Wednesday, 29 February 2012
This paper is the first in a series looking at interactions between the NHS, individuals and communities. A further four papers in the run up to the 2012 NHS Confederation annual conference and exhibition will explore: putting people first through shared decision-making; information and the power paradigm; micro-enterprises and building community assets; and building social value within the system and society.
Health secretary responds to emergency question from Labour counterpart after apparent discord within coalition
Andrew Lansley declared on Tuesday that the latest amendments to his controversial NHS reform bill would be "significant".
The health secretary was responding to an emergency question from his Labour shadow, Andy Burnham, after the coalition government's apparent confusion over the changes announced on Monday by the Liberal Democrat deputy prime minister Nick Clegg.
In an effort to head off a backlash against the health and social care bill from within his party at its spring conference in March, Clegg wrote to his MPs and peers promising important changes to "rule out beyond doubt any threat of a US-style market in the NHS".
However the promise of five new amendments through the House of Lords was undermined by his Conservative coalition partners after Downing Street said that the changes would be "not significant". On Friday, and at lunchtime on Monday, government ministers had also said there would be no further changes to the bill.
Burnham challenged Lansley to tell MPs whether the latest changes were "substantial or cosmetic", and whether they had been agreed by the prime minister and health secretary in advance.
"The government appears in complete disarray, or maybe it was … coalition choreography to save face for the deputy prime minister," said Burnham. "The NHS matters too much to leave it to be carved up in cosy coalition deals."
Lansley avoided at least three times answering questions about whether he had been consulted about Clegg's letter. "The point of the letter was to reflect the discussions we have been having," he said in reply to Labour MP Gisela Stuart, apparently referring to the government and the House of Lords, which has discussed amendments in the committee and now report stages. "The amendments to the report would, by their nature, be significant," he added later.
Labour MP Rushanara Ali challenged Lansley on the decision by Tower Hamlets clinical commissioning group, in her constituency, to ask the health secretary to drop the bill. "When the very structures he's establishing to advise him are telling him they don't want to have part to do with this nightmare he's creating, isn't it time to look again and drop the bill?" she asked.
Lansley replied: "They will use the powers in this bill and they will use them effectively."
Later Burnham also criticised the decision of the backbench business committee of MPs, which decided not to hold a debate on the e-petition signed by 162,000 people asking for the health bill to be dropped. E-petitions hosted by the government website are eligible to be debated when they are signed by more than 100,000 people. The Guardian
Draft report into treatment of elderly people in hospitals and care homes says 'fundamental changes' needed across the board
Nurses, doctors and care workers should be recruited as much for their compassion as for their exam results, according to an inquiry into improving the dignity of treatment of elderly people in hospitals and care homes.
A shake-up of the criteria used for selecting and appraising staff should give the same emphasis to their assessed values and capacity to engage with older people as to their formal qualifications, the inquiry recommends. But it stops short of backing any lowering of academic entry bars.
The call is among a raft of proposals by a commission set up jointly by bodies representing NHS organisations and local councils together with a leading charity for older people, following a series of reports and investigations exposing poor care in hospitals and care homes.
A dossier of cases published 12 months ago by the NHS ombudsman found failure to provide "even the most basic standards of care". Later this spring, the conclusions of the Francis inquiry into the breakdown of care at hospitals in mid-Staffordshire is expected to damn the quality of nursing and medical and management supervision.
The draft report of the Commission on Dignity in Care, published on Wednesday, says that improving matters will require nothing short of "fundamental changes to culture, leadership, management, staff development, clinical practice and service delivery".
Sir Keith Pearson, chair of the NHS Confederation, which represents health trusts, said there had been too many cases of failings in care. "We want this report to be a call to arms to the whole health and social care system. We need to work together to earn back public confidence."
The report, which is open to public consultation, urges an end to "command-and-control" NHS management that it says has disempowered frontline staff. It calls on nursing sisters to be given responsibility for everything that happens on their ward and "take the action they deem necessary in the interests of patients", and says that ward teams should have daily discussions on feedback from patients and relatives, with regular reports going up to trust boards.
Residents and their relatives should be involved in the running of care homes, the report says, and a national care quality forum should be set up to investigate all aspects of the staffing of homes, including pay and qualifications, as part of a drive to raise the status of work in the care sector.
Trish Morris-Thompson, NHS London's chief nurse and a member of the commission, said that recruitment and regular career appraisal of staff should consider their values and compassion as much as academic rigour. A pilot scheme involving Great Ormond Street children's hospital in London and the South Bank University nursing course had produced graduates of exceptional quality.
Katherine Fenton, chief nurse at University College London Hospitals foundation trust, said her trust was taking a similar approach, starting with medical consultants, involving assessment of their interaction with patients and group interviews.
The commission insists that many of its recommendations could be implemented at minimal cost. The University Hospitals Birmingham foundation trust, which is singled out for praise in the report, is said to have established a comprehensive "dignity for all" programme with what Morris-Thompson described as "very little resource".
