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The impact of poverty on the health of our children

Tuesday 23rd May 2017

Dr Guddi Singh

Dr Guddi Singh discusses the impact that poverty has on children’s health in the Sky News studio

Most people don’t know this striking fact, but the UK has a serious child poverty problem. More than 1 in 4 children in the UK live in poverty. That’s nearly 4 million. And if projections are correct, we can expect that number to rise to 5 million by 2020.

Earlier this month I discussed this problem on Sky News. The Royal College of Paediatrics and Child Health has been working with the Child Poverty Action Group to survey front line child health workers across the country, and their report, “Poverty and child health: views from the frontline” reveals some startling conclusions about the impact of poverty on child health. The report is based on a survey of more than 250 paediatricians whose comments provide insight into the grave reality of life for the millions of children living in poverty in the UK. What’s clear is that poverty hurts children – and more and more doctors are seeing this in their practice. More than two-thirds of paediatricians surveyed said poverty and low income contribute ‘very much’ to the ill health of children they work with, with more than 50% of respondents saying that financial stress and worry added to family vulnerability. But what this survey adds is a glimpse into exactly how poverty is hurting our children. Housing problems or homelessness and food insecurity were said to be significant contributors to the ill health of children seen by almost two thirds of respondents. Crucially, 40% of doctors had difficulty discharging a child in the last 6 months because of concerns around housing or food insecurity.

As a paediatrician, I see the connection between poverty and poor health in children every day. I will never forget the four-year old boy who turned up in the Emergency Department some weeks ago. He had rickets and skin problems because his mother couldn’t afford healthy food like fruit and vegetables. He had a chronic cough and recurrent chest infections because his mother couldn’t afford to move out of their cold, damp home. And his language skills trailed those of other children of his age because his single mother was so busy working to juggle two poorly paid jobs and so stressed by financial troubles that she didn’t have the time to teach him properly.

It is cases like this that lift the lid on the UK’s poverty problem. Whether it’s housing, income levels or food security, poverty hurts children. The latest research shows that in 2015 infant mortality rose for the first time in a decade. Worse still, while mortality has been rising for the poorest children since 2010, it has continued to fall for more advantaged groups. In other words, inequalities are widening – and this is not a situation we should be facing in the world’s fifth largest economy in 2017.

The importance of socioeconomic status and the social gradient to health are well established. A series of major analyses commissioned by successive Labour governments, from Sir Douglas Black’s 1980 report on Inequalities in Health to Sir Michael Marmot’s 2008 review, Fair Society, Healthy Lives: a Strategic Review of Health Inequalities in England post-2010 all reiterate that progressive health policy can only be delivered through progressive economic and social policy. These reports point to the things that we as a society can do to improve public health. The fact that we live with problems like air pollution, food insecurity and health inequalities is testament to the political choices that have been made about the economic organisation of our society. Despite the overwhelming evidence they provide, none of these reports has ever been seriously acted on, and since 2010 the policies of successive governments, particularly those linked to austerity and the withdrawal of social security, have aggravated the problems these reports aimed to alleviate. This failure has left us with a higher proportion of children in poverty than any other western European nation and persistent stark inequalities in health and well-being.

Without sufficient money and support services many families simply cannot provide the safe homes or healthy food that is required for children to grow and flourish, not to mention afford the travel required for hospital appointments if a child were to become sick. For me poverty delivers a double blow to children: first it removes access to the basic ingredients for a healthy life, and then on top of that the stress, anxiety and insecurity it causes triggers mental health issues to boot. As London GP Jonathon Tomlinson has recently shown trauma in childhood has effects in adulthood: tripling the risk of heart disease and chronic respiratory disease, and quadrupling the risk of type 2 diabetes. For children in poor families living in an unequal society like the UK – one that allows poverty rates to rise – this is a lose-lose situation.

Poverty and child health: views from the frontline” sends a very strong message to whoever comes into power on June 8th: child health matters. The high levels of poverty in the UK today are putting the health of over a quarter of an entire generation at risk. Low family incomes, inadequate housing and cuts to support services are jeopardising the health of shockingly large numbers of children. The result is that paediatricians like me are trying to do the best we can for our patients despite the shocking effects of economic and public health policies.

This report is a clarion call for the next Government to tackle poverty urgently. Child health is about much more than health services and throwing money at the NHS. Health care should not be treated as fire-fighting – the cornerstones of preventative medicine are public health & social care, so this has to be about the social and economic policies that shape the society we live in. An easy place to start would be to re-instate the UK’s poverty-reduction targets, but that won’t be enough. The next Government must also reverse the cuts to public health services and to universal credit, which will only leave families worse off.

The UK’s children are already lagging behind the rest in Europe. If health inequalities are not tackled soon we not only risk storing up health problems for future generations, but being left behind entirely. If this happens it will be the children of poor families who suffer most.

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The Five Year Forward View: do the numbers add up?

