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.



The consultation closes on May 1st.

Peter Walsh is chief executive of Action against Medical Accidents (AvMA).

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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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Why did so many more older people die in England and Wales in 2015?

Martin McKee, Lucinda Hiam, Danny Dorling, and Dominic Harrison

Monday 27th February 2017







Harold Macmillan was right when he told the British people, in 1957, that “you’ve never had it so good”. The post-war period was characterised by improving living standards and, above all, victories in the fight against disease and premature death. Indeed, for almost all of the post-war period, death rates have been falling steadily in England and Wales. Of course, there have been some fluctuations from year to year. This is to be expected, given the complex range of factors that determine the health of the population, some acting in early life, rendering individuals especially vulnerable, and others, such as outbreaks of infectious disease, acting now. On top of this, there is the inevitable random variation. Consequently, it is important not to read too much into a small change between one year and the next.

Sometimes, however, the changes are not small. On a few occasions, there have been large jumps in death rates. The two largest jumps in the post-war period happened in 1951 and in 1968. In both cases, the reasons were clear. In the first, it was influenza epidemic (followed a year later by London smog). In the second, it was an influenza pandemic. It was the third largest jump that we were concerned about. This happened in England and Wales in 2015, and there was no obvious explanation. We felt that it was important to try to find one, and we have just published two papers that describe our search.

We were interested for several reasons. First, we estimated that there had been about 30,000 more deaths than would have been expected. This was a lot of people. Second, although the increase that year had been especially high, when we looked at a longer time series, we could see that the sustained decline in death rates had begun to reverse as early as 2011, when austerity policies were beginning to bite. Third, when we looked in more detail, the pattern raised many unanswered questions, but what we saw pointed towards a problem for some of the most vulnerable in society, people aged over 75 who were especially dependent on health and social care. And finally, from other work that we’ve undertaken over several decades, we knew that a significant worsening in death rates was often a warning that something was wrong in society. Indeed, it was the stagnation of life expectancy in the Soviet Union in the early 1980s that showed that all was not well in that country.

The first, and most obvious, step was to ensure that we were not simply dealing with an artefact of the data. There are many examples of people being misled by problems with either the recording of deaths or the estimation of the population (had more people recently entered the country for example, especially elderly people?). It was also important to make sure that what we were seeing was not simply an effect of changes in the age composition of the population. There are well-established techniques for addressing these issues, and when we used them, it was clear that what we were seeing was real.

Having established that there was a problem, we then dug deep into the data, looking at who was dying, from what, and when during the year. We also collected a mass of other information, such as data on influenza (a common reason for annual fluctuations), and what was happening in the NHS and society more widely.

There are only a few reasons why death rates might increase substantially. One is that there was a natural disaster, such as an earthquake or hurricane. For example, in 1988 there was a large spike in deaths in Armenia when the country was struck by a massive earthquake. We could rule out this explanation easily.

Another possible reason was a flu epidemic, especially given that this was the main cause of the previous two largest post-war increases in death rates. There had been some concerns about the effectiveness of the flu vaccine in 2014/2015. When we looked at the data, we could see a very large increase in deaths in January 2015. This could fit with a flu epidemic, except that the timing did not match with notifications of influenza-like illness in general practices, nor did the shape of the increase resemble what had been seen in previous flu epidemics. And crucially, there was no similar increase in deaths in neighbouring European countries, despite evidence that some of them were experiencing small outbreaks of flu that they were keeping under control.

So what were we left with? Something had clearly gone wrong in January 2015. And when we looked at what had been happening in the NHS in England at the time, the findings were alarming. Using any of the common indicators of performance, it was clear that the system had been in crisis. Attendances at A&E departments had not increased, but the number of people waiting over four hours and as many as twelve hours when they went to A&E had gone up dramatically. Waiting times were exceptionally high. It was difficult to avoid the conclusion that the NHS had simply failed to cope for a few weeks. We can only speculate why. However, one plausible suggestion is that we were watching a complex interlinked system that had only just been coping — it would take very little to topple it over. We suspect that this was what happened in January 2015.

But that was not all. When we looked in more detail, we could see that there had been an increase in death rates throughout the year, in all but three months, compared with the average for the previous nine years. It was also affecting all parts of the country. This was more difficult to understand. We could see that the increase in deaths was concentrated among the very old, and many of the excess deaths have been attributed to dementia. However, we had to be cautious in interpreting this, as the government had launched a major programme to improve early diagnosis of dementia, which might at least in part explain the apparent increase in deaths from dementia. But what was clear was that the excess deaths were occurring in a group that was particularly dependent on the NHS and social care, and in a previous paper, some of us had shown that a worsening of mortality among pensioners over 85 was greatest in those parts of the country that had suffered the largest cuts in social spending and pension credits.