Nearly 50,000 hip-replacement patients will need annual medical checks as evidence grows that their metal implants can cause serious health problems, including severe pain and long-term disability. A leading manufacturer of the implants has known about potential dangers to patients since at least 2005, internal documents have revealed. Health regulators and the Department of Health have been aware since 2006. The Independent
Nurses should be assessed for their compassion, as well as their academic ability, when they are hired by hospitals and care homes, the Commission for Improving Dignity in Care of Older People recommends. The Independent
Mentally ill people are four times more likely to be victims of violence, the BBC has today reported.
This alarming statistic is based on a review of research looking at how often people with a range of disabilities had experienced violence in the previous year, and how this compared with non-disabled people. After combining the results of 26 previous studies, researchers found that more than 24% of those with a mental illness had been physically attacked in the previous year, as had more than 6% of people with intellectual impairments and more than 3% of people with all types of disability. People with disabilities were generally more at risk of violence than non-disabled individuals.
Although it had some limitations, this large well-conducted review supports previous research suggesting that people with disabilities are at increased risk of violence, and those with mental illness are particularly vulnerable. Most of the previous studies it looked at were in high-income countries including the UK, so the findings are particularly relevant for this country.
Further research on this important issue is now required to understand the magnitude of the problem in the UK and to develop further public health strategies to protect vulnerable groups.
Where did the story come from?
The study was carried out by researchers from Liverpool John Moores University and the World Health Organization (WHO). It was funded by the WHO Department of Violence and Injury Prevention and Disability. The study was published in the peer-reviewed medical journal The Lancet.
The BBC’s report was fair and included comments from independent UK experts.
What kind of research was this?
This was a systematic review and meta-analysis combining the results of previous research on violence against people with disabilities. It looked both at studies reporting on the rates of recorded violence against disabled adults, and at those that examined risk of violence to disabled adults compared with non-disabled adults.
The authors point out that about 15% of adults worldwide have a disability, a figure that is predicted to increase because of ageing populations and the rise in chronic disease, including mental illness. People with disabilities seem to be at increased risk of violence because of several factors including exclusion from education and employment, the need for personal assistance with daily living, communication barriers and social stigma and discrimination. The authors also say that there is an increasing number of media reports highlighting cases of physical violence and sexual abuse of disabled individuals living in institutions, but point out that formal research to quantify the problem is scarce.
What did the research involve?
The authors searched 12 online research databases to identify any studies that had reported on the prevalence of violence against adults with disabilities, or their risk of violence compared with non-disabled adults. They searched for all relevant studies published between 1990 and 2010. They also used additional methods to look for further studies, including hand searching reference lists and web-based searches.
To be deemed suitable for inclusion, studies had to meet various criteria. For example, their design had to be either a cross-sectional, case-control or cohort, they had to report on specific disability types, and they had to report violence occurring within the 12 months prior to the study.
All the identified studies were independently assessed by two separate reviewers using accepted criteria for assessing the quality of research. Individuals in the studies were grouped according to the type of disability: non-specific impairments (physical, mental, emotional or other health problems), mental illness, intellectual impairments, physical impairments and sensory impairments. The types of violence examined were physical violence, sexual violence, intimate partner violence and any violence.
The researchers calculated prevalence rates and the risk of violence faced by disabled people compared with non-disabled people, using standard statistical methods.
What were the basic results?
The researchers’ initial search identified 10,663 studies on the subject, but only 26 were eligible for inclusion. Overall, these studies provided data on 21,557 individuals with disabilities.
Of these studies, 21 provided data on the prevalence of violence among disabled people, and 10 provided data on the risk of violence compared with non-disabled people. By combining their results, researchers found that over the previous year:
- 24.3% of mentally ill adults had been subjected to violence of any type (95% CI: 18.3 to 31.0%)
- 6.1% of adults with intellectual impairments had been subjected to violence of any type (95% CI: 2.5 to 11.1%)
- 3.2% of adults with any impairment had been subjected to violence of any type (95% CI: 2.5 to 4.1%)
However, the researchers did note significant differences between individual studies (heterogeneity) in their prevalence estimates. Heterogeneity provides an indicator of how suitable it is to combine the results of different studies, with greater heterogeneity suggesting studies are of lower compatibility with each other.
When they pooled the results of studies comparing disabled with non-disabled individuals they found that, overall, disabled people were 1.5 times more likely to have been attacked than non-disabled people (odds ratio: 1.5; 95% CI: 1.09 to 2.05).
There was also a trend for people with specific types of disability to experience more violence, but not all associations were significant:
- People with intellectual impairments were 1.6 times more likely to have been physically attacked than people without intellectual impairments (results from three studies; pooled odds ratio: 1.60; CI 95%: 1.05 to 2.45).
- Mentally ill people were no more likely to have been physically attacked than non-mentally ill people (three studies; pooled odds ratio: 3.86; 95% CI: 0.91 to 16.43).
- People with non-specific impairments were no more likely to have been physically attacked than those without (six studies; pooled odds ratio: 1.31; 95% CI: 95% 0.93 to 1.84).
How did the researchers interpret the results?
The researchers conclude that adults with disabilities are at a higher risk of violence compare with non-disabled adults, and that those with mental illnesses could be particularly vulnerable. However, they add that the available studies have methodological weaknesses and that gaps exist in the types of disability and violence they address. They also point out that good studies are absent for most regions of the world, particularly low-income and middle-income countries.