The financial assumptions underpinning the Government’s plans to close the NHS’s 30-billion-pound funding gap by 2020/21 are unrealistic and are likely to lead to a decline in the quality of and access to healthcare for patients. Subsequently there is a growing risk that that some vital services will collapse. 18th May 2017

 

The full report can be found here.

 

To tackle the widely-publicised funding gap, the Government promised in 2015 that it would provide a real term increase in NHS funding for England, starting with an additional £2bn in 2015/16 and reaching £8bn a year by 2020/21. The NHS was left to close the remaining funding gap by achieving a net efficiency gain of 2-3% every year until 2020/21 via England’s 44 Sustainability and Transformation Partnerships (STPs).

 

The report assesses 7 key assumptions on which the plans for achieving the required efficiency savings rest and finds them to be unrealistic.  Key findings are that:

  • £1.8bn out of the £2.1bn of this year’s up-front funding earmarked for transforming NHS services has instead been spent on reducing hospital deficits. This leaves only £300 million available for the NHS to invest in achieving its efficiency targets.
  • Last year hospitals were only able to find recurrent cost savings of 2.8% and yet average targets of 4% and 4.2% have been set for this year and next. NHS Improvement has conceded that targets of 4% in previous years were unrealistic.
  • A 1% pay cap on NHS staff wages will be hard to maintain with national average earnings expected to grow by 2.9% a year and inflation at 1.9% a year. A 0.9% real wage cut amidst 6% staff shortages is unlikely to hold.
  • Social care is expecting a funding shortfall of £3.5bn by 2020/21. Less social care provision will mean longer stays in hospital for older people who are well enough to leave and higher costs being passed onto the NHS.

 

Commenting on the report’s findings, author Vivek Kotecha said:

“With the NHS under unprecedented financial pressure and the Government reaffirming that there will be no new money for the NHS after the election, it is time to take a closer look at how the NHS has been asked to plug the now infamous 30 billion funding gap.

If, as the report suggests, the ways in which the NHS has been asked to find efficiency savings are not achievable, the NHS funding gap will not be closed.  Unless additional funds are made available local NHS organisations will be forced to take more drastic measures to reduce costs. Rationing non-emergency care, the withdrawal of services, and/or reducing cost by reducing quality will be the only options.

Commissioners will be forced to limit the number of non-emergency operations, or the kinds of operations, that they will pay for, or the kinds of patients who can have them (tougher thresholds of need). Instead of the intended improvement in care there will be a decline in quality and access and there is a risk that over the coming years the NHS will degrade into two services: a more or less adequately funded urgent and emergency health service, and an underprovided and oversubscribed non-emergency service.

Public concern about the NHS is high and staff morale is crumbling in the face of this financial pressure. The Government needs to make clear what they are going to do if the STPs are unable to meet their target efficiency savings or patients will face longer waits for care, with some services at risk of being lost altogether.”

 

The full report ‘The Five Year Forward View: do the numbers add up?’ can be found here.

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What do Sustainability and Transformation Plans mean for continuity of care within the English NHS?

Tuesday 9th May 2017

Michal Shimonovich

 

One of the cornerstones of the NHS Five Year Forward View (5YFV) is the ambition to develop sustainable and integrative care that incorporates all levels of healthcare provision. The aim is to streamline care to patients and improve coordination of services and communication between providers. It is not surprising then that continuity of care has featured widely in the 44 Sustainability and Transformation Plans (STPs) that have been drawn up across England to fulfil the aims of the 5YFV and, amongst other things, ‘stabilise primary care’ and support ‘out of hospital collaboration.’ However, there is little sign that the complexity of continuity of care or the challenges involved in implementing and improving it, are recognised in the current collection of STP documents.

The STP for Shropshire and Telford and Wrekin is typical of the way continuity of care is treated within the broader plans for NHS reform. It states an ambition to:

“move care out of hospitals to the community, wherever possible, and enable better access to and continuity of care by aligning primary, community and mental health care teams, breaking down the existing barriers and providing integrated solutions to deliver improved health outcomes for our population.”

Here continuity of care is treated as a catch all term for promoting service integration, generating efficiencies and improving outcomes. Cost savings associated with continuity of care in the US context have been seized on by STPs, especially where better care coordination has been identified as a means of reducing redundant or unnecessary services. For instance, in North West London, continuity of care is one of the aims set for a £3.4 million investment which is estimated to save £6.2 million by 2020/21 through improvement of “self-management and ‘patient activation.’”

However, assumptions that improving continuity of care will deliver these benefits need to be questioned. Research has shown the link between continuity of care and efficacy, particular in reducing key outcomes such as hospitalisation and symptom severity, has been inconsistent at best. Continuity of care is also is largely dependent on other factors such as healthcare providers working full time, smaller practices and demands of a patient’s’ disease management. So, while aims to improve continuity of care are laudable there are significant but barely acknowledged challenges involved in realising continuity of care in the context STP reforms. For this reason, proposals in STPs that depend on the alleged savings from continuity of care need to be subject to greater scrutiny.

