned that despite Government assurances commissioners may not be able to put the quality of patient care and integration above the need to provide competition without facing potentially costly challenges.

“The priority for the health service right now should be encouraging integration between services to cope with increasing demand and driving up the quality of patient care. Without Government assurances being reflected in the Regulations, we are concerned that clinicians will not be able to focus on these priorities and commission the services that their patients need.”

Postscript

Here are the links to the LBC broadcast of the Royal Society of Arts debate on the future of the NHS referred to by Jon Danzig in his comment below:


Launch of NHS 111 must be delayed as crisis worsens, warns BMA


GP leaders today (Thursday, 28 March 2013) called for Sir David Nicholson, Chief Executive of the NHS Commissioning Board, to delay the launch of NHS 111 as the crisis affecting the system threatens to put patient safety at risk1.

NHS 111, a telephone triage service designed to direct people with non life threatening conditions to the right part of the NHS within the appropriate timeframe, has been trialled in England ahead of a nationwide launch on Monday, 1 April2. At the same time, Clinical Commissioning Groups are scheduled to assume responsibility for commissioning services in the NHS and oversee the NHS 111 system in their region3.

Dr Laurence Buckman, Chair of the BMA’s GP Committee, said:

“The BMA has written to Sir David Nicholson and asked him to delay the launch of NHS 111 until the system is fully safe for the public. We cannot sacrifice patient safety in order to meet a political deadline for the launch of a service that doesn’t work properly.

“There have been widespread reports of patients being unable to get through to an operator or waiting hours before getting a call back with the health information they have requested.

“In some areas, such as Greater Manchester, NHS 111 effectively crashed because it was unable to cope with the number of calls it was receiving.

“The chaotic mess now afflicting NHS 111 is not only placing strain on other already over stretched parts of the NHS, such as the ambulance service, but is potentially placing patients at risk. If someone calls NHS 111 they need immediate, sound advice and not be faced with any form of delay.

“The BMA is particularly concerned that CCGs will find it difficult to cope with the worsening crisis now gripping NHS 111 when they take responsibility for the service next week.

“CCGs will be taking over a service they did not commission or ask to be set up, at a pressurised time when they are also assuming responsibility for a raft of other services and budgets within the NHS. The government has also made it clear that CCGs will have to foot the bill for any financial costs, such as hiring staff to cover for NHS 111 failures.

“The BMA has been warning the government about the problems with NHS 111 for almost two years. They must act soon to ensure that patient safety is protected.”

Wednesday, 27 March 2013

Will 1 April mark the beginning of the end of England’s NHS?


Today on bmj.com, two professors debate whether the NHS reforms, which come into play on 1 April, mean the end of the NHS.

David Hunter, professor of health policy and management at the School of Medicine, Pharmacy and Health at Durham University believes that the “NHS will never be the same again” and that the changes, which are like nothing seen before, “should not be underestimated”.

Professor Hunter writes that once the Section 75 regulations in the Health and Social Care Act 2012 are passed they will allow competition to “freewheel” as more and more services will be put out to competitive tender, consequently “embedding market competition as the driving force in the NHS”. As such, he believes the NHS will begin to run under a different set of values which will “not be in the public interest”.

He says following a “marketization” programme in Sweden, profit-driven health services increased inequities with big cities and high income earners being favoured over rural areas and low income earners. Low income patients had reduced access to primary care.

Professor Hunter concludes that if we are to save the NHS, a public debate is urgently required on "where markets should operate” and “where they should not”.

On the other hand, Julian Le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics, argues that the reforms will not mean the end of the NHS. Instead he says that that there is no need to fear the competition which will provide the challenge needed to improve NHS hospitals.

Drawing in part on his experience as senior policy adviser to Prime Minister Tony Blair from 2003 to 2005, Professor Le Grand says that competition has had a positive impact on the quality of management with “knock-on effects on hospital quality”. He bases these conclusions on research from the London School of Economics, the University of Bristol and elsewhere that found that when more patient choice was introduced in England, hospital quality improved faster in more competitive areas. And he draws attention to research demonstrating that patient choice has the potential to improve quality further.

He also says that the privatisation worry is “odd”, given that large parts of the NHS, including most GP practices, are already private. He points out that many of the new providers will be social enterprises and mutuals; organisations that have a track record of out-performing the conventional private sector.

Professor Le Grand concludes that previous reforms did not lead to disaster or system collapse and instead contributed to a “steady improvement in the quality of care”. If anything signals the end of the NHS, he says, it will not be these reforms but the “Government’s determination […] to impose ill-conceived austerity measures on the public sector”.

An editorial from Clare Gerada, Chair of the Council of the Royal College of General Practitioners, also published today on bmj.com asks what clinical commissioning groups should do on 1 April.

She says that the government’s claims that general practitioners will lead commissioning are "misleading" and while trusted GPs will "bear the brunt" of the public’s wrath, much of the health budget will be handed over to the "for-profit commercial sector" which will lead to services closing and the erosion of entitlements to universal healthcare.