There are still many unanswered questions about what is happening to death rates in England and Wales. The most recent data, covering the first six weeks of 2017, a time when the newspapers were full of stories of the NHS in crisis, are cause for concern. We can clearly see another spike in deaths which, although not quite as large as in 2015, is much greater than in previous years (1951, 1968 and 2015 excepted). Unfortunately, there are long delays in providing the detailed data that we need for the analyses that we conducted for 2015. The early signs suggest that underfunding of both health and social care continues to be implicated in a sustained, much heighted, elderly mortality rate that is exacerbated in the winter months when the stresses on both health and care services are now highest. This has all occurred despite recent winters being unusually warm. What has been unusual are the depth and length of the funding cuts.




Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine where he founded the European Centre on Health of Societies in Transition (ECOHOST), a WHO Collaborating Centre. He is also Research Director of the European Observatory on Health Systems and Policies and Past President of the European Public Health Association. He trained in medicine and public health and has written extensively on health and health policy, with a particular focus on countries undergoing political and social transition.


Lucinda Hiam is a post-graduate student at London School of Hygiene and Tropical Medicine, and NHS GP.


Danny Dorling is the Halford Mackinder Professor in Geography at the University of Oxford. He was previously a professor of Geography at the Universities of Sheffield and Leeds. He has also worked in Newcastle, Bristol and New Zealand. He went to university in Newcastle upon Tyne, and to school in Oxford. He was a commissioner of the London Fairness Commission, which reported in 2016, he is a Senior Associate member of the Royal Society of Medicine and Honorary Fellow of the Faculty of Public Health of the Royal Colleges of Physicians of the United Kingdom. Danny’s work concerns issues of housing, health, employment, education, wealth and poverty.


Dominic Harrison is the Director of Public Health for Blackburn with Darwen Borough Council, a member of the Blackburn with Darwen CCG Board and an Honorary Professor at the University of Central Lancashire. His previous post was as the Deputy Regional Director of Public Health for the Department of Health in the Government Office Northwest. He has also worked for NICE and the Health Development Agency as Associate Director for the North West Region.




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STP Teams – Problems of Legal Status and Accountability


Professor Chris Newdick, University of Reading

21st February 2017



The idea that more competition would improve the NHS is history. Now, STPs are encouraging partnership and collaboration. Let’s agree that STPs are a good idea in principle. Let’s give them a chance. But what are the challenges?

Public health could be better served by CCGs, GPs and local authorities working together. CCGs could integrate commissioning by re-inventing their old PCT boundaries. Better co-operation between GPs and secondary care might make hospital stays shorter and less frequent.

But to say “do more, with less, and do it better,” camouflages some difficult decisions. Attempts to close hospitals are always difficult and measures to control non-communicable diseases can expect newspaper rants about the “nanny state” and “food fascism.” STPs may benefit some, but will certainly upset others.

There’s a weight of expectation on STPs. Just as NHS investment per patient is falling, patient numbers are rising and the population is ageing, so the per capita cost of treatment is increasing. Government will need a steady nerve to see this through.

This is challenging enough in politics, but who is accountable legally? What authority do STPs have over the NHS to respond and who is responsible in law for what they do? The legal principles governing statutory authorities are reasonably clear.

  • Statute may impose duties upon the Secretary of State to perform certain functions, eg on the Health Secretary to promote a comprehensive health service.
  • Statute may also delegate these statutory duties to other public authorities to perform, like NHSE and CCGs, (as in the NHS Act 2006). In this case, it is they, rather than the Secretary of State, that are normally responsible for performing them.
  • Subsequent statutes may modify, amend or abolish parts of one statute by replacing them with another (as the Health and Social Care Act 2012 does with the NHS Act 2006).
  • Duties delegated to statutory authorities must be performed lawfully and reasonably (eg CCG resource allocation). Crucially, however, they must be performed by the authority itself. For example, CCGs cannot “fetter their discretion” by delegating performance of their duties to others.

The problem is that STPs have no statutory identity. Although Simon Stevens is proposing they should be given “decision rights,” until then, the NHS is confined within its current legal framework. For example, CCGs can take advice from STPs and should treat it seriously, but they still remain the statutory point of accountability for the policies introduced.