To better understand the complexity in this area it helps to recognise that there are three distinct forms of continuity of care: relational, managerial and informational. Relational continuity of care refers to the ongoing therapeutic relationship between healthcare provider and patient measured either by the length of a patient’s relationship with a healthcare provider, or by the frequency of a patient’s visits to a healthcare provider. Relational continuity appears as a key concern in many STPs. Informational continuity refers to whether or not healthcare providers have access to the medical records of the patients they are treating. Management continuity of care refers to ensuring that services at different levels or on different settings of care management provide services in an efficient order and in a timely manner. Given the importance of each of these three strands of continuity of care it will be worth examining the extent to which STPs have plans in place to deliver on them. However, the current lack of detail makes this task difficult. While more information is expected to emerge as planning progresses, many STPs are light on detail, with plans for realising continuity of care coming across as vague aspiration. Currently it is not clear what priority relational continuity of care will have within the planned reforms, and where it will sit within the wider changes being implemented.

Where continuity of care is present within STP plans, the focus tends to be on relational continuity. For instance, North Central London’s STP recognises that there are breaks in continuity of care in General Practice: “there are issues within NCL in accessing primary care during routine and extended hours, and only 75% of people in NCL have a named GP to provide continuity of care.” While attention to problems surrounding relational continuity of care is important, STPs must also recognise the barriers to improving informational and managerial continuity of care to the community within their footprint area. There are already well-recognised challenges involved in improving information and managerial continuity with the NHS. For example, West, North and East Cumbria’s STP notes the challenge that high staff turnover – which comes from having small and isolated provider groups and a reliance on temporary workers – poses for continuity of care. It is a strength that each STP will have the opportunity to respond to the particular problems in their own footprint area, but this means each STP must adequately recognise the complexity involved in achieving the three elements of continuity of care. A key concern here is that informational and managerial continuity of care are routinely marginalised. This cannot be taken for granted: as a 2010 systematic review of 18 English cohort studies illustrated, while relational continuity of care is consistently measured, informational continuity was only measured once and managerial continuity was completely ignored.

Currently very few STP proposals recognise the complexity of continuity of care, or indeed the challenges involved in implementation and improvement. It cannot be assumed that continuity of care can be straightforwardly implemented, or that doing so will deliver cheaper, more efficient and effective care. We must demand that STPs recognise the necessary thought and resources required to implement new regimes of continuity of care effectively.

 

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Can we afford to close any more A&E departments? Evidence from North West London.

 

Closing A&E departments has led to a deterioration in the performance of those that remain in North West London. This analysis warns of the risk to patients if further A&Es are closed. 24th April 2017.

 

Across England NHS Sustainability and Transformation Plans (STPs) are proposing the closure or ‘downgrade’ of up to 24 emergency departments.

 

This analysis shows how A&E performance has suffered across North West London following the closure of two emergency departments in 2014.

 

Performance against the 95% 4-hour wait target dropped to as low as 60% shortly after the closures, meaning that up to 40% of patients requiring serious treatment had to wait over 4 hours to be assessed and admitted to an appropriate bed. Since then the performance of North West London hospitals has been some of the worst in the country, sometimes managing to treat fewer than half of the patients within four hours. For time-sensitive conditions such as sepsis or respiratory failure such delays are life-threatening.

 

In addition, since the A&E closures in 2014 the bed occupancy rate in all hospital trusts in North West London has been above 85%, compromising clinical safety through overcrowding.

 

This paper also points out that the closures aggravate health inequalities, hitting the most deprived boroughs in the region.

 

The full paper by Dr Gurjinder Singh Sandhu can be found here.

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The past, present and future health costs of inequality

Thursday 20th April 2017

Dr Jonathon Tomlinson

 

Photo credit: Flickr user Tjook (Creative Commons)

 

There is a risk factor that triples your risk of heart disease, but it is not hypertension. The same risk factor triples your risk of getting chronic respiratory disease, but it is not smoking. This risk factor increases your risk of type 2 diabetes by four times but it is not diet or obesity. It shortens your lifespan by almost twenty years, but leaves you so ill in the years you live that the costs of treating you exceed the savings bought about by your premature death.

 

I was taught nothing about it in medical school, yet have faced it every single day in my 21 years of clinical practice. We do not screen for it, rarely ever ask about it, do not treat it or advocate about it.

 

The risk factor is trauma in childhood. Like any risk factor, smoking for example, many people affected manage to live without serious consequences and we need more research to find out how and why. Like smoking there is a dose response; a little trauma may not cause much harm, but the earlier the trauma starts, the more there is, and the longer it continues, the greater the likelihood of harm.