She says that although both Andrew Lansley and Simon Burns said that it was not the government’s intention to force commissioners to put services out to tender, the latest legal opinion says that only in "exceptional cases" would competitive tendering not be allowable and now even the government’s officials "don’t know what to make of the new regulations".

She says that given the current confusion between the regulations and Ministerial assurances, Clinical Commissioning Groups are between a rock and a hard place. She adds that the only sensible, safe and fair course of action is to have a “legislative pause” and for ministers to “revoke the regulations while they undergo proper legal scrutiny”.

Dr Gerada concludes that putting GPs in a position of overlooking the "dismantling of our NHS" is a "monumental betrayal" by the government; one that will damage the trust between GPs and patients.

Also available on bmj.com is Terence Stephenson’s (Professor of Child Health, and Chair of the Academy of Medical Royal Colleges) statement on the withdrawal of the regulations of the Health and Social Care Bill 2012 following a letter to the Health Minister Earl Howe.

Tuesday, 26 March 2013

BMA comment on Government Response to Francis Inquiry


Commenting on the Health Secretary’s initial response to the Francis Inquiry report today, Dr Mark Porter, Chair of BMA Council, said:

“We share the Health Secretary’s commitment to greater openness and respect for the dignity of individual patients.

“Creating a culture of zero harm will depend on staff feeling able to speak out freely about poor care. Doctors already have clear professional duties to raise and act on concerns about patient safety. On the rare occasions when they do not, it is often because they are afraid of harassment by employers or colleagues. We share the Health Secretary’s concerns that the threat of criminal sanctions for individual staff would be counterproductive and risk creating a new climate of fear.”

Commenting on plans for a new inspection regime and ‘Ofsted-style’ ratings, Dr Porter said:

“The purpose of the inspection regime should be to ensure that NHS organisations are focusing on their primary mission – to provide safe, high-quality care. We need to avoid a system that encourages managers to focus unduly on ratings.

“It’s important that patients have access to information about the quality of services. However, most healthcare providers are extraordinarily complex organisations, and it is impossible to reduce everything they do to a single meaningful score. Even individual hospital departments and GP practices provide a wide range of different services.

“It is vitally important that we do not allow a ratings system to create a misleading picture of any hospital department or GP practice. This would be unhelpful to patients, as well as demoralising to staff.”

Friday, 22 March 2013

Should 'Ofsted-style' ratings be used for NHS? BMA comment on ratings review

Commenting on the Nuffield Trust review into whether the Government should introduce ‘Ofsted-style’, performance ratings, Dr Mark Porter, Chair of BMA Council, said:

"It’s important that patients have access to meaningful information about the quality of services, and the Nuffield Trust has adopted a refreshingly thoughtful approach to a possible new ratings system.

“It is particularly welcome that the Trust has taken on board concerns about ratings for entire hospitals. As the BMA and many others pointed out, hospitals are highly complex organisations and their ‘performance’ cannot be measured in any simplistic way.

“However, there are always going to be problems constructing indicators that measure quality in any meaningful way, and do not result in a target-driven culture.

“GP surgeries often have many staff and offer a range of different services, the quality of which would be difficult to reduce to a meaningful single score.

“Any system for measuring performance would also need to take into account the different demographic and financial challenges facing different practices. Data will only be useful if patients can make sense of it, and if it allows GPs to make improvements. It would also need to be used developmentally rather than punitively - we are concerned about the risk of demoralising staff in organisations with low scores, particularly given the link between morale and quality of care.”

Wednesday, 20 March 2013

Chancellor meddling in NHS pay process. BMA reaction to budget



Commenting on the statements on public sector pay in today’s Budget, Dr Mark Porter, Chair of BMA Council, said:

“We’re concerned that the Chancellor is seeking to meddle in NHS pay processes. As MPs noted this week, pay restraint cannot be seen as a long term savings strategy for the NHS. Efficiency gains will be achieved by focusing on quality, not by suppressing pay.

“Healthcare workers are at the forefront of the drive to improve efficiency in the NHS. They have already undergone major changes to their pensions, and many doctors have been subject to real terms pay cuts for several years. Pay progression is not automatic for most senior doctors.

Commenting on the Chancellor’s confirmation that NHS funding will continue to be protected, Dr Porter said:

“We welcome the fact that the Government continues to recognise the importance of the NHS, and the scale of cost inflation in healthcare. However, it is not the case that health has been exempted from the financial pressures facing the rest of the public sector. The NHS has been asked to deliver cost savings of £20 billion by 2015. Posts are being cut and services are being rationed.”

Commenting on the announcement of a reduction in duty on beer, Dr Vivienne Nathanson, the BMA’s Director of Professional Activities, said:

“We’re getting mixed messages from the Government about its commitment to tackling the harm caused by alcohol misuse. On one hand the Prime Minister says he wants to crack down on cheap alcohol, and on the other the Chancellor announces a penny less on beer. “The success of the Government’s alcohol strategy for England and Wales will be undermined if cheap booze continues to be available. We urge the Government to demonstrate that it is committed to tackling alcohol misuse and introduce a minimum unit price.”