Violence and abuse against anyone is not acceptable, but there is an even greater need to ensure that vulnerable groups who may be less able to help themselves receive adequate protection against this type of victimisation. This valuable systematic review helps to establish the proportion of people with disabilities who have experienced violence, as well as how this compares to people without disabilities. The estimates it provides may prove useful for planning services and policies to protect vulnerable individuals such as people with mental health issues.
However, the review does have several limitations, many of which the authors acknowledge:
- The studies were limited to looking at violence within the 12 months before each study, which means the review probably underestimates people’s lifetime exposure to violence.
- It is not clear from some of the studies whether the violence was a cause or a result of people’s health conditions, i.e. whether disability led to violence, or if violence caused people to develop disability such as mental health issues. This factor could particularly affect studies of people with mental illness, which form a large proportion of the studies included.
- The studies included in the review varied in quality, with only one achieving the assessors’ maximum quality scores. The researchers say that combining the results of individual studies was severely hindered by lack of methodological consistency between studies, including variations in samples used, definitions of disability and violence, and methods of data collection. When they pooled the study results there was significant heterogeneity (differences) between individual studies in the proportion of people who experienced violence, making it difficult to give an accurate estimate of the prevalence. Also, many studies failed to include comparison groups, which are needed to compare risk of violence between those with and without disability.
- In studies that did compare people with and without disability, overall there were higher odds of experiencing violence in those with any disability compared with those with none, but analyses by individual type of disability did not consistently give significant associations.
- Regardless of whether or not people have disabilities, they may be unwilling to report violence or abuse, and therefore the rates reported in the reviewed studies may not reflect what happens in reality.
Despite these limitations, this is a valuable attempt to quantify the prevalence and the risk of violence faced by disabled people. Further high-quality research on this important issue is required to understand the magnitude of this problem if strategies are to be developed that can help prevent it.
Links To The Headlines
Mentally ill 'at high risk of being victim of violence'. BBC News, February 28 2012
Links To Science
Hughes K, Bellis MA, Jones L et al. Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies. The Lancet, Early Online Publication February 28 2012
Tuesday, 28 February 2012
A BREAST-FEEDING cafe in Northampton that was the subject of a mothers’ protest march recently, will close three weeks early, campaigners have said. Northampton Chronicle and Echo
Northants FT ahead on budget plan
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The number of people diagnosed with dementia rose from 265,000 to 283,000 in a year. However, only 41% of people living with dementia have a diagnosis – an increase of 2% since last year.
Alzheimer’s Society and Alzheimer Scotland are currently updating their dementia map, which shows diagnosis rates for different parts of England, Wales, Scotland and Northern Ireland. NHS Networks
Experts believe cost will be far less than possible costs of treating someone in hospital for Aids
Asylum seekers and other non-British citizens are set to be given free HIV treatment after the government indicated it was willing to accept an amendment from Lord Fowler to the health bill.
Doctors working with people who have HIV have long argued that refusing free HIV drugs on the NHS to overseas visitors, including asylum seekers, is morally wrong and risks spreading the virus. Fowler, who chaired a House of Lords inquiry into the state of the HIV epidemic in Britain, nearly 25 years after he launched, as a Tory health secretary, the first major campaign warning of the the dangers of Aids, agreed with them.
His amendment to the bill will allow overseas visitors to be treated for HIV on the NHS if they have been here for six months. Experts believe the cost of providing drugs from a clinic will be far less than the possible costs of treating someone in hospital for Aids. The drugs also prevent new infections.
Ministers have indicated they will accept the amendment without a vote later this week. Anne Milton, the public health minister, said: "This measure will protect the public and brings HIV treatment into line with all other infectious diseases. Treating people with HIV means they are very unlikely to pass the infection on to others." Perhaps anticipating possible criticism from some sections of the press, she added: "Tough guidance will ensure this measure is not abused."
Professor Jane Anderson, chair of the British HIV Association – which represents doctors who have been placed in a dilemma by the current rules – said: "This is good news, both for people living with HIV and for public health in general. For too long access to treatment and care for some of the most vulnerable people has been compromised by the English charging arrangements.
"There is no ethical or economic reason to leave people living with HIV without appropriate treatment. Recent research shows that proper treatment can also reduce infectiousness and so stop other people becoming infected.
"I am delighted that Lord Fowler has finally won the argument on this point. It's a decision that will certainly save lives and improve the quality of life of many who were previously shut out from appropriate treatment." The Guardian
This alert reminds NHS healthcare providers, Trusts, NHS Foundation Trusts, PCTs, Dental practices and GP surgeries of the importance of reporting defects and failures involving non-medical devices, and the dissemination of Estates and Facilities Alerts.
This alert replaces previous guidance (DH 2008/01).Department of Health
According to a report published in the British Medical Journal (BMJ), a report from Monitor claims that over 40% of prices for NHS services set under the current Payment by Results system change by 10% or more every year. Such changes undermine the confidence that providers and commissioners have in the tariff, and this can lead to poor compliance with the system.
The report presents a comprehensive analysis of pricing in the NHS and the reimbursement system for NHS funded care, and is the first stage in establishing the evidence for Monitor to use to develop new ways of using pricing to deliver benefits for patients. The evaluation found some evidence that the existing system had brought about improvements in the quality and efficiency of care, however it suggests that there is much room for improvement in the way that providers of NHS services are paid.
