US Government shutdown shows why we should reject private health

The US government shutdown should remind us of the power of the US private health care lobby and why we don't want it here.

I was listening to an American political analyst on the radio this morning commenting on the US Government shutdown. This astonishing mess is caused by the Republicans wanting to shut down Obama's modest health care reforms, before they even start. He starkly described the USA political system as being as dysfunctional as Italy.

That may well be true, but for me it demonstrated something else about the US political system - the lobby power of the private health care lobby. A few years ago we sponsored a showing of Michael Moore's film 'Sicko' at the Glasgow Film Theatre, followed by a debate on healthcare. We had politicians from all the political parties on the panel, but they all agreed on one thing - thank god for the NHS!

This film shows just how powerful the lobby is in protecting their massive profits that results in the most expensive health care system in the world. Billions spent on administration rather than care - a system that excludes millions from health care and bankrupts even more. Health bills are the major cause of bankruptcy in the USA. My favourite clip is Moore taking public service workers, including firefighters who survived 9/11, to Cuba to get free health care that they couldn't get at home.

So why does this matter in the UK. Well in England the NHS is moving rapidly in the same direction. Under the guise of competition, the English NHS is allowing the very same health care corporations to get a very big foot in the door. Once there, they will defend their profits in same way as they do in America. The Tories will be bought and paid for, just as the Republicans are in the USA.

In Scotland, we should be very grateful for devolution and the political consensus on the NHS. We resisted the New Labour reforms  and scrapped the Tory trust model that placed marketing managers before nurses. The political consensus has largely held, to the level that commercialisation is actually unlawful in some circumstances. Private contractors have largely been banished and services brought back in house, reuniting the health care team. Only the CBI is left arguing for privatisation, an issue I was sparring with them over at the Health Committee last week. Even they are largely going through the motions at the behest of English member companies. The only significant blemish is the PPP hospitals and community facilities that waste scarce £millions every year. Sadly, they are likely to do so for years to come as the SNP introduce new PPP schemes through the hub Initiative and so called NPD model.

Of course we are not entirely exempt from the consequences of Tory NHS privatisation in England. The aim is to cut spending and that has a knock on effect on Scottish budget allocations. That's why Scots joined their colleagues in Manchester on Sunday in the largest demonstration Manchester police had seen for a generation.

So when we look in astonishment as the richest country on the planet closes down its government. Remember that the cause is private health care corporations and their lobbying muscle. Then vow to redouble our efforts to campaign against it happening here.

Scottish Health Budget

The Scottish Government has published its draft budget today for the next two years. The health budget continues to receive a  degree of protection from UK Government cuts. However, in real terms, inflation and other demand costs  are likely to keep up the financial pressure on services.



No such protection for local government that takes another big revenue hit.

The power of big business to undermine public health

Two recent health stories highlight the challenge for public health when sensible measures to tackle tobacco and alcohol abuse run up against the commercial interests of big business

A recent study by Cancer Research shows that almost 20,000 children in Scotland start smoking every year. They have called on the Scottish Government to act quickly on its pledge to introduce legislation on plain packaging for cigarettes. A similar move by the UK Government was put on hold earlier this year with a strong suspicion (subsequently denied) that Tory strategist Lynton Crosby influenced the decision on behalf of his commercial clients. 

The Scottish Government's recently published programme for government confirms that they are still committed to introducing this measure. However, for now, they are promising a consultation and legislation is not likely before 2014/15.

The public health benefits of this measure are clear. The research shows that packaging without branding is less appealing to children and would support other action to discourage young people from starting to smoke. Vicky Crichton said: “Smoking is a serious problem in Scotland with almost 20,000 children, tempted by glitzy, slickly designed packs, being lured into starting smoking every year. It is an addiction that is often life-long and kills more than 4,000 Scots annually. If the Scottish Government is serious about curbing the death toll caused by this lethal habit and meeting its goal for Scotland to become a nation free from tobacco by 2034, then swift action needs to be taken.”

The importance of tackling smoking amongst the young is highlighted by the statistic that  eight out of ten adult smokers start the habit by the age of 19. If the tobacco industry can catch them young, they are likely to have a customer for life. While the rest of us pick up the public health tab.