Monday, 18 March 2013

GP contract changes will undermine delivery of patient services, warns BMA


The government’s failure to listen to the concerns of thousands of family doctors about changes to the GP contract in England will undermine how patient services are delivered, the BMA warned today (Monday, 18 March 2013).

The warning came as the Department of Health confirmed a raft of changes to the GP contract in England that will come into force on 1 April 2013. The government’s proposals will see general practice facing a range of new targets and additional workload responsibilities, as well as reductions in the central funding that many practices receive.

These changes are being implemented despite thousands of GPs expressing concerns about the proposals in a BMA survey that was submitted, along with other evidence, to the government’s consultation on the changes1.

Dr Laurence Buckman, Chair of the BMA’s GP committee said:

“GPs are committed to working with patients and the government to deliver the highest quality of care to the public.

“However, ministers have completely failed to take on board the concerns of thousands of GPs about the cumulative impact of these proposals on general practice. Practices will face numerous new targets that will divert valuable clinical time and resources towards box ticking and administrative work.

“The decision to make changes to the Quality and Outcomes Framework (QoF) from 2014/15 and other funding areas will make it more difficult for practices to maintain services. This comes at a time when many practices are already struggling to cope under the pressure of rising workload and shrinking resources.

“A BMA survey that drew nearly 8,000 responses demonstrated that the impact of these changes would result in GPs considering reducing patient access and staffing hours.

“Last year, the BMA and NHS Employers came close to agreeing a tough, but fair package of changes that would have resulted in real improvements for patients. These talks were ended when the government decided to pull the plug and threaten to impose their own proposals. This has been followed by a total failure to listen to grassroots GPs during the recent consultation.

“It is unacceptable that the government has ignored this weight of opinion and ploughed ahead with so many ill thought out proposals that run the risk of destabilising patient care.”

Unprecedented action to reduce health inequalities


It is indeed rare these days that I write something 'good' about the coalition government. Today's post is one of those rare moments. One of the major determinants of poor health is inequality. We cannot expect to break the cycle of poverty and disease unless we address this.  This is why joining up the dots between socio-economic circumstances and health care is essential. To treat poor health without regard to such circumstances is to ignore a substantial primary cause of ill-health. It is also one of the reasons I have been critical of the indiscriminate nature of the effects of the governments policies that are likely to increase poverty and inequalities. But today there is at least some good news.

Health professionals from a wide range of royal colleges and professional organisations have joined forces to improve patients’ health and reduce health inequalities by considering patients’ social and economic circumstances as well as their medical history. It is estimated that this 'unprecedented' commitment to act by more than 20 health organisations could save the NHS well in excess of £5.5 billion every year.

The action, which includes making ‘social’ referrals more important, is detailed in a landmark report ‘Working for Health Equity: The Role of Health Professionals’. The Report, which is supported by the Health Secretary Jeremy Hunt, will be launched at a global conference at BMA House in London today, Monday 18th March.

There are numerous examples up and down the country where health professionals are already taking action to tackle the social and economic causes of ill health   The country-wide action is being documented, assessed and driven by the Institute of Health Equity, based at University College London, and led by the global expert on reducing health inequalities, Professor Sir Michael Marmot:

‘We have the most equitable health service in the world. Of that we should be extremely proud. But it is inequalities in social and living conditions that are driving inequalities in health. Even among health professionals who have this insight, there has been a sense that it is for others to respond, there is not much we can do. But the response we have had from the many organisations and individuals that have helped us with this report is not only SHOULD we be taking action but there is ample evidence that we CAN.

The report and statements from health professional organisations make clear that action on the social determinants of health should be a core part of health professionals’ business – it improves clinical outcomes, and saves money and time in the longer term. In partnership with others in the wider society, health professionals can help reduce socially unjust and avoidable inequalities to ensure everyone has the same opportunity to live as healthy a life as the very best off.’

The Marmot Review of health inequalities ‘Fair Society, Healthy Lives’ highlighted that inequality in illness, in addition to health care costs, accounts for approximately £31-33 billion annually in productivity losses and lost taxes, and in higher welfare payments in the range of £20-32 billion . The government-commissioned review of health inequalities stated health could only be improved by considering an individual’s social circumstances and taking action on the ‘causes of the causes’ or the ‘social determinants’ of health.

Health inequalities feature across all of society, apart from those at the very top (around 1% of the population) – there is a social ladder, or gradient, for ill health and life expectancy, with the most deprived suffering the most and everyone below the very top experiencing worse outcomes than the best-off.

The gap in life expectancy across England between the best and worst-off is seven years  (this figure is substantially more within local areas, for example, 17 years in some areas of London  and 28 years in Glasgow). Disability free life expectancy (how long someone can expect to live free of life limiting illness) has an even steeper gradient and wider gap – there’s a 17-year difference between the best and worst off .