 

Evidence is growing that shows how adverse childhood experiences are both correlated and causative risk factors for the development of disease in later life. The effects of stress and fearfulness bought on by being subject to or witnessing abuse, neglect, violence, hunger, abandonment, and criminal behavior in childhood, are both biological and emotional. The biological changes can be seen in neurological, immunological, hormonal and even genetic systems which begin during development in the womb and are most sensitive in the first 3 years of life. Adults who have survived this and flourish nevertheless no more disprove the dangers of adversity than elderly smokers who live without smoking related diseases.

 

The additional inpatient costs to the NHS of treating the adverse consequences of deprivation are estimated to be £4.8bn a year. But because over ninety percent of NHS interactions happen in primary care, A&E and outpatient settings so the true cost to the NHS is likely to be far, far higher. The psychological consequences include fearfulness and shame – making it hard for people affected to develop trusting relationships and engage with long-term care, but increase their attendance rates in times of crisis.

 

We need, as a society to take far more seriously the promotion and protection of good health by paying more attention to the risk factors for disease. Trying to prevent diabetes by treating obesity is a typical example of focusing on treatment rather than prevention. The risks of adverse childhood events are cumulative: you might survive emotional neglect, but if you are also exposed to sexual abuse and an alcoholic parent your chances of enjoying good health in adulthood will be slim. The original research that showed the importance of childhood events began in an obesity clinic in the 1980s where doctors discovered the role that comfort-eating played in ameliorating the symptoms of childhood trauma, especially child sexual abuse. The greater the number of adverse events, the greater the chances of obesity and the greater the difficulties losing weight. Bariatric surgery is a poor treatment for trauma.

 

The chronic diseases the NHS treats today are all too often the end-result of processes that began decades ago. Those who suffered abuse – from deprivation, violence, etc – in the 1970s and 80s are beginning to develop the chronic diseases that are pressuring NHS services today. Because we all contribute to the NHS we are paying for the failure of politicians in the past and will pay for the failure of politicians today.

 

 

Further reading:

  • The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic.
  • Asaria M, Doran R, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of epidemiology and community health 2016 vol. 70 (10) pp: 990-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036206/

 

Jonathon tweets as @mellojonny. His blog can be found at https://abetternhs.net/

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Can we afford to close any more A&E departments? Evidence from North West London.

 

Closing A&E departments has led to a deterioration in the performance of those that remain in North West London. A new analysis warns of the risk to patients if further A&Es are closed.

 

Press release, 19th April 2017.

EMBARGOED UNTIL 00.01 Monday 24th April 2017. The full report can now be found here.

 

 

Across England NHS Sustainability and Transformation Plans (STPs) are proposing the closure or ‘downgrade’ of up to 24 emergency departments.

 

A new report for the Centre for Health and the Public Interest shows how A&E performance has suffered across North West London following the closure of two emergency departments in 2014.

 

Performance against the 95% 4-hour wait target dropped to as low as 60%, meaning that up to 40% of patients requiring serious treatment had to wait over 4 hours to be assessed and admitted to an appropriate bed. Since then the performance of North West London hospitals has been some of the worst in the country, sometimes managing to treat fewer than half of the patients within four hours. For time-sensitive conditions such as sepsis or respiratory failure such delays are life-threatening.

 

In addition, since the A&E closures in 2014 the bed occupancy rate in all hospital trusts in North West London has been above 85%, compromising clinical safety through overcrowding.

 

The paper also points out that the closures aggravate health inequalities, hitting the most deprived boroughs in the region.

 

Report author Dr Gurjinder Singh Sandhu [2] said:

 

“Despite a dangerous deterioration in A&E performance since the closure of two local A&E Departments, the North West London STP still envisages closing a further two A&E units at some point in the future. Future planning needs to learn lessons from the reconfigurations that have already taken place and not continue with A&E closures based on assumptions which have not been borne out in reality.”

 

Ends

 

Contact: Dr Gurjinder Singh Sandhu on 07788 25 88 26 or info@chpi.org.uk

 

Notes for editors

 

  1. The Centre for Health and the Public Interest is an independent think tank promoting evidence-based policy in line with the founding principles of the NHS. We publish reports and analyses on key issues affecting the NHS, social care and public health. These reports are produced by respected academics and health and social care practitioners. The Centre seeks to frame the policy debate in a way that is evidence-based and open and accessible to citizens.
  1. Dr Gurjinder Singh Sandhu is a Consultant Physician specializing in Infectious Diseases and Acute Medicine. He has a specialist interest in Tuberculosis, Poverty and Health Inequalities. He was awarded a Wellcome Trust Tropical Fellowship and completed his PhD in 2010, studying Tuberculosis in resource poor countries. Dr Sandhu currently works in Acute Medicine and is developing an interest in health inequalities in elderly care medicine. Dr Sandhu is an active member of Ealing Save Our NHS.

 

 

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STPs and the 5YFV – Appendix

 

 

NB. This is the Appendix to the report: The Five Year Forward View: do the numbers add up? by Vivek Kotecha.

The report can be found here.