The second story covered the latest alcohol consumption statistics. Adults in Scotland are continuing to drink more heavily than those south of the Border. Beer, wine and cider sales are similar to England and Wales. However, Scots drink far more spirits, almost three litres per adult per year, compared to less than two litres in England and Wales. Vodka, not whisky is the tipple of preference. It should be said that the good news is that alcohol consumption overall is reducing. However, it remains to be seen if this is more about the economy than a long term shift in consumption. 

NHS Health Scotland also found two-thirds of alcohol sold in 2012 was below the proposed minimum price of 50p per unit. The Scottish Government has taken steps to reduce harmful drinking, with measures such as banning multi-buy discounts, and it wants to create a minimum price to eliminate cheap alcohol from the market. They believe the fact that a quarter of alcohol bought from off-sales in 2012 was below 40p per unit, and two-thirds below 50p, adds weight to its legislation to introduce a minimum price.

Public health minister Michael Matheson said: “We still drink around a fifth more than England and Wales. That is fuelling much higher levels of harm, which results in 100 alcohol-related hospital admissions a day and costs Scotland £3.6 billion each year – £900 for every adult in Scotland.”

And that brings us back to big business because the Scottish Government’s plans have been delayed by a legal challenge from the drinks industry. Even at EU level objections have come in from cheap wine producers. Campbell Evans of the Scotch Whisky Association said: “Minimum unit pricing is not the way to tackle misuse – it does not target the heaviest drinkers, it would be illegal and it would damage the Scotch whisky industry.”

You see it's not about profit, the measure just wouldn't be effective. A familiar refrain from big business to justify their actions over the years. In the case of tobacco and alcohol, a combination of lobbying and legal action is certainly delaying important public health measures.

Scottish Government health programme

The Scottish Government has published its programme for government for the coming year. The health section provides the predictable long list of achievements. While this is expected, it unsurprisingly ignores the very real pressures that real term budget cuts are having on the service. Everything in the garden is apparently rosy, when self evidently it isn't.

The paper does helpfully reiterate the Scottish Government's approach to health service delivery by contrasting their approach with the shambles in England. 

"Scottish Ministers have categorically ruled out the disruptive type of reforms and upheaval being put in place in NHS England, and are committed to continuing to provide high quality health and social care to the people of Scotland that reflects the true values of the people delivering health and social care services in Scotland. The internationally recognised successes Scotland’s health services have achieved have been earned through working in partnership across the Scottish Government, the wider public sector and with staff. Looking ahead, Scotland’s approach remains one of integration, collaboration, innovation, and a focus on outcomes."

There is one new Bill. The Mental Health and Adults with Incapacity Amendment Bill aims to improve the operation and efficiency of mental health legislation for service users and practitioners alike. It will implement recommendations from the McManus Review Group, which reviewed specific aspects of the Mental Health (Care & Treatment) (Scotland) Act 2003. The Bill will also introduce new powers in relation to a Mental Disordered Offenders (MDO) Victims Notification Regime and will amend the Adults with Incapacity (Scotland) Act 2000 to remove the requirement for a single statutory ethics committee to consider all research-related applications involving incapacitated adults.

In addition to legislation, the programme includes other measures the government intends to implement in the coming year. These include:

providing a whole system response to improve the patient pathway in order to reduce pressure on Accident & Emergency (A&E) departments;

develop their strategy for engaging and empowering their workforce, providing a response in Scotland to addressing many of the issues raised by the Mid- Staffordshire/Francis Inquiry, and equipping them to work in an integrated way which reflects the different needs of different people and different places across Scotland;

achieve a sustainable performance on 4-hour A&E waits by the end of December 2013;

implement the world’s first national multiagency early years quality improvement programme across partner organisations to give Scotland’s children the best start in life;

achieve a measurable increase in early detection of cancer across Scotland, particularly in deprived areas, resulting in better outcomes.

Scottish Ministers regret the UK Government’s decision not to proceed with legislation to introduce plain packaging for cigarettes and other tobacco products. They will consult on the issue in the coming months, with the intention of introducing legislation in 2014-15. Similarly, the Scottish Government remains committed to introducing minimum pricing

per unit of alcohol, in order to reduce the terrible impacts of over-consumption. They will defend the legislation against any subsequent appeals in the courts. 