Every minute 463 people are seen by one of the 1.4 million people who work for the NHS – that’s eight people every second. They see and understand how patients’ socio-economic circumstances affect their health. Health professionals are highly trusted by the general public and therefore have a unique opportunity to support and improve their patients’ social and economic situations. The NHS is therefore well placed to coordinate action on the social determinants of health to reduce health inequalities.

The Coalition Government has placed a number of legal duties on health professionals to reduce health inequalities through the Health and Social Care Act. The Report’s six main recommendations are designed to help satisfy these duties:

Summary of ‘Working for Health Equity’ Recommendations:

1. Workforce education and training – mandatory social determinants of health (SDH) training within under and post graduate education as well as continued professional development (CPD). Education should include practice-based skills such as taking a social history and referring to non-medical services, students placement within non-health organisations and widening access to health care careers to all socio-economic groups.

2. Working with individuals and communities – prioritise social history alongside medical information to understand root causes of ill health and provide best care including referral to range of medical, social services and other agencies.

3. NHS organisations – ensure good quality work for all employees, including minimum income for healthy living (MIHL), occupational health and other services, and use purchasing power to assess health equity rigorously within contracted services.

4. Working in partnership – make tackling health inequalities a priority within the health sector and with external bodies by supporting joint commissioning, data-sharing and delivery and measuring progress.

5. Working as advocates – individual health professionals, students and health care organisations should act as advocates for patients, their families and local communities to improve the social and economic conditions and reduce inequalities; and advocate for change within the health workforce and to national policy.

6. The health system – maximise the opportunities offered by legal duties under the Health and Social Care Act 2012 and through the Public Health Outcomes Framework to act on the social determinants of health to reduce inequalities. Twenty-one health organisations have drawn up their own statements for and commitments to action.

It seems a pity that, whilst this initiative is welcome, the governments reforms of the benefits system and their indiscriminate effects will more likely than not drive more people  into poverty and increase the very social and economic inequalities this approach seeks to address.

Friday, 15 March 2013

Why the government fails to understand 'fairness'.

Why does the Secretary of State for Work and Pensions, Mr Ian Duncan Smith get the concept of 'fairness' so wrong? All his policy initiatives he claims are based on fairness. There is little wonder then that he gets so upset when told his policies are not simply unfair but unethical. Some have described them as immoral because of the disproportionate effect on the poorest. It hits him where it hurts, in his softer moral underbelly. Why then does Mr Duncan Smith and his colleagues get it so wrong? I think the answer lies in a common philosophical mistake; the notion that it is ethical to treat people 'equally'.

On so many policies we are asked to compare one group with another. For example, for the 'bedroom tax' we are told it is 'unfair' that differences should exist between those in the private rented housing and in social housing. The problem with this kind of proposition is that it misunderstands 'fairness'. It confuses  'treating people the same' with 'treating people fairly'. The two  are not the same proposition at all.

There is a regularly used example in teaching. I ask the group to tell me whether the statement 'all people are equal' is 'good'. Most often we start with the class saying it is 'good'. But then I point out that we are not equal. We differ in socio-economic condition; we differ in a whole variety of ways. And then we agree that whatever we mean by 'equality' it isn't that people are or should be the 'same'.

The next question we deal with is whether 'all people should be treated equally' is a good statement. Again after discussion we find the concept isn't as good as it sounds. If we are not the same, then how can it be good to treat us as if we were? It is a recipe for unfairness, and this is the problem Mr Ian Duncan Smith and his colleagues fail to appreciate. It is why they have to rush in with concessions and changes in the criteria.

So now, for the 'bedroom tax', we have concessions for those in the armed services or for those fostering. Once the dam is breached it is difficult to hold the line, because there are equally deserving exceptions. Any policy that treats people fairly will seek to account for circumstances. But if the policy is simply to make cuts in spending, taking circumstances into account is unlikely to be a priority. Circumstances requires administration and assessment which costs money.

And here is the problem. The coalitions's policies of cuts in benefits are indiscriminate, which is why they are more likely than not to be unfair, or have unfair outcomes; and it is outcome that matters. If the impact of a policy is likely to be disproportionate on some, then it clearly cannot be fair unless there is a good justification for it.

I cannot see much justification for making the poorest poorer, or making them homeless because they have a 'spare room'. It isn't just unfair, it is cruel and heartless. And let's be aware that the 'bedroom tax' isn't simply something on paper. It is real and it will affect real people and families. It reduces the amount they have to spend on food and heating and other necessities. This is why many call it a tax. Pedantic argument about it doesn't address its unfairness.

If Mr Duncan Smith is really so concerned with fairness, then he would do well to look elsewhere for the causes of  unfairness in our society. Making the poorest in social housing pay a price for the shortage of social housing stock fails to address the real cause of any unfairness in allocation of housing.