 

 

 

NHS Five Year Forward View spending gap forecast

Figure 1 shows the original spending gap forecast by NHS England in 2013. [1] [2] It is in cash terms, i.e. not adjusted for inflation (more cash is given to the NHS every year – the blue curve rises – but health cost inflation wipes out the benefit – the NHS’s real spending power remains flat). In cash terms the forecast gap between what the NHS was to get and what it was projected to need over the eight years from 2013 to 2021 adds up to a total of £123bn.

 

Figure 1 The NHS spending gap as forecast by NHS England in 2013 [1]

 

The NHS Spending Review – further analysis

Later analysis has shown that the announced £10bn figure of additional funding for the NHS included funding transferred to the NHS from other areas of Department of Health spending such as public health, national bodies and regulators (such as The National Institute for Health and Care Excellence and the Care Quality Commission), education and training.

The net additional money to be given by the Treasury to the Department of Health, measured in 2015/16 prices, increases annually from 2015/16 to 2020/21 to reach just £4.5bn (an increase of 3.9%). NHS spending will rise by £7.6bn (a 7.5% increase), while other Department of Health spending will be cut by £3.1bn (21.2%).

 

Table 1. NHS and Department of Health funding following the NHS Spending Review.

Source: http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/impact-of-the-comprehensive-spending-review-on-health-and-social-care/written/28159.html

 

Capital funding available – a rough calculation

It has been repeatedly highlighted that capital funding is short in the NHS. Below is a calculation showing how little funding may be available over the five years to 2020/21.

 

Table 2. Capital funding available for the NHS.

(1) – CDEL is the department budget available for spending on capital spending. Figure in cash terms. [4]

(2) – Additional capital funding for STPs and £100m for A&E departments. [5]

 

References

  1. NHS England (2013a). The NHS belongs to the people: A Call to Action. Online. https://www.england.nhs.uk/wp-content/uploads/2013/07/nhs_belongs.pdf (accessed on 6th February 2017).
  2. NHS England (2013b). The NHS belongs to the people: A Call to Action – The Technical Annex. Online. https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf (accessed on 6th February 2017).
  3. HM Treasury (2013). How to understand public sector spending. Guidance, 29th May 2013. https://www.gov.uk/government/publications/how-to-understand-public-sector-spending/how-to-understand-public-sector-spending#departmental-expenditure-limits-del (accessed on 30th January 2017).
  4. Department of Health and HM Treasury (2015). Department of Health’s settlement at the Spending Review 2015. Press Release, 25th November. https://www.gov.uk/government/news/department-of-healths-settlement-at-the-spending-review-2015 (accessed on 19th January 2017).
  5. HM Treasury and The Rt Hon Philip Hammond MP (2017). Spring Budget 2017: documents. Policy Paper, 8th March 2017. https://www.gov.uk/government/publications/spring-budget-2017-documents (accessed on 8th March 2017).
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STPs – An Opportunity for Much Needed Health System Transformation

Professor David J Hunter

Thursday 23rd March 2017

 

The 44 STP footprints in England.

 

With health systems globally facing new and complex challenges, transforming the way services are organised and provided to meet rapidly changing needs has become a major preoccupation of policy-makers. The UK is no exception although the resistance to current health system transformation efforts is especially evident in England. Arguably, the rest of the UK seems less hostile to transformation and less compelled to seek out conspiracy theories or devious schemes to privatise or dismantle the NHS.

While such theories and schemes may not be entirely without substance, all too often they become an excuse for not transforming the NHS but rather for seeking to preserve it in some utopian ideal state. But if one looks more closely at the transformation agenda being rolled out across the NHS, things are rather more complicated.

Underpinning the transformation agenda is the notion of the Triple Aim developed by Don Berwick, no destroyer of the NHS, and colleagues at the Institute for Health Improvement in Massachusetts.   Improving health systems requires the simultaneous pursuit of three aims: improving the health of populations, improving the experience of care, and reducing per capita costs of health care.

The NHS currently does not meet the Triple Aim’s challenges – and most lamentably not in population health which has barely figured in the NHS since its creation nearly 70 years ago. Remember the Wanless reports from 2002 and 2004 which accused the NHS of being a sickness service and of paying far too little attention to public health? As the opening paragraphs of the NHS Five Year Forward View (5YFV) rightly noted, despite the government endorsing Wanless’s fully engaged scenario, it was never implemented.

Only now with public health back in its rightful home in local government is there the prospect of a whole systems or place-based approach to health taking root. In many cities, including Coventry and Newcastle, the Marmot Six (the key policy priorities covering the life course as set out in Michael Marmot’s 2010 review of health inequalities in England, Fair Society, Healthy Lives) are informing health and wellbeing strategies and being implemented.

Of course the overall political and economic climate is hostile and hardly conducive to, or helpful in, meeting the enormity of the challenge but the 5YFV is a start and discussions are being held and initiatives are being put into practice which just didn’t happen when public health struggled for a place in the sun, eclipsed for the most part by the big beasts in the NHS jungle, namely, the acute hospitals, especially those with Teaching and/or University in their titles. Raids on public health budgets were commonplace.