As with other sections of the programme there is nothing remarkable or unexpected in the programme. The Scottish Government's focus is on the independence referendum and little else.

Another go at health and care integration

Parliament will have another go at health and care integration next month with the Public Bodies (Joint Working) Bill. But will this be any more than moving the managerial deck chairs? 

Proposals for the integration of health and care services go back at least to the 1970‟s when the first joint finance arrangements were introduced. Since then we have had at least eight different initiatives and Acts, plus many reports. Staff who deliver these services could be forgiven for taking a somewhat cynical view of yet another reorganisation.

Almost everyone believes that health and care integration is a good idea in principle. However, the evidence from a range of studies indicates that structural integration in itself, and top down change in particular, does not deliver anticipated levels of service improvement. Petch (2011) states: “Differences in culture and in values and differentials in power tend to distort any blueprint and to undermine any projected model. Moreover major financial and time resources can be absorbed by attempts to implement such structural change without demonstrating effective outcomes”. These studies also show that local implementation is the key to effective service delivery across health and social care and that depends on culture, leadership, local history, context, time and vision.

 

If local implementation is the key, the apparent flexibility in the Bill for councils and health boards to agree a form of integration that meets local circumstances is to be welcomed. However, it may not be that clear. When you read the Bill, line by line, you are left with the impression that Scottish Ministers are granting themselves an extensive battery of powers to centrally direct their model of integration. Reserve powers of direction are reasonable, but this Bill goes much further and could result in a significant centralisation. 

Ministers can set outcomes that could be prescriptive - notably without any requirement to provide ‘inputs’ i.e. resources.  They must approve integration plans and have wide ranging powers to direct and set out requirements in regulations. Overall these powers reflect the NHS performance management approach that takes little account of local democratic accountability. Lets not forget that some £2.1bn of council spending is involved.

 

As these services are staff intensive you would have expected some detailed consideration to be given to the staffing aspects of integration. In which case you will be disappointed. The staffing provisions in the Bill are limited to contract protection aspects of TUPE only. There is no staffing framework as UNISON has proposed and this will, at best, lead to reinventing the wheel or at worse disruption. In addition there could be legal confusion over staffing decisions made by integration boards when they are not the employer.

 

Part 2 of the Bill includes shared services powers for the CSA and the establishment of Joint Ventures. These are enabling provisions, except that in Part 1 of the Bill ministers have powers to approve plans and direct contracts and services.  There is scope here for further privatisation and the Financial Memorandum indicates that regulations could direct third sector involvement. All too often on this issue there is a confusion between community engagement and ‘commercial’ voluntary sector delivery interests. £150k has also been provided to the private sector to support their engagement.

 

On costs, the Financial Memorandum is somewhat speculative and vague. The big financial gain from integration is supposed to be NHS bed costs from unplanned admissions. This has been estimated at around £1.5bn. However, these savings are only realised if the beds are closed and the Health Minister has put a big question mark over that. Glasgow and Lothian health boards have also recently called for more beds not less. I would also question if VAT will be recoverable by integration boards under the s33 exemption - remember the police and fire debacle on this point. £32m to the Treasury, rather than care services, would be an outrageous waste.

Overall, the powers in the Bill don't  match the rhetoric of local solutions.  There is a real concern that the centralising tendency of government, overrides the strong evidence that top down direction doesn't work. 

Dave Watson

Austerity Kills

Dave Watson argues austerity kills and offers some reading to prove it.

I was out for a drink in Glasgow recently (I know, not a good start for a health blog!) and bumped into a group of psychiatric nurses I used to represent in Glasgow hospitals. We got chatting about work and the impact of the recession on their job. They could all give examples of patients who had been admitted to hospital with a range of mental health conditions linked to their changed economic circumstances. A CPN told me of a patient in the community who lost his volunteering role and other support and is now back in an acute ward.