This report examines both the feasibility, and the advantages and disadvantages, of setting out explicitly the care patients are entitled to, in the form of a nationally specified NHS ‘benefits package’. It draws on the experience of countries that have sought to explicitly define the health care benefits that their publicly-funded health systems will pay for. It outlines the current system in which decisions for determining which treatments are funded by the NHS are arrived at implicitly and makes several recommendations for how the system could be improved.
This document outlines the importance of language competency assessment and aims to provide good practice guidance for employers. It has been produced in consultation with key partners including the European Office, the Department of Health and professional regulatory bodies. It reflects current law under the European Directive 2005/36/EC – recognition of professional qualifications.
The effect of a hospital nurse staffing mandate on patient health outcomes: evidence from California’s minimum staffing regulation
This paper evaluates the impact of California Assembly Bill 394, which mandated maximum levels of patients per nurse in the hospital setting. This paper finds evidence that the legislation had the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, these improvements in staffing ratios do not appear to be associated with relative improvements in measured patient safety in affected hospitals.
In the Lords, an amendment is being put forward that seeks to retain a vital level of protection for vulnerable people
Peers are set to further scrutinise the health and social care bill as the House of Lords debates a proposed amendment on Monday evening that, while not among the most high-profile elements of the legislation, could have a drastic impact on the recovery of mental health patients.
The proposed amendment, being put forward by Lord Patel of Bradford, concerns clause 39 of the bill. This clause addresses section 117 of the Mental Health Act, which guarantees aftercare provision for a vulnerable group of patients who have been detained, or "sectioned", because of their mental health.
Crucially, section 117 requires primary care trusts and local authority social services to work together to jointly provide necessary aftercare. Examples of aftercare include visits from a community psychiatric nurse, attending a day centre, administering medication, and providing counselling services or accommodation within the community.
As things currently stand, a patient can expect their PCT and local authority to provide an appropriate aftercare package, and to sort out the funding between them. The services cannot be withdrawn until both the PCT and local authority are satisfied that the patient no longer needs them.
In practice, this joint duty means that the patient is more likely to get access to the integrated health and social care services they need and has an enforceable right to those services.
The services provided under section 117 are free of charge because the people who benefit are exceptionally vulnerable members of society. If they do not receive the aftercare services, there is a real risk of relapse, self-harm, and falling out of mainstream society into homelessness or social isolation.
Clause 39 makes a number of worrying changes to the provision of aftercare services in England. The most concerning of these will remove the joint duty so that the new clinical commissioning groups (CCGs) and local authorities will be able to take separate decisions.
In practical terms, this means either health or social services could be withdrawn from individuals without the other provider being consulted, seriously damaging that person's care package at a time when they are incredibly vulnerable.
Section 117 will no longer be a freestanding duty and, instead, CCGs will only provide health services under the NHS Act 2006. As the NHS Act includes provision for charging for aftercare, this opens up the possibility of the individual having to pay for their vital services.
Clause 39 flies in the face of the government's rhetoric about health and social care integration. It does precisely the opposite of this, removing the need for each provider to communicate with the other and increasing the likelihood of codependent services being removed, at great risk to the individual.
At present, section 117 does not make any distinction between what is a health or social aftercare service. PCTs and local authorities are required to provide and fund whatever treatment is necessary. But if the duty is split, CCGs will be able to stop providing "health care" services when they decide that the person no longer needs them, and local authorities will be able to stop providing "social care" services, and they will not have to reach this decision together as they do now.
We are greatly concerned that this will lead to disputes between providers over which authority pays for a particular aftercare service, and, where services are not clearly in the remit of either health or social care, they may not be funded at all.
Patel's amendment proposes that the joint duty for CCGs and local authorities to co-operate is retained, and that the current safeguards against charging for aftercare is kept. Section 117 provides a vital level of protection for vulnerable people and it is essential that it remains a key part of mental health care. Mind strongly support Patel's amendment and we hope that his fellow peers will also do so in Monday's debate.
Louise Kirsh is parliamentary manager for Mind.
Do people who use adult social care services want to be able to take risks?
People who use adult social care services identify different risks to those commonly identified by professionals and policy-makers. Many fear losing independence, which suggests that risk assessments need to have independence as their starting point. There is a particular need to reach into mental health and residential care services to find ways of enabling people to realise their independence. Joseph Rowntree Trust
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Monday, 27 February 2012
The Chief Medical Officer (CMO) has written to Medical Directors of NHS and Primary Care Trusts, and to independent sector abortion clinics, to draw attention to the conditions under which abortions can be carried out.Those involved in the provision and commissioning treatment for termination of pregnancy need to comply with all requirements of the Abortion Act 1967. This is extremely important because if the condtions are not met then abortion remains a criminal offence under the Offences Against the Persons Act 1861.
Further information is available in the CMO’s letter which was published today. Department of Health
This guidance has been produced to help pharmacy staff with some areas of practice. The areas of practice covered are: consent; raising concerns; patient confidentiality; and maintaining clear sexual boundaries.
The government's mental health strategy set out five key issues affecting mental health, but current policy across departments is failing to address them.