By their own calculations the Department of Work and Pensions knows that there is a mismatch in the numbers of houses available and those who are likely to have to move from their social housing as a result of the 'bedroom tax'.  So it cannot solve the problem of unfairness in distribution; that some families are living in overcrowded conditions whilst others have spare rooms. You cannot do a direct swap.  It is simply misdirecting the public to argue otherwise. I wouldn't say it was a lie, but it is certainly a deceit.

Thursday, 14 March 2013

BMJ finds conflicts of interest "rife" on new NHS commissioning boards.


An investigation for the prestigious British Medical Journal (BMJ) published today finds GP conflicts of interest “rife” on the new NHS commissioning boards.

More than a third of general practitioners on the boards of new clinical commissioning groups (CCGs) have a conflict of interest due to directorships or shares held in private companies providing services for the NHS.

The report provides the clearest evidence to date of the conflicts many doctors will have to manage from April 1, when the GP-led groups are handed statutory responsibility for commissioning around £60bn of NHS healthcare.

The BMJ used Freedom of Information requests and CCG websites to analyse the registered interests of almost 2,500 board members across 176 of the 211 commissioning groups in England.

It found 426 (36%) of the 1,179 GPs in executive positions had a financial interest in a for-profit private provider beyond their own GP practice – a provider from which their CCG could potentially commission services.

These ranged from senior directorships in local for-profit firms - set up to provide services such as diagnostics, minor surgery, GP out of hours and pharmacy - to shareholdings in large private sector health firms providing care in conjunction with local doctors, such as Harmoni and Circle Health.

In some cases, the majority of GPs on the CCG governing body had financial interests in the same private healthcare provider.

Although some doctors have relinquished interests in private enterprises because of their new roles as commissioners, the BMJ found that in total, 555 (23%) of 2,426 governing body members – including all clinical, lay, and managerial representatives – have a financial stake in a for-profit company.

Last week, the BMA’s UK Consultants’ Committee passed a motion at their conference expressing concern at “the clear conflict of interest of GP commissioners who run their own private companies”, and calling on GP commissioners to “be barred from being involved in companies that they are giving contracts to.”

The NHS Commissioning Board has issued a code of conduct to CCGs stating that board members must remove themselves from decisions that they could materially benefit from. But doctors’ leaders have expressed concern that clinical input into commissioning decisions may become diluted if too many doctors are forced to remove themselves from particular decisions.

All of the CCGs found to have notable conflicts told the BMJ they had robust systems in place for managing potential conflicts, including publishing conflict of interest policies, and regularly updating members’ declarations of interest.

But Michael Dixon, chair of NHS Alliance and interim president of NHS Clinical Commissioners, warned placing too much emphasis on the issue may prevent clinical commissioners from bringing more care into community settings.

The NHS Commissioning Board said it was reviewing its existing guidance and would shortly be publishing “final, comprehensive guidance on managing conflict of interest”

The Department of Health has also acknowledged that concerns about conflicts needed addressing, and pledged to strengthen Monitor’s power to act where conflicts “may affect the integrity of a commissioner’s decision."

Dr Fiona Godlee, editor in chief of the BMJ, said: “This is the first time the full extent of the involvement of CCG GP board members in private health companies has been revealed.

“These conflicts will make the commissioning of some services difficult. Although board members can excuse themselves from meetings when conflicts arise, this could mean some decisions are made by a group of predominantly lay people.

“Some of these conflicts of interest are too great to be ‘managed’. We think that those GPs who have positions at executive board level in private provider companies need to choose between their competing interests and, if need be, step down from the commissioning boards.”

BMA calls for safeguards against conflicts of interests


Commenting on the BMJ investigation into potential conflicts of interest for GPs involved in commissioning, Dr Laurence Buckman, Chair of the BMA’s GPs Committee, said:

“While the majority of GPs have no involvement in private companies, we have long called for stronger safeguards against possible conflicts of interest in the new commissioning process.

“In our view, GPs who are directors of, or who have significant financial interests in, companies who might be awarded contracts to provide services should seriously consider their membership of CCG governing bodies. Alternatively, they should consider their position within provider companies.

“We support the principle of greater clinician involvement in commissioning, but it must not come at the expense of the trust of patients. Measures to prevent conflicts of interest will improve confidence that decisions are being made to benefit patients.”

Waiting for the horse to bolt before shutting the stable door 


The Department of Health acknowledged in its response to its consultation “Securing the Best Value for Patients” that concerns about conflicts needed to be answered, and it pledged to strengthen the power of the healthcare regulator Monitor to act where conflicts “may affect the integrity of a commissioner’s decision.”

According to the department this would mean “the Monitor is able to take action where conflicts have not been managed appropriately in awarding a contract, and not only where Monitor is able to establish that the decision to award a contract was the result of an interest in the provider—which may have set the bar too high to allow action to be taken.”

In other words we are really waiting for the horse to bolt before locking the stable door. 

The General Secretary of the General Medical Council, the doctor's governing body, said  "This is all about honesty and integrity—we expect doctors to be open about any financial and commercial interests linked to their work.”