Of course, NHS managers are notoriously compliant. They mostly do as they are told, or retire gracefully on agreeable terms. CCGs, local authorities and GP practices will probably fall into line and act in the interests of the larger STP community. So the challenge is unlikely to come from them. To say STPs have no statutory authority, therefore, is not to say they have no actual authority. Never the less, they are vulnerable to attack.

More likely are challenges from patient groups unhappy about the new patterns of resourcing. Judicial review courts scrutinise whether the public authority’s statutory discretion has been “fettered.” In such a case, the policy could be overturned and referred back, eg to the CCG, to be taken again consistent with the court’s instructions. This would need to happen only once for STPs to lose their credibility.

In principle, the solution is easy – amend the NHS Act 2006 (and all the 2012 Act amendments) to give STPs proper statutory identity and to describe precisely when and over whom they have authority. But the 2006 Act has already been so heavily amended by the 2012 Act that we need on-line technology to find out how much has been changed and when. To introduce another statutory layer of STP “decision rights” with such significant organisational consequences would further confuse an already confusing system.

We all understand the problems created by successive NHS “re-disorganisation.” Sir Robert Francis warned about it in the Mid-Staffs Inquiry, just after the 2012 Act became law. Constant readjustments confuse everyone and make it more difficult to discover who is responsible for doing what.

Yet, within a regime of public service austerity, where conflict becomes more likely, clear lines of responsibility are more important, not less. If the basic logic of Andrew Lansley’s reforms is now rejected, it is difficult to introduce new NHS institutions and patterns of accountability without appropriate changes to NHS legal structures.

Now is precisely the time to be clearer than ever about rights and duties in the NHS. We need a new National Health Service Act to stabilise the NHS and make it fit to confront a future very different from its past. With so many competing demands for NHS resources, how can we re-invigorate its links with the community? With the rising personal and financial burden of avoidable illness, how can we reduce the costs of non-communicable diseases? How can we generate better harmony between health care and social care? How far should England follow Scotland and Wales and abolish the purchaser-provider split?

International trade complicates accountability further. If Liam Fox is considering a trade deal with the US, will private corporations be excluded from making profit from the NHS? If not, will they be regulated by judicial review, the Human Rights Act and the Freedom of Information Act like other NHS institutions? Or simply by confidential, private contracts that we have no right to see? Will disputes be settled transparently in public courts, or out of sight in private arbitrations? And will publicly appointed judges decide these cases, or corporate lawyers with little understanding of the NHS?

Austerity and globalisation confront the NHS with special challenges. The problems of accountability are really just beginning.




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Life in the front line: a junior doctor’s view

Nadia Masood

13th February, 2017

Nadia is a senior trainee anaesthetist in London. She was part of the Justice for Health campaign against the imposition of the junior doctors’ contract in England in 2016.



“I’m fine”, I responded automatically to a colleague who paused to ask me how I was as we crossed paths one day in the hospital. Five minutes later I was being consoled by her in a staff room as tears streamed down my face.  I was anything but fine. I had given everything all morning to be meticulous and safe during a jam-packed list of procedures on young children. Everything had had gone by without a hitch, but then, feeling spent, I had been asked to do yet another case – the insertion of an intravenous line in a child –  since there was such a backlog of patients waiting. Acutely conscious of having these young lives in my exhausted hands, my emotions rose up and attacked me, refusing to be ignored any longer.


When you are a doctor on shift you cease to exist as a person. With patients’ lives in your hands, there is no other way to get through the job. The problem is, we are spending increasingly more time at work. Most NHS staff regularly work extra hours and shifts as staffing gaps widen and service pressures rise.


My realisation of how damaging this was to me as a person came slowly and reluctantly. I did not want to admit I needed time away to be myself. I was worried I would be seen as a failure – after all, that was how I saw myself. When I began my journey as a doctor over a decade ago I could never have imagined I would find myself feeling this way. I remember how proud I was of my job. I felt supported and valued as a human being, I had time to be me.  This largely continued as I entered my specialty training in anaesthesia, where there is still a real sense of community. My training school has never made me feel like a number on a spreadsheet, although in that respect I suspect that I am one of the fortunate few.  Despite all this I still found myself in that staff room feeling broken.


I am not the only one. In December 2016 the Royal College of Anaesthetists conducted a survey of the morale and welfare of trainee anaesthetists. Over half of all trainees, 2300 of us, completed the survey. The results, although unsurprising to those of us familiar with the stresses of working in the NHS, were more than worrying.  Over 60% said their mental health, and a greater number felt their physical health, were being adversely affected by their jobs. When asked what impacted patient safety the most, the top three answers were bed shortages, rota gaps (i.e. staff shortages), and low morale.