A year ago the government's mental health strategy, No Health Without Mental Health, was published, with the aim of ensuring all departments and agencies worked together to reduce the annual £105bn cost to the UK of psychological ill health.
When the National Mental Health Development Unit was scrapped the month after the strategy was published, that work was given to mental health charities including Mind, Rethink and the NSUN network for mental health.
As part of attempting to design a practical implementation plan for the strategy, NSUN has assessed what progress has been made so far on delivering No Health Without Mental Health's objectives across government.
The strategy clearly identifies five main predeterminants of mental health that must be improved in order to deliver the practical objectives of the strategy: employment, housing, education, community cohesion and physical health. An assessment of the state of each of these factors reveals that ministers appear to be wrecking their own strategy.
Unemployment is now at an 18-year high and forecast to rise further while the latest Department for Work and Pensions' impact assessment on their own benefit changes found that 310,000 people are at risk of losing their homes. Investment in social housing has halved with less than 500 new social homes built last year.
Ofsted has recently been instructed to drop 'wellbeing' from the school inspection regime with schools minister Nick Gibb describing emotional and social education as "ghastly" and "peripheral", leading to entire school counseling and health programs being scrapped. Likewise schools are no longer required to encourage 'community cohesion', another prerequisite for good mental health according to the strategy.
On physical health, the first action Andrew Lansley took on taking office was to scrap the traffic light food labeling scheme and attack Jamie Oliver's attempts to improve nutrition in schools. Public health bodies are united in rejecting the government's 'responsibility agenda' involving McDonalds, Tesco, Pepsi and the Portman Group of brewers and distillers in ministerial food and drink policy commissions.
An email from health minister Earl Howe, recently published by the Guardian, revealed that he had asked the advice of tobacco manufacturer Philip Morris on how to resist imposing plain packets for cigarettes, despite the fact that people with mental health conditions smoke 40% of the tobacco in the UK.
The strategy also calls for new local public health bodies to prioritise mental health but the first and largest, the London Health Improvement Board chaired by mayor Boris Johnson, has instead opted to concentrate on childhood obesity and problem drinking.
While the DH would argue that it has invested £18m in continuing the anti-mental health stigma time to change campaign and sought to increase access to psychological therapies, these measures pale into insignificance in the wider context of worsening health and wider services.
If we in the third sector are to have a hope of delivering a practical implementation plan for No Health Without Mental Health then we need a genuine cross-government commitment to its aims particularly from the Department for Education, the DWP and the new public health bodies, to promote good mental health in schools, create good quality homes and jobs and clamp down on junk food, alcohol and cigarettes.
Edward Davie is communications and engagement office for the NSUN network for mental health
Government says it will provide free care for 40,000 women fitted with PIP implants but plans to recover costs from clinics
More than 3,500 women who attended private clinics to be given breast implants made by a scandal-hit French company have been formally referred to the NHS, government figures show.
Statistics released by the Department of Health (DoH) on Friday indicate that 3,512 women – 553 in the last week alone – have been referred to the NHS for care following the global scare surrounding Poly Implant Prothèse (PIP) silicone implants.
The DoH said that, two months after the scandal first broke in France, more than 1,400 scans had been completed and that, of those women scanned, 120 would be having their implants removed. Sixteen had already had implants removed, it added.
The government has said it will provide free care for any of the estimated 40,000 women fitted with the PIP implants, which were found to contain cheap, non-medical silicone. It said it intended to recover costs from the private clinics concerned.
The women who had initially gone private but were now coming to the NHS for scans and potential implant removals had been clients of a number of clinics including the Harley Medical Group and the cosmetic surgery provider Transform, the DoH said.
Transform initially refused to pay for removals before performing a u-turn and saying that any patient who received PIP implants could have free scans and the offer of removal, although replacement could cost £2,500.
The Harley Medical Group, which fitted almost 14,000 British women with the implants, also initially refused to foot the bill. It subsequently said it would remove implants from those who underwent operations in the last 10 years, but only if they had suffered a rupture and had a scan as proof.
If implants were put in within the last six years, patients will be eligible for a replacement and, between six and 10 years, will be charged cost price to replace the implants.
According to the latest figures, an estimated 747 women are believed to have PIP implants provided by the NHS, but only 10 have received scans so far. Thirty-three have decided to have the implants removed, and four have already done so. The Guardian
The director of the Nuffield Trust explains why it is crucial that all aspects of frontline care are carefully scrutinised
Forget the bill. The biggest issue facing the NHS is the longest budget squeeze in its history, penned in to last until at least 2015. Unless the service can do more with less, the pips will squeak.
Cutting back on managers and red tape was first. Freezing pay of staff and cutting prices paid to hospitals for treatments was next. But these won't be enough. A hard look will have to be taken at all aspects of frontline care. Could costly admissions to hospital be prevented? If so, should some hospitals close? Could more services be delivered digitally? Could nurses substitute for doctors in some areas of care? Taken together, these and other such changes could deliver the savings needed.
The good news is that in a service as large as the NHS there are plenty of efficiencies to be made. And the £20bn budget challenge will prompt innovation. But the question is, can the service move fast enough to stave off more unpalatable responses to austerity?