We certainly expect that; but then we expect that in all professions, but often conflict of interest becomes difficult to unravel. 


Monday, 11 March 2013

The bedroom tax is cruel because it is indiscriminate and fails the test of justice.

Since publishing my previous article on the cruelty of  the 'bedroom tax', several readers have pointed to the unfairness of people occupying houses with 'spare' rooms whilst others are in need. It is an argument repeated by government ministers. Often they cite the numbers of empty houses, as if the two could easily be matched.

But pointing to one unfairness, the shortage of suitable homes, cannot justify another, the indiscriminate injustice of forcing the poorest deeper into poverty, or for them to lose their homes. It is  particularly unjust if it is unlikely to resolve the problem, for it cannot then be justified on any utilitarian ethical consideration. It fails to give an equal consideration to the genuine interests and needs of all concerned. It neither addresses the plight of the homeless or those in overcrowded accommodation, nor does it address the problem of low pay and families struggling to pay their bills. Justice requires that people should be treated fairly.

The 'bedroom tax' is cruel because it is indiscriminate in its effect. It fails to take account of circumstances and real availability of housing stock. It seeks to turn one sector of the community against another. And it should be clear, the objective of the 'bedroom tax' is to reduce spending, not to solve the housing shortage. It is disingenuous for government ministers to suggest otherwise.

The Secretary of State, Mr Ian Duncan Smith says “These changes are about fairness. We will be able to make better use of our social housing stock, and help more families into their own home whilst keeping the welfare budget sustainable.”  This is not so.

Freeing up accommodation according to  'need' is at best a secondary objective, and from the studies cited in the DWP impact assessment,  is unlikely to be effective. Indeed, this is acknowledged by the DWP  in their impact assessment:

 "If all existing social sector tenants wished to move to accommodation of an appropriate size, there would be a mismatch between available accommodation and the needs of tenants."

The real cause of the shortage of suitable homes is the lack of social housing stock, not under-occupancy.  The stock of social housing is pitifully low.

But there are  two problems with the the empty housing argument. It makes the assumption that 1) a 'spare' room is not 'needed' and 2) that matching those who might need to move with available empty properties would be easy.  Simply counting the numbers of unoccupied social houses doesn't make them available or suitable for those who might be forced out of their homes by the 'bedroom tax'. It assumes the homes will be located suitably for available work, schools, transport links. it also fails to address the social cost of families being forced to move from communities where they have established ties. Focusing on the number of empty properties distracts us from the real need to build more homes.

Thursday, 7 March 2013

The Spark of Life – electricity in the body.

What is the link between a lightning flash, the poet Percy Shelley and a cure for diabetes? It is the kind of question you might hear on a radio quiz program such as ‘Brain of Britain’. The quest for an answer takes us on an exciting scientific journey with unexpected twists and turns. It is an extraordinary voyage of discovery, beautifully navigated for us by the distinguished Oxford scientist, Professor Frances Ashcroft in her book “The Spark of Life”, which she discusses with Denis Noble for Voices from Oxford.

Since the 18th Century Italian physician Luigi Galvani showed that an electric shock can cause muscles to twitch, scientists have been fascinated by the role of electricity in life.  Modern science has discovered that electric currents flow in and out of cells in the body mediating and initiating their function.

All cells in the body in all organisms on earth, “from the simplest bacteria to the trees in the giant redwood forests of California” have tiny protein structures in the cell membrane which can pass electric currents in the form of ions, “charged atoms”, such as sodium, potassium and calcium. 

Frances Ashcroft is particularly interested in how sugar levels in the body are controlled.  If it falls too low then the brain is starved of fuel; if it remains high for too long then it can cause the complications of diabetes. Blood sugar levels are regulated by the hormone, Insulin, released from the pancreas in response to a rise in blood sugar. “We and others discovered a tiny protein pore which is found in the membranes of the insulin secreting cells.” She explains. “When the pore is open insulin is not released, and when it’s shut insulin is released.” When blood sugar levels rise the pore shuts and this triggers a cascade of events resulting in insulin release.

By making mutations of the gene for the protein pore it is possible to understand how the protein pore works, and also, as Professor Ashcroft says, “there are mutations resulting from accidents of nature which may lead to disease.” In one mutation she is working on the protein pore remains open, insulin is not released, glucose levels remain high “and then you get diabetes.”

What Frances Ashcroft and her colleagues realised was that the pores could be closed by drugs, sulfonylureas that were already in routine clinical use for late onset diabetes. Those who have the mutation are born with the disease, and are dependent on regular insulin injections. But it was realised that the existing drugs could be used to close the pores and release insulin. Frances Ashcroft tells us about the excitement of this important discovery and the impact it has had on people’s lives. A truly breathtaking result. 
  
Understanding electricity and how it works in the body has led to the development of new treatments for diseases. Disease caused by mutations in protein pores has now been given its own name “channelopathy”. An example is one found in goats that causes them to fall down. But what is really significant is that this is similar to the human condition myotonia congenita, where muscles lock up when the patient is startled. Understanding channelopathies has the potential for development of treatments for such diseases.