What the transformation agenda has given permission to do is allow local areas to chart their own destinies within a national framework. It is too early to draw on the results of the many evaluations underway of the Vanguards and New Care Models (NCMs) that have sprung up across the country. But those close to the action locally and involved in local evaluations, including a research team led by Durham, Newcastle and Northumbria Universities examining the impact of the five North East Vanguards, are impressed by the enthusiasm and seriousness with which issues that have dogged the NHS for decades are being confronted and new ways found of breaking the logjam.

There will be failures but hopefully important lessons can be learned from them once the numerous evaluations underway start to report their findings. There are also risks and doubtless those on the lookout for attempts at dismantling of the NHS will be rewarded by finding examples of suspect developments that might appear to undermine NHS core values.

At the same time, much of the thinking behind the NCMs, and more recently the Sustainability and Transformation Plans (STPs), is actually seeking to achieve what critics of the ill-fated and badly designed Health and Social Care Act 2012 have been at pains to point out. The Act had three deep-seated flaws. First, it once again repeated the mistakes of earlier reforms which focused on structure, not culture. Second, it encouraged competition at the expense of collaboration. And, third, it encouraged fragmentation when what was needed was integration.

Rather than inflict yet another major, costly, and almost certainly misconceived, top-down structural change on a beleaguered service, the changes triggered by the 5YFV are aimed at bypassing the worst excesses of the 2012 Act and, in their place, restoring a degree of order and stability that was being rapidly lost.

A little noticed, but welcome, feature of the work on STPs is that they spell the end of the purchaser-provider split which has become something of a religion to health policy-makers in England. Scotland and Wales saw the light many years ago and abolished the separation but England has been slow to heed the evidence demonstrating what a waste of time and resource retaining it has been. The transaction costs alone have been significant with no appreciable gain in improved performance or outcomes.

No one would deny that the process of giving birth to STPs has been painful and much work remains to be done to get them into shape that both connects with the public and stands a reasonable chance of success. But STPs are a journey and not a set of plans of the type which the NHS used to be famous for. They are dynamic and will change and adapt as they are progressed and adapted to local circumstances. Moreover, despite the misleading name, they are less about planning and more about implementation.

Another significant feature of STPs is the process they have unleashed. For the first time in the NHS’s history, local government and other key stakeholders are part of a local conversation to identify and meet the health and health care of their communities. The timing is not ideal, the timetable is too rushed, and the resource climate is desperate. And yet, undeniably, the sense of urgency and the horrendous resource pressures have been important drivers of the change process. The opportunities available to engage and influence the outcome must be embraced by all.

As the STP juggernaut gathers pace, progressives across the political spectrum must of course retain and focus their critical gaze on what is happening to the NHS. But they should also seek to acknowledge and build on what is good about the changes which are long overdue and show some promise.

Of course more money is needed and the March budget went some to acknowledging this by releasing £325 million over three years for capital investment for the strongest STPs. However, ultimately what STPs are trying to do is not about money. What they have created space for is the opportunity for all NHS staff to exercise their creativity and find solutions to problems that have largely been ignored or side-stepped. And many of those staff are relishing the opportunity to redesign services and better meet the health and care needs of their populations. The latest King’s Fund review of STPs provides evidence of this ferment of activity. And a message from our evaluation of local new care models is that improving the quality of care and life for people in care homes is possible.

Innovative public services should not be regarded as an anachronism or as something only the private sector can do. We know this is a myth – the NHS is an ant-heap seething with innovation. But the myth takes on meaning when every attempt to reconfigure the NHS is condemned as having sinister or suspect motives. A more nuanced and balanced critique is called for if the opportunities presented by STPs are to be seized and capitalised upon.

 

David J Hunter

Professor of Health Policy and Management

Director, Centre for Public Policy and Health

Durham University    

 

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Will limiting the costs in clinical negligence claims make patients less safe?

Peter Walsh

Tuesday 14th March 2017

“The annual cost of clinical negligence in the NHS in England has risen from £1.2bn in 2014/15 to £1.5bn in 2015/16 and legal costs were 34% of the 2015/16 expenditure. The current system of claims resolution is often lengthy and adversarial. This creates the dual problems of delaying possible learning of lessons from incidents, and escalating the costs of litigation when claims are brought. This is particularly the case for lower value claims, where recoverable costs often reach two to three times the value of damages actually awarded. In 2015/16, claimant recoverable costs were 220% of damages awarded in claims between £1,000 and £25,000. Most parties agree that this is disproportionately high. Our proposition is that the disproportionality and the time taken to settle are not in the best interests of either the patient or the taxpayer.”

(From the Department of Health’s consultation document, Introducing Fixed Recoverable Costs in Lower Value Clinical Negligence Claims)

 

At first glance one might assume the Department of Health (DH) consultation on imposing fixed recoverable costs in clinical negligence cases is nothing to get exercised about. However, look a bit deeper and you will realise that these proposals are not about curbing so called “excessive” legal costs or all about lawyers. They would have a profound effect on patients’ rights, access justice, and the culture and safety of the NHS.