There has been plenty of analysis of the economic and social impacts of austerity economics, but much less on the disastrous effects on human health. Cutting key public services at a time when people need them most. As a result many countries, including the UK, have turned their recessions into veritable epidemics, ruining or extinguishing thousands of lives in a misguided attempt to balance budgets and shore up financial markets. Yet sound alternative policies could instead help improve economies and protect public health at the same time.

This is charted by public health experts David Stuckler and SanjayBasu in their provocative book, ‘The Body Economic, Why Austerity Kills’. Through extensive data and case studies they show how government policy becomes a matter of life and death during financial crises. Clive Cookson’s review in the Financial Times sums this up well:

“Austerity kills – and on a grand scale. So argue David Stuckler and Sanjay Basu in The Body Economic, a powerful attack on efforts to curb public spending since the financial crisis, which holds belt-tightening politicians responsible for a health catastrophe.... [B]y telling the stories of individual victims of austerity as well as analyzing its impact at the population level,Stuckler and Basu provide a wealth of evidence that it is bad for our health. That is a valuable contribution to the current debate.”

The charts below illustrate just one example of their analysis. You might think this is a heavy data read and not for me. But the case studies help to break up the data and make this a very readable book. Try it.

Happy Birthday NHS Scotland

Happy Birthday to the NHS, 65 years young today. Probably Labour's greatest political achievement and as essential today as it was after the Second World War. There is no question of retirement, at least not in Scotland. We can be grateful for a broad political consensus that recognises the value of public service delivery.

Not so in England. As Polly Toynbee highlights in the Guardian today, health competition is hugely inefficient and comes at a cost. Queues of ambulances stack up outside bursting A&Es, with emergency admissions up by 35%. 4,000 nurses gone and patients waiting over six weeks for diagnostic tests that are up by 88%. GPs are seeing 40 patients a day with their appointments systems gridlocked.

Almost everything can be tendered out to Any Qualified Provider. NHS Direct is broken up among 46 bidders for local services, paid only 30% of the old cost per call, so already many contracts are going bust. The result is unqualified call-centre operators pouring extra patients into A&E with trivial complaints. The London ambulance service is using 10 times more private ambulances, at a cost of £4m a year. Between a quarter and a half of all community services are now run by VirginCare.

The most outrageous example quoted by Toynbee, is two hospitals trying to merge in Poole and Bournemouth have spent £1.67m on legal advice from costly competition lawyers. It reminds me of when Scottish hospitals were structured into trusts, employing marketing managers before doctors.

Of course all is not well with NHS Scotland. Despite some protection from the cuts, around 6000 staff have been lost since the financial crash. This has resulted in real pressures on the service.  Emergency beds made available to help the NHS cope with a flood of patients last winter are still being used because regular wards are overflowing. The average number of available staffed beds in Scotland's acute hospitals have fallen by 1400 since 2003, with a big increase in private bed spending as a consequence. A&E waiting times have trebled in some boards and MSPs are calling for patient records to be checked for waiting time manipulation. These are largely the consequences of financial cuts, but at least we are not wasting resources on an ideological drive to competition.

Financial and demographic pressures have started a debate on what should be provided by the NHS. The latest is Hugh McLachlan in today's Scotsman. He argues: "If we tried to provide on the NHS all that might reasonably be thought of as appropriate medical treatment, it is likely that we would be unable to pay for services such as pensions or free primary, secondary and higher education without raising significantly more money in taxation."

He follows and supports Professor Frazer's view that we should consider discrimination on the basis of age in the allocation of NHS health care. He argued that: “We have to be realistic and say if you spend the resources on treating an 85-year-old with pneumonia, then you won’t be able to treat a 35-year-old who’s had a car crash. It is as simple as that.”

While there is a valid debate to be had about what NHS Scotland should do, we must remember that the NHS is primarily a treatment service. The biggest challenge for health in Scotland is not the NHS, but health inequality. In Glasgow alone we can still see differences in life expectancy as extreme as 54 years in the poorest communities and 82 years in the most affluent, a near 30 year difference. David Conway's post on this site outlines what we need to do, recognising that this is not a matter for NHS Scotland alone and requires a comprehensive policy response across all government departments.

A new drive to tackle health inequality would be a fitting way to celebrate the NHS in Scotland's birthday.