The NHS has been in crisis for a long time, and it is breaking junior doctors. As they find themselves battling to keep up with unmanageable service demands alongside their training commitments, the latter often falls to the wayside; patients will always take priority.  Doctors are left feeling as if they have failed – failed to deliver their best care at work and failed to meet their training commitments. The harder they try, the closer they come to breaking point. They cannot possibly work any harder. What they need is a better understanding from those in charge of the NHS of the resources that doctors and other healthcare staff need to fulfil their duties effectively and safely.


This feeling of failure is compounded by the constant media narrative of a “failing NHS”. being constantly told that you are working in a “failing” system makes you feel part of that failure, or even worse, a cause of it. It is no surprise then that morale is at its lowest point ever, and this seems to be driving talented doctors out of the NHS, doctors who desperately want to stay and whom we desperately need. But what choice do they have when they can’t face any further blows to their mental and physical wellbeing?   If we don’t address the root cause of low morale we will be left with fewer doctors, more broken than ever.


Last year, thousands of junior doctors united over a contract dispute. The weight of losing the contract dispute makes it hard for many of us to see what we gained in the process. As the contract imposition rolled in, many of us slowly resumed our previous trance-like state of quiet resignation towards the disintegration of our working conditions. But there were gains that we can hold on to from last year, if we really want to.  Many of us found a voice we did not know we had. We found empowerment in speaking honestly and openly about our working conditions, something many of us had never done before, certainly not on the scale that we did last year. We found courage in challenging those we believed were abusing their positions of power and threatening the NHS in the process.


Last year there was an extraordinary awakening amongst junior doctors to the threat confronting the health service, and the last thing we should do now is go back to sleep. As well as the patients in front of us every day we have a duty to consider all the patients who will need our care in the future. That means fighting to keep the NHS on the principles it was founded, that good healthcare should be available to all regardless of wealth.


We need to find our voices again. This time with the aim of reclaiming our love for our jobs, and our pride in our profession. We need to start speaking out about what we need to do our jobs, but don’t have. We don’t have enough staff, so we need to talk about it. We don’t have enough beds, so talk about that. We can’t afford to let more hospitals and services be downgraded and closed. Talk about it. Tell the public what we really need to keep them healthy and safe.


We are not ‘failing’, and neither is the NHS. It is not waiting to be put out of its misery. It is a world-class system but it is being subjected to cuts in funding that will eventually destroy it. That it is not yet destroyed is down to healthcare staff who give everything and more to their work for their patients, but who are being brought close to breakdown in the process.



Editor’s note: Across the UK there are over 60,000 junior doctors in the NHS. They are ‘junior’ in that they are not yet fully trained in a specialty, but are in training to become hospital consultants. A consultant’s training takes 8 years or more and during that time junior doctors form the backbone of the hospital medical workforce. We hope to publish a number of blogs by junior doctors based on their working life in the NHS in 2017.




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The Sustainability and Transformation Plans: a critical assessment

John Lister assesses the published drafts of the plans for implementing the Five Year Forward View published by NHS England in 2014. They envisage a major switch of treatment from hospitals to non-hospital settings, and a reduction in the need for healthcare through measures to prevent illness and through helping people to take more care of their own health. NHS services are expected to become more accessible and effective while at the same time costing less, and thus closing the growing funding gap between what the government is committed to spend and what the NHS, as currently organised, needs.

The assessment finds that the plans rest on implausible assumptions and lack credible implementation measures. It concludes that the scale of the planned reduction in hospital services implies rationing and risks the collapse of some services.


Download the full paper [PDF]


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Examining the Work, Health and Disability Green Paper

Nick Pahl

16th January 2017


The government’s Green Paper on work, health and disability proposes a plan for helping disabled people into employment. This was an ambition that initially appeared in the Conservative Party manifesto in 2015.

The overarching aim is to close the disability employment gap. Of the 5.7 million disabled people of working age, 4 million are working but a further 1.3 million who have the potential to work are unemployed. A significant part of the reason is that employers resist taking on disabled people. Only 8% of employers report recruiting a worker with a long term disability in the course of a year and a Cardiff University study found that the recent recession affected disabled people more – with their pay being frozen and overtime restricted more than for other workers. In the case of people disabled by cancer, for example, Macmillan say that the top issues raised by people affected by cancer were the need for reasonable work adjustments to let them cope at work, discrimination, and unhelpful and unsympathetic employers.