Suggestions will come thick and fast: charge people to see their GP; give NHS patients details of how much their care has cost (debated last week in parliament); encourage people to take up private insurance; deny treatments such as IVF to women over a certain age, cosmetic surgery or bypass surgery for smokers. Letting waiting lists grow is no longer an option, as the 18-week waiting promise is enshrined in the NHS constitution.
Denying specific treatments is, in fact, a reality in every health system in the world. While the NHS offers a comprehensive service, not everyone can have everything, and priorities are already made locally up and down the land. Although relatively few services or treatments are "rationed" in this way, pressure on funds could force more, as we have seen with the new restrictions in some places on hernia operations, vasectomies and diagnostic scans.
If the bill is passed, groups of GP practices will be making these decisions. Dislike of a postcode lottery in care is strong among the public, who think what is available in Southampton should be available in Sunderland. Unsurprisingly then, professional and patient groups have started to get vocal. The prospect of setting out explicitly and nationally what is and isn't available on the NHS may become more attractive, as discussions on the ConservativeHome website have recently shown. It would be a wrong step.
Drawing up such a list on any rational basis would be impossible and unfeasible, due to a lack of information about the costs and benefits of services. Thus, applying it rigidly would be inappropriate. Those needing off-list treatments would have to pay out of their own pocket or insure themselves – hardly an equitable solution. Most countries who have flirted with this idea have backed off.
More fundamentally, should we be considering this when efficiencies can still be made? We could do better, but without such a list. The National Institute for Health and Clinical Excellence (NICE) has made a good fist of giving guidance on which drugs are cost-effective. This principle could be extended to a wider range of existing, as well as new services, building on NICE's list of "do not do" recommendations (examples include screenings of low-risk populations and the prescription of antibiotics for children with gastroenteritis). This should also be backed up by scrutiny of variations in treatment rates, which essentially go unchallenged.
This will take time. Some believe the pips will squeak loudly enough for George Osborne to write a big fat cheque for the NHS just before the next election. But even if he does, the relief is likely to be temporary. There is no option but radical change. The Guardian
More than 100,000 doctors are to be balloted on industrial action as the stand-off between the Government and the medical profession escalates. The Independent
Friday, 24 February 2012
Northamptonshire Healthcare investigates 26 incidents
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Dame Fiona Caldicott has agreed to lead an independent from Government review of the balance between protecting patient information and its sharing, to improve patient care.
The Department expects to respond to the panel’s recommendations when the review publishes during 2012.
The recommendation for a review of the balance between protecting patient information and its sharing, to improve patient care was part of the Future Forum’s recommendations to Government on the modernisation of health and care.
Set up as an independent group in order to ‘pause, listen and reflect’ on the Health and Social Care Bill, the Forum made 16 key recommendations in total.
Dame Fiona is known across the NHS as the originator of ‘Caldicott Guardians’, the individuals responsible in every NHS and local authority organisation for making decisions about sharing identifiable information. This requires balancing the public interest of protecting confidential information with the public interest for sharing the information. She will be calling on an expert panel made up of clinical, social care, research and other professionals, as well as patients and service users. The panel will determine the detailed scope and priorities for the review.
Dame Fiona Caldicott said:
“It is timely to reconsider the principles of information protection and sharing. Since the original working group’s report on the security of patients’ information in 1997, it has become clear that there is sometimes a lack of understanding about the rules and this can act as a barrier to exchanging information that would benefit the patient. On other occasions, this has resulted in too much information being disclosed. These are issues of importance to everyone who uses health or social care services and our review will look across both sectors. We need to examine when and how to seek and record consent, to support the flow of information to enhance patient and citizen care.”
”Ensuring that information is shared for best care and to promote excellent research is central to the Government’s vision for the new health and care system, as is protecting confidential information. This is a complex issue and I am most grateful that Dame Fiona has accepted the challenge – I can think of no better person to complete the review.” Department of Health
Launch of single operating model: part 1 - SHA development and FT assurance for NHS trusts in the pipeline
Between February and May 2012, SHA clusters will be introducing a single operating model to support and assure NHS trusts through their FT applications. The Department of Health has published documents outlining the details about the new SOM.
Specially trained paramedics to assess whether they can treat patients out of hospital in plan to improve 999 response rates
East Midlands ambulance service trust is piloting a new project that allows specially trained paramedics to decide whether patients should be treated at home, or referred to a GP or walk-in centre.
The trial is part of the trust's plans to keep people out of hospital where possible in an effort to cut the strain on A&E, and help improve ambulance response rates to emergency calls.
If rolled out fully, emergency care practitioners – paramedics with an extended set of university qualifications – would view 999 calls on a computer-aided dispatch system at the trust's emergency operation centre in Lincoln, and select the jobs that they believe would normally result in an ambulance taking the patient to accident and emergency.
They would then respond to the call and decide whether the patient needed to be taken to hospital, or if an alternative option was appropriate, such as being treated on the spot or referred elsewhere, for example as an out-of-hours GP. Under normal circumstances, the trust would respond to a job with an ambulance crew, which would probably take a person to A&E straight away without any other considerations.
Pete Jones, the assistant director of operations in Lincolnshire for the trust, told the Guardian that automatically taking people to hospital could no longer be the default option, due to unprecedented pressures on A&E departments.