In one sense Frances Ashcroft says “we are nothing more than soup and sparks”.  Or as Percy Shelley put it “...man is a mass of electrified clay.”

This article is also published by Voices from Oxford

Voices from Oxford video link

Wednesday, 6 March 2013

Bankers' bonuses and the 'bedroom tax'

I have heard all sorts of interesting justifications for the size of bankers bonuses, some reasonable, others downright tendentious. But the justification I heard today just about trumps them all; we shouldn't regulate bankers' bonuses because 'they pay for welfare'!

This appears to be the new line, and the Prime Minister used it in today's PMQs; no doubt it will become a mantra and we will hear it repeated. It is the kind of justification we hear often from this government. We mustn't regulate the rich because 1) they will go elsewhere and 2) their taxes pay for welfare. Thus the richer we allow them to become, no matter how obscene and unjustifiable in terms of productivity or effort, the more we have for welfare.

So, the wealthy are allowed to hold us all to ransom with their potential tantrums and threats take their expertise abroad. It is time we called their bluff. The newspapers should have the same attitude to such ransom as they often do to train-drivers when they threaten to strike for more pay; outrage.

How quickly Mr Cameron has changed his tune over bankers bonuses. In 2011 he was calling them 'obscene', now he is prepared to justify them because 'they pay for welfare'. It is as absurd a position as he has adopted about taxing the wealthy. Tax for the wealthy has almost become voluntary; a charitable gesture for which we must be grateful.

Mr Cameron objected vociferously to the use of the term 'bedroom tax'. He got very cross about it. It isn't a tax he shouted in the House of Commons. Well of course he is right; it isn't a tax. But its impact is the same as if it was. I wouldn't call it a tax; it is much more a penalty. It is a 'bedroom penalty'. Whatever it is called it all has the effect of driving more families deeper into poverty, and because it deprives them of household 'income' I would say it is in its effect, well....a tax.

Tuesday, 5 March 2013

This medieval, cruel and unfair 'bedroom tax' will push families deeper into poverty.

From next month all working age tenants renting from a local authority, housing association or other registered social landlord will receive Housing Benefit based on what the government calls "the need of their household". It sounds libertarian and just: to each according to his need. If only they had also adopted the other half of the balance: from each according to their ability. But the 'bedroom tax', as it has been called, is by its nature a medieval piece of legislation. Its aim is primarily to cut the costs of housing benefits, but also to encourage tenants to move out of their homes. It isn't 'giving according to need', it is taking away from the poorest. It isn't an incentive, but a penalty, and that is why it is unjust. It assumes 'need' can be determined solely by considering numbers of rooms and numbers of people. If only it was that simple.

The 'bedroom tax' means those tenants whose accommodation is 'larger than they need' may lose part of their Housing Benefit. Those with one extra bedroom will have a 14 per cent reduction applied to their eligible rent and those with two or more extra bedrooms will have a 25 per cent reduction applied. And all this at a time when household budgets are being squeezed from all directions.

 It is the worst kind of social engineering to force people out of their family homes. David Cameron famously described society as being 'broken'.  In the wake of rioting and looting in the streets in 2011, he put fixing what he called 'broken Britain'  at the top of his agenda. He is also on record as wanting to put family life on the political agenda, promoting the importance of good parenting. All very commendable. But the government's 'bedroom tax' is  at odds with these ambitions. At best it demonstrates a very poor understanding of how families work, and no recognition of the impact of such policies on communities.

Of course there is a shortage of houses and there is also an injustice when families cannot be properly housed. But there is a world of difference between a financial incentive and a financial penalty. Financial incentives may be an appropriate way to encourage people to 'downsize' in the social housing sector, but financial penalties create the potential for a different kind of injustice; forcing people deeper into poverty, because they cannot readily move.

A family who have grown up in a neighbourhood, made friends, established mutual support in caring for children are being encouraged to move, not by choice and opportunity, but because they have one room too many. Yet the DWP in their assessment of the likely effects of the change acknowledge no social impact, no potential impact on health and well-being or any potential for injustice. In their impact assessment they simply write against these assessments the word 'none'. And yet clearly there will be impacts in all these areas, and they know this to be so. Where they have been assessed, the DWP have ignored the findings.

One assessment was of the likely impact of the change on a community of 452 families.  Over two thirds of the households in the study had a household income (excluding housing benefit) of less than £150 per week.  Forty-two percent report struggling to manage financially to some extent and 41% say they regularly run out of money before the end of the week/month. The main reason for for having spare rooms is children leaving home but other factors such as bereavement and separation are significant. Needs often reflect complex family relationships rather than simplistic assumptions about need based on bedrooms. The vast majority (82%) thought their accommodation was 'about right' for their needs. Only a minority would consider moving. Many households regularly have relatives stay overnight, shift working alters sleeping arrangements. More than a third were likely to move into arrears as a result of the change in housing benefit.