The Green Paper encourages action and innovation by employers and commits the government to understanding what works with a view to longer-term reform. The Paper proposes to provide the support needed to recruit and retain disabled people, and to consult on evolving current government schemes and on the barriers to take-up of Group Insurance products. It also aims to help employers manage sickness absence, including by consulting on reform of Statutory Sick Pay. An important area of the Green Paper regards changing culture to improve workplace wellbeing and the retention of disabled employees.  Consultation will occur on how government can: best provide and publicise accessible information and guidance; facilitate employer networks; empower employees to manage their condition; and help employers make relevant adjustments such as providing flexible working hours. Encouragement will be provided to employers to collect data on disability and ill-health, build the business case for investing in supporting health and disability in the workplace and the government will also aim for the public sector to be an exemplar.

For health services, the Green Paper aims to help people access the right support at the right time by:


  • Reviewing the Fit Note (a document signed off by the GP after 7 days off sick), and looking at options for referrals to a health professional to carry out Occupational Health assessment and advice e.g. to a GP with a special interest in occupational health, or to a consultant in occupational medicine for complex cases
  • Trialing mental health support in new settings such as in Job Centres and via the Increasing Access to Psychological Therapy service
  • Consulting how Occupational Health, vocational rehabilitation and related provision can be better matched to individuals’ needs
  • Increasing access to psychological therapies and doubling the number of Employment Advisers in talking therapies
  • Consulting on developing and testing new and more effective pathways of care for MSK conditions


A core aim of the Green Paper is to embed work as a health outcome, including through building workforce capability and capacity. The Green Paper also indicates a wish to support joined-up health and employment services, which are locally designed and delivered, consulting on:


  • An intention to set a standard for employment information in NHS health data sets, to monitor working-age health and employment
  • Plans to provide a basket of health and work indicators at local level
  • Improved sharing of health and employment data, innovation, co-location and local networks, all to support local service integration


However, while the challenge set out in the Green Paper is welcome, one may be sceptical about it in several respects.

Firstly, on current trends it will take until 2065 to close the disability employment gap! It assumes the UK economy can deliver these jobs, and disabled people can access these jobs, but more needs to be done to address these issues effectively.

Secondly, employers, particularly small employers, need to get the right support at the right time to enact change positively. Current arrangements don’t work well for small employers in particular, and new approaches need the same level of carrot and stick focus as workplace pensions to really be effective. Does the government have the will (and will it commit the budget) to make such changes?

Thirdly, the heavy focus on helping people into work means that there is a lack of focus on job retention, a point well made by a report last year by the Resolution Foundation. And as Scope point out, people who acquire a impairment as adults are 4 times more likely to fall out of work than non-disabled people.

A fourth important unaddressed issue concerns the workforce capacity of occupational health professionals. This will need to be expanded to deliver the new occupational health models that are required by the Green Paper. The occupational health profession must take a leadership role in creating employers that are “disability-sensitive”.

The Green Paper also leaves a number of outstanding questions:


  • Should other health professionals be able to issue fit notes? If so, which ones and what qualifications / training would we expect them to undertake?
  • Can the fit for work service be improved – or does something very different need to replace it?
  • What is the role of insurance to help recruitment and retention of disabled people?


But, it is worth remembering that while cost of course matters, disability-sensitivity does not necessarily drive up costs. And, the Green Paper does not talk about mandating people to treatment and into work (despite press reports when the Green Paper was launched cynically suggesting this was the case).

Overall, the Green Paper also has a wider significance. It issues a challenge to society: we can no longer ignore or underplay the multiple barriers that influence entry into work, return to work and health in the work place. It is not about assuming exit, with a redundancy package (or without one). The Paper will help challenge assumptions about work, health and disability, and spread awareness of good practice. Disabled people have as much right as everyone else to good work and change should start now.

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Santa’s Transformation Plan (STP)

By Vivek Kotecha. 14th December 2016.


The past 20 years have been trying ones for Santa Claus and the National Elf Service. The decision to split the purchasing of presents from their delivery was meant to improve efficiency, but he’s been having second thoughts. There are just too many CCGs (Christmas Commissioning Groups) and Present Providers (parents and grandparents).

As a consequence, the National Elf Service has been going through some of its toughest years on record. Presents have gone missing, the elf workforce is ageing, quality has fallen while the outsourcing of present wrapping to premium agencies seems to have added to costs rather than saving them. Furthermore, the cost of providing Christmas grows relentlessly each year. Santa wistfully remembers when a Meccano set was a cutting-edge present.

