Making parity of esteem a reality

- September 5, 2014 posted by Dorothy ChenDorothy Chen

In any year, one in four British adults experience at least one mental disorder. Poor mental health is the largest cause of disability in the UK, and is closely connected with poor physical health and reduced life expectancy.

For conditions that affect such a large proportion of the British public, it is astonishing the extent to which mental health needs are unaddressed.  Only 25% of people with common mental health problems receive treatment, compared to 94% for diabetes, 91% for hypertension and 78% for heart disease.  Inequities are also reflected in monetary terms, with mental health services claiming only 13% of NHS expenditure while accounting for 28% of total morbidity.

Recent years have seen important progress made towards achieving parity of esteem in policy terms.  The Health and Social Care Act 2012 explicitly recognises the Secretary of State’s duties in relation to both physical and mental health.  This principle underpins the mental health strategy and implementation plan for England, as well as the work of NHS England through the NHS Mandate.  No doubt this will also be reflected over the coming months as the major parties lay out their visions for the NHS.

However, funding for mental health has not kept pace with its improved profile.  A recent analysis by the Health Service Journal (HSJ) has shown an average 2.3% real-term funding cut for NHS mental health providers between 2011/12 and 2013/14, with the income of nearly a third of these providers slashed by more than 5%.  Even in the context of the affordability challenge facing the provider sector, it is difficult to see how mental health trusts could squeeze more out of their services without compromising quality of care.

As attitudes surrounding mental health continue to change for the better, it will be important to fuel this momentum through the right financial levers and incentives.  The proposal for an end to mental health block contracts in the 2015/16 National Tariff is a step in the right direction.  But more needs to be done to develop and refine an alternative approach which would ensure that money goes where it is needed to give patients the best possible care.

In a speech to the Royal College of Psychiatrists, Health Minister Norman Lamb said that it is only when we change how people think about mental health will we be able to change how people prioritise and spend their money.  Good headway has been made towards the first of these ambitions.  It is time to turn to the latter and make parity of esteem a reality.



Healthcare: a major issue for marginal voters

- August 29, 2014 posted by Edward NickellEdward Nickell

In theory, everyone’s vote in the 2015 General Election will count.  In reality, it’s votes in marginal seats that will decide who ends up in Number 10.  Marginal seats are important to the election, but is the NHS important to marginal seats?  If it is, what does that mean for the candidates?

In the run up to the election, pundits and journalists will talk about marginal seats a lot, but they only give a simplified picture.  We need more detail to understand how health issues actually affect voters in marginal seats.

Election blog ‘’ intends to fill that niche.  Run by three recent graduates, the blog will visit the 50 most marginal seats before the election to meet the candidates and voters.  I joined the 50for15 team on their visit to Oxford West and Abingdon.

Members of the Abingdon public were certainly forthright with their opinions.  I got an earful on everything ranging from a slip road onto the A40 to the prospect of mass deportations.  Health was near the top for most people and for Labour voters it was issue number one.  Labour can still win some easy votes off the back of the NHS; one person asked me which party founded the NHS, then with no further thought, pledged to vote for them.

50for15 will also be visiting North Warwickshire where Dan Byle MP (Conservative) won his seat from Labour by only 54 votes.  The Keogh review, which investigated hospitals with higher than expected mortality rates, found serious failings in two nearby NHS Trusts: George Eliot Hospital and Warwick Hospital.  These hospitals were placed in special measures, which meant they had to produce an improvement plan and be subject to closer monitoring.  Going into special measures also means embarrassing headlines in the press, which can be followed by health care horror stories as journalists cover examples of bad practice.

Warwick isn’t a one off: Unite have identified 11 similar marginal seats.  This week in the Health Services Journal election blog, Jenny Ousbey writes, ‘Many of the original 11 trusts placed in special measures were located in marginal Conservative constituencies and they will be the ones that ultimately decide the next election.’

People know these hospitals are exceptions, but people naturally explain what happens locally through some wider narrative such as immigration, cuts or privatisation.  This narrative then influences their vote.  This is true in areas with good hospitals too, where many people have friends or family working in the NHS.

All this means that NHS managers will notice Westminster hopefuls becoming increasingly attentive to their local health providers in the coming months.  Candidates who are seen to press for local improvements in healthcare could reap electoral rewards.