"The future is not bright in terms of commissioning and extra money. We can't just keep adding to the bill in terms of resources. What we've got to start doing is taking patients off the front end of that list, and start treating them in the community and keep them away from the hospitals if possible," he said.
Around 20 ECPs are taking part in the trust's pilot, which is being funded by NHS Lincolnshire. Jones said meeting response time targets for 999 calls was also an important consideration when launching the scheme.
"The government sets these targets and we have to reach them, and that's what we have to aspire to, but from our point of view what we're trying to do is concentrate on the quality of care and patient safety. But these targets do have to be achieved. It's a by-product, and I don't like it, but it's there and we've got to do it," he explained.
Ambulances are expected to respond to life-threatening emergencies within eight minutes under the government's current rules. This is an area the trust is trying to improve after councillors in Lincolnshire expressed concerns about East Midlands ambulance service's response times at a recent cabinet meeting.
Jones stressed that the trust was doing its best in this area, but said it faces the additional burden of around 4.5 million tourists visiting the area each year.
"We're not funded for that in any big way. The emergency ambulance cost adjustment payment that is made to the division is about £700,000 each year and that doesn't even begin to bridge that gap," said Jones.
"These people bring with them their requirements for pharmacies. In the summer, particularly when it's busy out in the east coast, we set up triage centres on weekends just to try and alleviate the necessity to trundle up and down the road to hospital."
Jones is hopeful that the new system could help the trust become more efficient, and plans to show the benefits of the project to clinical commissioning groups and service providers once the scheme finishes at the end of March. If successful, the pilot could be rolled out across Lincolnshire, with ECPs potentially gaining additional responsibilities, such as giving out antibiotics for chest infections.
"If we've got a framework around this concept of clinicians going out into the community … and they're keeping patients in the community and treating them at home or in their workplace, that's where we want to go with this," he added. Guardian Professional.
Community providers are being pushed aside as commissioners recognise only those with money, not their track record
In any economy, let alone one in recession, capital is king, so it is a primary consideration when contemplating reform of public services.
As both the chief executive of Social Enterprise London and chair of the Transition Institute, which supports public services, I am an advocate of those independent providers who offer affordable, quality services with social impact and real accountability.
Today we are being asked how we stand on NHS reforms. Through the work we have done in public services and, in particular, health, we have seen some wonderful organisations offer innovative, patient-centred services on reduced budgets. To achieve this does mean acknowledging competition in the NHS.
But here is where I have a problem: almost without exception, the procurement processes that have come from government in the last 18 months have been large – and are getting larger. They have increasingly favoured those applicants with capital, lots of it. In some bidding rounds, applicants have been required to prove the existence of large capital sums or capital bonds as an essential part of the process, which excludes most if not all community-driven providers.
The innovators I refer to offer extraordinary opportunity to link motivated staff with happy patients, such as those treated by City Health Care Partnership CIC in Hull. City Health is an employee-owned service, like Central Surrey Health, that provides award-winning, community-based healthcare. I have to say both these organisations do not have the look or feel of a privatised company, but a new generation of public service, with the strongest possible public service ethic.
I read with interest Sir Stephen Bubb, chief executive of Acevo, the Association of Chief Executives of Voluntary Organisations, and a board member of the Transition Institute, whose article in the Times on Wednesday considered the NHS reforms. Bubb was a member of the Future Forum that reviewed the reforms over the summer and he attended the No 10 NHS summit on Monday.
As someone at the heart of the debate, Bubb tells us: "Almost everyone agrees we have a problem when over 70% of NHS funding is spent on treating long-term conditions, usually in the most inefficient way there is: in hospital.
"And almost everyone agrees that if the NHS is to cope with these pressures, it must shift resources towards preventative, patient-led, community-based services which treat chronic conditions far more effectively and which act to pre-empt acute crises of ill health."
He goes on to say: "Might I also suggest that the majority of observers agree that to carry out this change effectively, the NHS must allow new providers with new ideas to break the bureaucratic stranglehold on service delivery … What frustrates many of my members, the leaders of the country's charities and social enterprises, is that, despite the consensus on both problems and solutions, the debate over reform focuses on the phantom of 'privatisation'."
All of us on the front lines of community service share Bubb's belief that, with a fair crack at the whip, we could make a real contribution, but to do that a number of things have to change.
I don't think this is a debate about whether to privatise or not: the NHS has always been a mixed model and will continue to be so. No, this is about big versus small or, more specifically and sadly, this is about financial versus social capital.
Most of the members Bubb is referring to have a great track record but limited access to capital. Like Social Enterprise London members and those approaching the Transition Institute, they are finding it harder and harder to succeed in a commissioning process that pits them against companies which don't have the track record but do have the cash.
The principle of this debate is clear: everyone wants universal, quality healthcare, free at the point of use, but the means to achieving that are bound to be complex, even if money wasn't so tight. The Transition Institute thinks it has part of the answer in that we can supply willing providers of quality, community-driven service solutions. All government has to do is procure those services and look for capital elsewhere.
Allison Ogden Newton is chief executive of Social Enterprise London
The number of clinically obese people in England is following a worrying trend the NHS report today. We check the latest statstics to see what this means
• Get the data
26.2% of the male population in England to said to be clinically obese according to the lastest Obesity, Physical Activity and Diet report published today by the National Health Service (NHS).