The DH’s objective is to reduce the cost of clinical negligence cases so that savings can be invested in patient care. Who wouldn’t want that? However, the way that would be done is to impose caps on the amount of legal costs claimants can recover when they settle their claim (eg when it becomes clear it was a deserving claim). It wouldn’t matter how long and unreasonably the claim was defended. No more than the fixed amount could be recovered, no matter what the actual cost of challenging the denials actually was.

DH’s ‘preferred option’ is to apply this scheme to cases with a monetary value of below £25,000. However, they may extend the scheme to cases of much higher value. Even if it were to be restricted to cases under £25,000, the monetary value of a claim is not an indicator of its seriousness or complexity. This approach could have very serious unintended consequences.

One consequence is that many people who have claims ‘worth’ less than £25,000 simply won’t be able to get a solicitor who is prepared to represent them if liability is denied. The sorts of cases that will fall into this bracket include stillbirths, other child death cases and neglect of older people. (Because these groups do not tend to have income or dependants the monetary value of these claims are low).

In many cases the actual legal costs can perfectly legitimately escalate well beyond the amount of the damages if liability continues to be denied. Many solicitors are in this field for the right reasons, but they work for commercial firms who cannot justify incurring costs that they will never be able to recover. Inevitably, many people will be left with no way of challenging denials of liability or of getting the compensation and accountability they deserve.

It’s not just injured patients and their families who would be affected. Most of the cases affected by these proposals involve denials of liability which are eventually found to be inappropriate. If people are not able to challenge the denial, the NHS will continue to delude itself that it did nothing wrong and lessons will not be learnt to help prevent the same mistakes.

A perverse incentive would also be created to simply deny liability when a claim is received, in the knowledge that most people in these circumstances simply won’t be able to challenge it. It is precisely this kind of “deny and defend” culture that experts agree works against patient safety. Your local hospital or GP surgery could become less safe as a result of these proposals

Of course some of these cases would end up being taken forward. However, because of the very low caps on recoverable costs envisaged, even if a solicitor did agree to take a case on and won, they would be likely to have to recover some or all of the costs from the claimants’ actual damages. Such claimants could have most of their damages taken in helping meet the legal costs. The DH consultation does not even mention this likelihood.

There are better ways to avoid both the human and financial costs of these cases. These proposals would have the opposite effect. Improving patient safety to avoid them in the first place is the obvious thing, and ensuring that there is adequate and appropriate staffing is key to that. Also, even when there has been an incident, if it is investigated properly, the causes identified and an admission of liability made early, almost all of the legal costs disappear. As recent reports like the CQC’s Learning Candour and Accountability make clear, the standard of local NHS investigations is inconsistent and often dire. If this was dramatically improved and if the Duty of Candour were complied with, again, most of the legal costs of litigation would be avoided. Sadly, not only the quality of investigations, but bad case handling, inappropriate denials of liability and protracted defence of claims add exponentially to the cost of claims which are settled.

However, the Department of Health does not even consider how bad defendant behaviour on the part of its own agencies causes disproportionate costs. It pushed ahead with these proposals in the knowledge that the National Audit Office is reviewing the NHS Litigation Authority and reporting back later this year. Only a few years ago the Government took clinical negligence out of scope for Legal Aid against the wishes of even the NHS Litigation Authority itself, who recognised it was a cost- effective means of allowing the resolution of these cases.

One last point of principle to consider. Is it right that one Government department with a clear conflict of interest should be able to drive policy which is not in its domain? Isn’t the reason we have a Ministry of Justice that such issues can be looked at objectively, with access to justice in mind, rather than the DH being able to fix the system in its own financial interests? This could set a very worrying precedent.

 

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The consultation closes on May 1st.

Peter Walsh is chief executive of Action against Medical Accidents (AvMA). www.avma.org.uk

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How trustworthy is NHS Digital?

Colin Leys

Monday 6th March 2017

 

 

Between May 2013 and February 2016 a heated argument took place between Kingsley Manning , the chair of the Health and Social Care Information Centre (now called NHS Digital) on the one hand, and the Home Office and the Department of Health on the other. At stake was the HSCIC’s independence as an Executive Non-Departmental Body responsible to parliament, not to any minister, and its trustworthiness as the guardian of the personal details of every NHS patient in England.