The calm before the storm

- August 7, 2014 posted by Andrew WilkinsonAndrew Wilkinson

We may still be 275 days away from the next General Election, but its place on the horizon is already weighing heavily on health policy.  Despite the calm of the long parliamentary recess, the upcoming battles are nevertheless beginning to take shape.

Let’s work backwards from polling day.  For the five and a half weeks before 7th May 2015, Parliament will have been dissolved and the pre-election convention of ‘purdah’ will have been in force.  During this period, which in 2015 will be significantly longer than usual owing to changes brought in by the Fixed Term Parliaments Act, only essential business can be carried out by Government or public bodies such as NHS England, given the need for political neutrality before the election.  In practice, risk aversion around policy in advance of the election is likely to commence even earlier.

The Party Conferences, taking place from the middle of September through to early October, will see political debate intensify, with barely any let-up in the seven months to the General Election as the parties seek to set out, sell and debate their proposals for the future of the health service.  Within this period, the Christmas and New Year break are likely to provide only brief respite – and less than that if a winter crisis, averted last year, should hit the NHS this time around.

The Conservatives, with a Ministerial team in Health left untouched by the Prime Minister’s recent reshuffle, will seek to frame their offer as one of continuity, with nods to GP-led commissioning and their efforts to present themselves as patient champions.

Meanwhile, Labour will seek to advance a debate on the integration of care, widening discussion to encompass not just the NHS but the ailing social care system.  Of course, Labour will also take every opportunity to position the party as defenders of the NHS against privatisation and to remind voters of the chaotic passage of the Health and Social Care Act.  Labour has pledged to repeal the legislation but leave the associated structures intact.

The Liberal Democrats will also focus on integration with a particular emphasis on parity of esteem between mental and physical health, championed by Norman Lamb.

However, this year the political debates will be formed in the shadow of two additional considerations.

First, an unprecedented funding challenge for the NHS.  With NHS England only belatedly projecting a break-even position in its finances for 2014-15 and worse to come, expect major health stakeholders to raise the alarm if political parties fail to provide credible reassurance of their plans to finance the NHS in the years to come.

And secondly, unlike any previous election year, the political parties will have to respond to the healthcare agenda set out by NHS England in its newly autonomous role.  Simon Stevens, practised in politics, will bring to a close his publicly guarded first six months as Chief Executive by announcing his Five Year Forward View this autumn.  Both parties will need to consider this carefully and calibrate their response.

Big debates therefore lie ahead, and sooner than you might expect.  The summer break will be over in no time!

Clinical commissioning group’s restrictions on IVF may be a taste of what’s to come

- July 30, 2014 posted by Rosie BeauchampRosie Beauchamp

It was reported last week that Mid Essex clinical commissioning group (CCG) is considering whether to place significant restrictions on access to fertility services in an attempt to manage its growing deficit.  The CCG estimates that by limiting IVF to HIV positive men and people with cancer, it could save up to £550,000 a year.  The CCG has been criticised for “discriminating” against couples, who would be eligible for three courses of treatment in accordance with NICE’s clinical guidance, updated as recently as  February 2013.

The rhetoric surrounding the announcement of GP led commissioning in Equity and Excellence back in 2010 came out of the Government’s desire to instil a commissioning system that was sensitive to the needs of its local populations.  While in theory this meant that services would be commissioned to meet the needs of local populations, the unspoken reality was that local commissioners would be required to prioritise services, making judgements about those which were more or less important.

This prioritisation process is made all the more difficult by the financial turmoil facing CCGs, with a significant proportion reporting unplanned deficits.  CCGs’ financial woes existed almost from the moment of their inception; historical underfunding from PCTs, unexpected rises in demand and unplanned top-slicing by NHS England for the commissioning of specialised services in 2013, have made it increasingly difficult to balance the books.  The somewhat inevitable outcome is that rather than making positive commissioning decisions about what services will best serve their communities, CCGs are assessing what their population can do without.

Comments left by HSJ readers on the story represent a range of views on the value of IVF, but this is almost beside the point.  The NHS must of course ration its resource but it must do so equitably.  Geographical location, it has consistently been agreed, is not an acceptable way to determine what services individuals should have access to.  Nor should local commissioning mean prioritising services for the majority at the expense of the minority.  Mid Essex CCG only funds IVF for between 70-100 people each year and one suspects that these small numbers make it an easy target for those seeking to cut costs.