So it’s not surprising that Santa has decided to take action; he can’t afford another Winter Crisis: the waiting list for Xbox Ones has only just started to shrink. In the face of Mrs Claus’s refusal to loosen the purse strings (she is focused on her jams) new Santa Transformation Plans (STP) have been proposed. CCGs and Present Providers will now work together in each locality in order to balance the growing demand for presents within Mrs Claus’s austere budget.

Some of it sounds sensible and it may work, but Santa is worried that his elves’ predictions of a fall in demand for presents thanks to children eagerly adopting anti-consumerism views are a bit optimistic. ‘Self-satisfaction’ is a great idea but hard for many to attain. Santa wonders whether the p/p split was a big mistake and is beginning to think that a joined-up system based on having more trust in his elves might work wonders. After all, if in the true spirit of Christmas people co-operated and shared more with their fellow neighbours all year round there is no limit to what could be achieved.


Season’s greetings from all at CHPI

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Defending public health against ‘nanny state’ accusations: we need to talk about freedom

Vikki A. Entwistle, Stacy M. Carter & Miles Little

28th November 2016


Accusations of ‘nanny statism’ are often levelled against initiatives that aim to improve people’s health by, for example, taxing tobacco, alcohol and fatty or sugary foods, or limiting the places and ways in which these products can be advertised, sold and used. Recent examples of ‘nanny state’ language in UK news headlines are shown below:


Revealed: Britain is third worst country in EU for nanny state regulation. …The 2016 Nanny State Index, published today by the Institute of Economic Affairs, gave every EU country a score out of 100 according to how it regulates private lifestyle choices on alcohol, food, soft drinks, tobacco and e-cigarettes. (Headline and extract from article by Michael Wilkinson, The Telegraph, 31 March 2016)

The relentless march of the nanny state. Sugar is set to take its place among the UK’s sin taxes. (Headline and first sentence from article (no byline), Financial Times, 26 March 2016)

Dawn of the nanny state? The government certainly seems to be on a mission to get people in England healthier, if the flurry of recent announcements is anything to go by. … For a Conservative government that has traditionally rallied against the so-called nanny state, it represents a remarkable change in tack. In the early years of the coalition, there was a much more hands-off approach… (Headline, first sentence and extract from article by Nick Triggle, BBC News Online, 28 March 2016)

Nanny state has gone too far’ anger as new smoking laws come into force TODAY.

(Headline from article by Vickie Oliphant, Sunday Express, 20 May 2016)

Health chief attacked over ‘nanny state’ alcohol guide that says a single glass of wine a day raises cancer risk. (Headline from article by Sophie Borland/Kate Pickles, Daily Mail/Mail Online, 25 August 2016)


‘Nanny state’ accusations can function as powerful rhetorical weapons against interventions that are intended to benefit people. This blog, based on our recent academic paper, offers suggestions both to help public health advocates develop effective defences against nanny-state accusations and to ensure that public health interventions are well justified.


What are nanny state accusations about?

Many nanny state accusations are politically, commercially or ideologically motivated. They are often rather vague, and the particular concerns that lie behind them are rarely clearly explained by the accusers. In general, however, as the examples in the box illustrate, they allege undue interference by governments or other agents in people’s lives. They also imply that the solution to the alleged problem is to drop the interventions they object to in order to safeguard individual freedom or autonomy. (Autonomy, roughly speaking, is a matter of shaping and controlling one’s own life rather than have it shaped and controlled by others. We’ll say a little more about it below).

Sometimes nanny state accusations are simply flippant pejoratives – attempts to discredit interventions without any thoughtful critique. When the accusations have substance, however, it is important to note that they have two parts. First, the accuser alleges that an intervention entails some important undermining of people’s freedom or autonomy. Second, the accuser recognises that the intervention is made ‘for the good of’ the people whose freedom or autonomy is allegedly undermined – for example, to increase their health. Interventions that limit freedom or autonomy do not always do so for the good of the people constrained. When people with infectious diseases are quarantined, for example, this is usually for others’ benefit. Interventions like quarantining rarely attract nanny state accusations because they don’t fulfil the second part of those accusations. Nanny state accusations are typically reserved for interventions that are considered paternalistic on the grounds that they both limit people’s freedom and are done for their own good.