 

After his appointment as chair in May 2013 Manning discovered that since at least 2005 the HSCIC and its predecessor, the NHS Information Centre, had been giving details of patients’ present and past addresses and GP registrations to the Home Office, to enable it to trace and deport people who were living in Britain without the right to do so. This appeared clearly to be in breach of the HSCIC’s ‘statutory duty to ensure that the information we hold in trust for the public is always kept safe, secure and private’. But the Home Office, supported by the Department of Health, insisted that tracing ‘illegal immigrants’ was a public interest that overrode any other. The outcome was a Memorandum of Understanding (MoU) between NHS Digital, the Department of Health and the Home Office, which specifies that NHS Digital will hand over the information requested by the Home Office for patients who have ‘breached s.24 of the Immigration Act 1971’, if all other ‘reasonable avenues’ (such as the Department of Work and Pensions and the DVLA) have been exhausted. The memorandum came into effect on 1 January this year.

 

In an interview with the Health Service Journal published in February this year Kingsley Manning described how the Home Office and the Department of Health resisted his demand to know the legal basis for what was going on, and to make it public. And on the eventual MoU his comments were as follows: “There is no provision for transparency, no provision for oversight or scrutiny and there is no role for the National Data Guardian. Nor is there any provision to alert patients to the possibility that information from their NHS patient record could be passed on to the Home Office.”

 

Two questions need to be asked about the memorandum. First, what is the legal basis for the breach of confidentiality it normalises? The minutes of an NHS Digital Board meeting in August 2016 record that ‘NHS Digital had received internal advice that there is a high of risk of legal challenge but that there was a robust legal defence’. By the time of the Board’s November meeting this had become ‘we have established the legal basis for data flows to the HO [Home Office]’. Second, whom does the MoU’s codification of procedures protect? Evidently, at least NHS Digital. The Board insisted that the request form specified in the memorandum to be used by the Home Office should ‘note in the form that the form provides an explicit audit trail in the event of challenge or query’.

 

NHS Digital may still refuse to hand over information if it is not satisfied that there is a public interest in doing so. In practice, however, a public interest appears to be established if the Home Office says the details are those of someone who is in breach of the Immigration Act and can’t be traced in any other reasonable way.

 

The scale of these ‘data flows’ is not insignificant.

 

 

Requests for patients’ data received by NHS Digital (HSCIC) 2013-2016*

 

Requests for patients’ data accepted by NHS Digital (HSCIC) 2013-2016*

 

 

The data release registers show that patient data are also routinely given to the police and the National Crime Agency (NCA), and to the courts in response to court orders (presumably relating to serious crime), without any MoU; and in 2016 the number of requests from the NCA (mainly) and the police increased by 40%, compared with 2015, accounting for a quarter of all the personal data that NHS Digital handed over last year – on what grounds, in these cases, and on the basis of what authority, we do not know. The effect of a memorandum of understanding seems simply to formalise an unaccountable practice with a debatable basis in law, but which the government wishes to continue. It will be interesting to see if this is compatible with the far-reaching new data protection regulations which will come into force in June.

 

The risk to public health from handing over personal information that people have been assured is confidential is obvious. Kingsley Manning told the HSJ that ‘My key concern has always been that highly vulnerable people will be deterred from accessing the health system because they are worried that their information will be shared with the Home Office. This puts their health at risk and the health of the public at risk, since infectious diseases such as tuberculosis will become harder to treat.’ He could have gone further. It is estimated that some 600,000 ‘irregular residents’ live in the UK (including children who have been born here and are not immigrants, legal or otherwise). NHS Digital‘s collaboration with the Home Office to help it find and deport them is bound to become common knowledge in these circles, not to mention among those wanted by the police and the NCA. A logical consequence is avoidance of the NHS and the development of an underground private medical system, vulnerable to exploitation and extortion. (The health charity Doctors of the World runs free clinics in London and Brighton, but mainly to help people to get access to needed care from the NHS, whereupon they become liable to have their data shared.)

 

NHS Digital is a critically important resource for high quality health care and its 2,700 staff have a well-earned reputation for competence and courtesy. But its independence, and public trust in its determination to protect patients’ privacy, have been seriously compromised, if not destroyed. The message sent by the MoU is, as a briefing by Doctors of the World points out, that ‘when it is politically expedient to do so, our personal information will be shared’. Trust can be restored only by ending the use of NHS Digital (along with landlords, schools and universities) as an agency of law enforcement. It would seem from his strongly-worded criticism that this was what Kingsley Manning wanted, and it is to his credit that we know as much about it as we do.

 

But why was it so relatively easy for the Home Office to have its way? Manning told the HSJ that he ‘came under immense pressure to leave matters as they were… The threat was that if we pursued this line of questioning we would be deemed to be an ‘insufficient partner within the system’. An ‘insufficient partner within the system’? What exactly was the threat in that? ‘If I didn’t agree to cooperate they would simply take the issue to Downing Street.’ How terrifying! The Board of NHS Digital have a statutory independence from government and, one would think, a moral duty to defend it. Manning announced his resignation in February last year, without giving any reasons. The memorandum was signed by his former colleagues in November.

 

 

 

* Source: NHS Digital data registers. In February 2017 the registers covered only the last nine months of 2013 and the first eleven months of 2016. To avoid understating the data for these years, data for the missing months have been added based on the averages for the reported months in the respective years.

 

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