That's over 26% of men in England whose body mass index is greater than 30 kg/m2, and an increase of 13 percentage points in 17 years.
Obesity has been increasing, not only for men, but for women too. Here's the data for the whole adult population of England:
We can see an 11.2 percentage point increase from 1993 to 2010.
The effects of this change are many and varied. Today the Press Association reported that weight loss operations have risen:
In 2010/11, there were 8,087 weight-loss stomach operations in England's hospitals, up from 7,214 in 2009/10, according to data from the NHS Information Centre.
The report highlights around a 30-fold increase in the number of people going under the knife in the last decade, from just 261 weight loss operations in 2000/01.
Recent figures include operations to adjust an existing gastric band rather than fit a new one. Of the 8,087 procedures in 2010/11, 1,444 were for maintenance of an existing band.
The report shows the number of hospital admissions with primary diagnosis of obesity has also risen really quite dramatically too. Here's the data:
But perhaps the most concerning part of the report is the data on children. The chart shows the percentage of children (aged between 2 and 15) who are overweight and obese:
Although there has been a decrease in overweight and obese children from 2004 levels, we can still see that the percentages are higher than in 1995. Here are some more detailed facts about boys and girls in 2010 compared to 1995:
• In 2010, 17% of boys and 15% of girls (aged 2 to 15) were classed as obese, an increase from 11% and 12% respectively since 1995.
• In 2010, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31% and 29% respectively).
• In 2010/11, the around one in ten pupils in Reception class (aged 4-5 years) were classified as obese (9.4%) which compares to around a fifth of pupils in Year 6 (aged 10-11 years) (19.0%).
Are we doing enough to provide young people with good food and an active lifestyle? This data suggests the answer is no when compared to 17 years ago.
We've included in the spreadsheet of the key data sets from the Obesity, Physical Activity and Diet report. What can you do with them?
Download the data
Thursday, 23 February 2012
It is aimed at commissioners who may be interested in stimulating the creation of new forms of organisation as an alternative to direct service provision or conventional outsourcing, and staff who may be interested in setting up some form of employee ownership and/or social enterprise. More ….
This guidance outlines the areas most important to patients’ experience of NHS services. It provides a common evidence-based list of what matters to patients, and can be used to direct efforts to improve services. For example it can be used to help define what questions to ask patients in surveys and in real time feedback.
Subject to the Health and Social Care Bill, from 2013-14, CCGs will have access to public health advice, information and expertise in relation to the healthcare services that they commission, provided by local public health teams based in local authorities. This draft guidance aims to help commissioners with local planning in this transition year.
The service section of the NHS standard contract has been updated for both the multilateral and bilateral contracts. The standard contracts should be used by those commissioning acute, mental health and learning disability, community or ambulance services.
People with conditions such as cancer, diabetes or lung or heart problems, and women who are pregnant, will be asked to take daily measurements and text the results to a central computer system where they will be analysed. Healthcare Today
Live discussion round up: long-term conditions and mental health
If you get mental health right, then costs elsewhere in the system can go down Liaison psychiatry services helping people in hospital who have physical and mental health problems can save the hospital four times the money it costs to provide the ...
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BMJ report says NHS already works 'remarkably well' compared with health services of other countries
The NHS is performing so well that it does not need to undergo the radical transformation planned by the coalition, according to a new study published by the British Medical Journal.
While the health service in England has some weaknesses, it should be left to continue making improvements that began when Labour was in power, and not face another massive upheaval, an analysis by health researchers led by Professor David Ingleby of Utrecht University in the Netherlands concluded.
Their findings "do not support complacency about the current performance of the health system in the UK", the authors stress. "They do, however, cast serious doubt on any claim that there is widespread popular support for radical reform.
"Improvements are needed, but continuation and expansion of the measures already set in motion – more of the same – seems to be a better formula than totally rebuilding a system that, by international standards, already works remarkably well."
The researchers based their findings on two recent Commonwealth Fund reports comparing the NHS's performance across the UK, and patients' perceptions of it, with that of the health systems of 13 other countries.
"The main messages are that the NHS outperforms other high income countries on many measures, despite spending less than most of them; it enjoys the highest levels of public confidence and satisfaction of all the countries studied; [and] the effects of increased investment and policy improvements over the past decade are clearly visible," said Ingleby.
But while healthcare is more accessible, better organised, safer and more patient-centred in the NHS than elsewhere, ongoing concern about some of the clinical outcomes it achieves in patients is a worry, they say. "Three measures warrant particular concern: deaths amenable to healthcare; survival rates for breast cancer; and survival after acute myocardial infarction," they add.
The Department of Health said the NHS could not be allowed to stand still. "This analysis highlights concerns around clinical outcomes, and the fact the current system has to improve. Separately, another report from Age UK and the National Osteoporosis Society today said our reforms could improve patient care," said a spokesman.
"The independent NHS Future Forum confirmed that every health system in the developed world faces the same challenges, but that they won't be met by the NHS doing more of the same. That is why our plans will hand power to GPs, put patients at the heart of the NHS, and reduce needless bureaucracy. The Guardian