When critics make ‘nanny state’ protests about public health interventions, they are not usually saying that health is unimportant, or that the interventions will be ineffective for improving it. This is important to note. Public health advocates have often tried to respond to nanny state objections by explaining how much health gain the contested interventions could generate. Such responses miss the central point of the accusations. To successfully respond to charges of nanny statism, public health advocates need to address the accusers’ concerns about freedom or autonomy.

It will be important, then, to establish why the accusers think the interventions they object to are problematic for people’s freedom or autonomy. If they have cried ‘nanny state’ simply as a flippant pejorative, they will probably have little to say, and the shallowness of their objections can count against them. But it will still be useful for public health advocates to be able to recognise and engage with the ideas about freedom and autonomy that are associated with nanny state objections to their interventions.


Thinking about freedom and autonomy

Nanny state accusations generally focus on one broad kind of freedom: freedom from interference by the state or other people. This kind of freedom is sometimes referred to as ‘negative liberty’. It is emphasised in what political philosophers call libertarian thinking.

Libertarian thinking reflects and reinforces a view that almost all government (and much other) intervention in people’s lives is unjustified simply because it is interference. It takes freedom from interference to be more important than any other consideration. Libertarian thinking thus seems to render the vast majority of public health interventions unjustified. But there are good reasons not to accept it. What libertarian thinking implies about freedom and autonomy simply does not fit with what we know about human life.

In what follows, we will use several basic points about freedom and autonomy to expose some key weaknesses in many nanny state accusations and to encourage public health advocates to think carefully about the implications of their interventions. The basic points, in general terms, are that:

  • There are different kinds of freedom and different aspects of autonomy, and although people will vary to some extent in terms of which of these they value most, some are widely regarded as more important than others.
  • Freedom and autonomy rely, at least in part, on social arrangements, including laws, policies, cultural norms and what what goes on in social groups and interpersonal relationships; and
  • Some (state imposed and other) limitations on freedom are widely accepted and can be well justified.


Some freedoms are more important than others

The strong emphasis on freedom from interference that is central to libertarian thinking seems to imply that everything (including other kinds of freedom) that might be saved by freedom from interference is equally important. But this does not fit with the widespread recognition that some freedoms are much more important to us than others. Freedom from torture, arbitrary arrest and detention, and freedom of thought and belief, for example, are so widely recognised as worthy of protection that they have been accorded the status of human rights. In contrast, some of the personal freedoms that nanny state advocates seem keen to protect, including freedoms to buy cigarettes in branded packets, or to avoid being told by government what levels of alcohol consumption are considered safe, are not so highly regarded. They are not the kinds of freedoms that matter most in people’s lives.


Important freedoms and autonomy depend on social support

A strong emphasis on negative liberty seems to imply that people are most free when they are completely independent of both government and other people. But few people want to live remote and isolated lives, and sustained self-sufficiency is, for the vast majority of us, impossible. We cannot escape the fact that we live in networks of social relationships and take advantage of the services and supports offered by state and local cooperation (or, indeed, are disadvantaged by their lack, as we will say more about shortly).

Freedom from government or other public health intervention cannot secure all the freedoms that matter to people. Indeed, some interventions can be crucial for important freedoms, such as freedom from discrimination in relation to employment and housing, and freedom from disease through access to clean water and safe and effective medicines.

Neither can freedom from intervention by government or others secure the personal autonomy that people value. The idea that personal autonomy requires social support has been particularly well established by feminist philosophers. Their so-called relational theories of autonomy recognise the importance of some negative liberties, but also stress that to shape and control their own lives in any meaningful sense, people need a broad range of opportunities, skills and forms of recognition that depend in various ways on the societies they live in. Catriona Mackenzie, for example, argues that personal autonomy is a matter of being self-determining, self-governing and self-authorising. She points out that to be self-determining, people need social structures such as laws and policies to provide opportunities for them to make and act on important choices about their lives (e.g. who to marry and what kind of work or career to pursue); to be self-governing, people need socially supported opportunities to develop the skills and capacities to be able to regulate what they do in line with who they want to be; and to be self-authorising they need recognition from others to develop the self-respect, self-trust and sense of self-worth that will enable them to take personal responsibility for what they do.

Relational theories of autonomy thus highlight various ways in which public health and other interventions can positively support and increase people’s autonomy, as well as various ways in which they can undermine it. They offer richer and more demanding ways of considering the implications of public health interventions for freedom than the simplistic libertarian thinking that underpins some nanny state accusations.