The DWP are selling the 'bedroom tax' on the injustice of the current distribution of housing and housing shortages. But the primary aim is to reduce housing benefit costs. Freeing up accommodation according to 'need' is secondary and from the study done is unlikely to be effective. Indeed as the DWP say in their impact assessment if "all existing social sector tenants wished to move to accommodation of an appropriate size, there would be a mismatch between available accommodation and the needs of tenants." In other words this is an ill-thought out policy that won't meet its promise, but will meanwhile cause anxiety, suffering and injustice and push families deeper into poverty. 

Friday, 1 March 2013

A budget for growth would be best to address the structural deficit.

There is little I find more frustrating than listening to Labour Party front-bench spokespersons presenting the 'case' for an alternative to coalition austerity.  It is as if they are afraid of their own shadow. They fail to explain, not simply that deficit reduction is not the only or the right objective, but also they fail to outline what the alternative is and why, even when challenged by their opponents to do so.  So what is the problem?

I suspect it is because Labour are too cautious about being labelled 'deficit deniers', which is very sinful, and because 'deficit' is poorly understood or explained. The problem is the distinction between 'budget deficits' and 'structural deficits'. Although related, they are not the same. The distinction is important.

Voters clearly see that there is a massive deficit. More problematic for Labour is that they largely blame the last Labour government for it. So it is not surprising Labour don't want to appear to deny it exists, or that it is a problem.

"We have to get the deficit down" the coalition mantra runs. "Labour has no alternative other than to 'spend our way out of trouble'", or 'more borrowing'. And this is the problem for Labour. More borrowing is the solution, and it is the answer to reducing the deficit. Timidity in dealing with this problem fails to address it. But the argument can often appear opaque. Yes a policy for growth would mean an increased budget deficit, but in the longer term it would increase revenue. Only by increasing growth and revenue can the deficit be reduced. And, indeed, the coalition is finding it very difficult to 'get a grip' on the deficit, and the reason is falling tax revenue.

It struck me this week how easy it was for the British Chambers of Commerce to present an alternative objective to the government. It wasn't 'cut the deficit'; it was 'act urgently to stimulate growth'. When Labour says this it seems to get itself into trouble. One problem is economic terminology and public understanding.

 Vince Cable rightly talks of dealing with the 'structural deficit'. He is very precise, unlike many of his colleagues. Budget deficits may come and go; structural deficits are long lasting. It is possible for governments to legitimately run budget deficits, particularly when dealing with short term problems or expenditure.

Thus, it is possible to increase budget deficits to 'stimulate the economy' as these measures have a likelihood of increasing future tax revenue and reduce the deficit in the future. An example was the cut in VAT to stimulate high street activity. It costs initially but is likely to increase tax revenue through increased sales and productivity. So, up to a point and within certain criteria you can 'spend  your way out of trouble'. Indeed the only effective way in the longer term to deal with a structural deficit is to increase revenue.

Structural deficits present problems in the long term because they are costly to manage. Deficits are financed by borrowing and interest has to be paid on the amount borrowed. The longer the deficit last, the more costly it becomes. If the debt ratio to GDP gets too high, then there may be concern that a country may default on its payments. It becomes more costly to borrow to sustain the deficit. This is one reason Osborne worried so much about the triple A rating. Losing it might make it more costly to borrow.

But it is possible to run large structural deficits and still be able to borrow. The US, for example, has large structural deficits but is still able to borrow at very low interest rates. The UK’s debt-to-GDP ratio is now high, but it has little problem borrowing.

Another important aspect of structural deficits is that they don't have to be reduced immediately. By their nature they are 'structural' or long lasting. This doesn't mean they shouldn't be reduced but they could be reduced more gradually over time and it is better to do this through growth and revenue than cuts that push the economy into recession. This was always the case made by Alastair Darling.

So we should distinguish the two types of deficit. This is difficult to get across in a short television exchange where 'deficit' is lumped and no distinction is made. This doesn't mean we should ignore the problem of running a large structural deficit. That would be wrong. But it does mean we can be more sensible about budget deficits and strategic fiscal policies to stimulate growth.

The distinction between structural and budget is essential if we are to have a sensible debate about economic policies. Labour must be bolder in getting its message across. They must stop being afraid of their shadows.

Postscript

I have just had a discussion with a colleague about the distinction between budget and structural deficits. He asked if I had an example from everyday life. If I borrow to hire a van to take some goods to market, I might run a budget deficit that lasts only as long as it takes to get revenue from the sale of those goods. Without borrowing, the wheels of the economy wouldn't move. One problem at the moment is difficulty getting banks to lend to businesses, which is why the Bank of England tries 'quantitative easing' to encourage it. Borrowing to stimulate infrastructural building may also be strategic in the long term by increasing growth and revenue.

The problem of poor growth is highlighted by Bank of England figures showing that lending to businesses had fallen by almost £19bn in 2012, double the decline in 2011. More needs to be done to get banks lending to businesses and improving the relationship with businesses.