Insights from relational theories of autonomy can support the defence of some public health interventions against nanny state accusations. They can be used to point out, for example, that taxing high sugar-content drinks or putting cigarettes into plain packaging is unlikely to significantly impair people’s autonomy because they do not undermine their opportunities for self-determination, self-governance or self-authorisation. On the other hand they can also raise the standard that might be required of public health interventions, including media campaigns that aim to promote healthier lifestyles. For example, they suggest that campaigns that perpetuate negative stereotypes of people with obesity as lacking in self-control, or campaigns that rely on arousing disgust or fear, can undermine autonomy because they fail to support self-governance and perhaps undermine self-authorisation.


Some state-imposed restrictions are widely accepted and necessary for important freedoms

If the strong emphasis on negative liberty that lies behind many nanny state accusations is followed through consistently, it tends to negate the possibility of all but the most skeletal government. Yet as the points made above suggest, an absence of government intervention is unlikely to ensure the kinds of freedom and autonomy that people most value. It is also not what most people seem to want.

Some state-sanctioned constraints are widely accepted, and at least implicitly recognised to be important for the preservation of valued freedoms. It is generally uncontroversial, for example, that all children should receive at least a basic education, that all drivers should follow certain rules of the road, and that all products marketed as medicines should pass at least basic tests of their safety and effectiveness. These create more valued opportunities than they constrain. Some interventions are, of course, contested because they shift the balance of trade-offs between different freedoms. Recent bans on smoking in public places, for example, limited some smokers’ freedoms in terms of where they could smoke, but increased their and other people’s freedoms to engage in social activities in smoke-free environments. Not introducing these bans would not have ensured everyone was in all important respects more free.

This is just one example of how the status quo sometimes limits important freedoms and opportunities – at least for some people. States are often uniquely positioned to ensure people have the kinds of freedoms and opportunities that really matter, so when important freedoms and opportunities are threatened, for example, by the adverse effects of absolute or relative poverty, social oppression and exclusion, or by commercial practices that contribute to these, a state that does not intervene is arguably limiting freedom more than one that does.


Rebutting nanny state claims

When faced with accusations of nanny statism, then, public health advocates might reasonably start by asking the accusers to explain what exactly they are concerned about and how they believe the intervention might limit important freedoms or personal autonomy. This should provide opportunities for rebuttal based on the points made above. It invites debate about questions such as: How important to people are the freedoms that the accuser focuses on? Will the intervention meaningfully limit people’s ability to shape their own lives? And on what grounds are these claims made? Public health advocates can also draw attention to the broad range of freedoms and opportunities that people do care about, suggest that it is a reasonable role of government to ensure some freedoms and opportunities, and point out that doing so can increase rather than impair the autonomy of citizens. They can position discussions about particular interventions as part of a larger conversation about whether and why different kinds of limitations on freedom can be considered justifiable and legitimate.


Assessing public health interventions more broadly

Our analysis is in some respects more demanding than nanny state thinking for assessments of the implications of public health interventions for people’s freedom and autonomy. It maintains the requirement that public health interventions that limit important freedoms need to be carefully justified (think here again of quarantine) and draws attention to various other ways in which freedom and autonomy can be undermined. In terms of health promotion in particular it suggests some important limits to the way that public health agencies interact with citizens. As noted above, communication campaigns that encourage disgust, disrespect or disdain towards, for example, people who are heavier than most, or people who smoke, can be criticised for their tendency to undermine autonomy. They might even be deemed unjustifiable despite their potential to lead people to eat more vegetables or smoke less.



Dealing well with nanny state criticisms requires opening up a conversation about what freedoms and opportunities matter, how much, to whom and why. It will take public health advocates into debates about which freedoms should be protected and which are less important. These might be difficult conversations, but they must be had. If nanny-state accusations are allowed to dominate public discourse, many attempts to improve public health will be framed as unjustifiable, and the benefits of interventions that both promote health and support important freedoms and personal autonomy will not be realised.



Vikki Entwistle is Professor of Health Services Research and Ethics in the Health Services Research Unit at the University of Aberdeen. She has a broad interest in the ethical aspects of health care delivery, including the challenges of providing ‘person centred care’.

Stacy Carter is Associate Professor at the Centre for Values, Ethics and Law in Medicine at the University of Sydney. Her interests relate broadly to ethical aspects of public health and she is currently particularly focused on concerns about “too much medicine”.

Miles Little is Emeritus Professor at the Centre for Values, Ethics and Law in Medicine, which he founded in 1995 at the University of Sydney. Miles works in various ways to help keep medicine in touch with its moral base.


This post is based on our article ‘Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions’ published in Public Health in 2015 (Vol. 129, No. 8.)


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