When CCGs are withholding services from their constituents which are available to others, they are not meeting the needs of their population.  At times it seems as if the idealistic vision of clinical commissioning as set out in Equity and Excellence is a distant memory.

Screening: known unknowns

- July 21, 2014 posted by Sarah FisherSarah Fisher

The House of Commons Science and Technology Committee held its final evidence session on national screening programmes recently, hearing the concluding remarks on an inquiry which has hosted everyone from the deeply sceptical Professor Michael Baum to the Chair of the UK National Screening Committee, Professor David Walker. The inquiry’s remit was very wide-ranging –  looking at whether prenatal screening for inherited metabolic conditions should be considered alongside population screening for breast cancer was problematic from the outset and so it proved.

For me, what emerged most clearly from the evidence sessions was that, as Síle Lane from Sense about Science put it: “screening is not like any other kind of medical intervention”. Screening is not diagnosis and most people who are screened for a disease will never go on to develop it.  It is unsurprising, therefore, that population screening can easily be portrayed as a hammer to crack a nut.  A further complication is that the impact of screening is very difficult to quantify and the figures can easily be skewed to suit arguments on either side of the fence – Professor Baum noted that breast cancer screening is often described as having a relative risk reduction of 15%, however, when translated into absolute terms, he observed that you have to screen between 1,000 and 2,000 women for 10 years to avoid one breast cancer death.  Similarly, studies demonstrating the over-diagnosis and over-treatment effect of breast cancer screening are flawed in their reliance on observation and association rather than direct causation.

Although they might have been divided in their diagnosis of the situation, the inquiry’s witnesses were relatively united in their prescription: better information, clearer lines of accountability and ongoing assessment.  The case for better information was illustrated particularly forcefully, with Robert Meadowcroft of the Muscular Dystrophy Campaign highlighting the heartbreaking example of parents being told that the test for Duchenne muscular dystrophy “always comes back negative, you’ll be fine” before receiving the devastating result.  Likewise, accountability for screening programmes is split between NHS England, Public Health England and the UK National Screening Committee – necessitating a coordinated approach across organisations with diverse remits.  The Committee will try to address some of these issues in its report, however as technology develops and new screening techniques emerge with the ability to predict the likelihood of us contracting an ever greater range of conditions, its recommendations are unlikely to be the final word on this divisive and important subject.

The NHS and political interference

- June 26, 2014 posted by John MurrayJohn Murray

The same week as a BMA survey finds that the public is keen to see an end to political interference in the NHS, Jane Ellison, the Minister for Public Health is reported as bemoaning that she and her colleagues no longer have the ability to crack the whip with NHS England.  Can both be right?

Well it’s certainly true that Andrew Lansley’s stated intention in 2010 was to liberate the NHS from day-to-day political interference.  This was significantly watered down during the passage of what became the Health and Social Care Act 2012.  We have, however, seen many examples of NHS England cocking a snook at ministers, whether by holding their ground on the revised Mandate or reducing mental health tariffs disproportionately.  Just because Jeremy Hunt invites Simon Stevens to Richmond House doesn’t mean that he is bound to follow.

It’s ironic then that the spectre of political interference should be such a potent mantra for the BMA in its ongoing guerrilla campaign against the government.  In truth, Whitehall’s ability to respond to a dropped bedpan has never been lower.  But then again, nor has the stock of the political class been at a lower ebb and thereby, most probably, hangs the tale.

More to the point, should we be alarmed or concerned about the significant but waning ability of government to pull rank with the NHS, also evident in the far greater autonomy enjoyed by Foundation Trusts?  That perhaps depends on the responsiveness of those public bodies.  If NHS England genuinely engages with and responds to the wider world so much the better.  In the absence of consumer power in healthcare, however, ministers and politicians remain the only recourse for those faced by a powerful bureaucracy should it turn a deaf ear to legitimate concerns.

For the time being, political interference therefore remains a necessary evil.



A politician takes the NHS helm

- May 15, 2014 posted by John MurrayJohn Murray

Simon Stevens has only been in post as the Chief Executive of NHS England for six weeks but those weeks have been instructive.

A typical public servant would go into a period of purdah on arrival at something as large and complex as NHS England, venturing forth after perhaps 90 days to begin sharing first impressions.

It doubtless helps that Simon Stevens has considerable past experience of the service but the extent of his early travels has nevertheless been striking, putting him in contact with patients of all kinds, young and old.  Furthermore, as he has been photographed on tour, he has demonstrated the relaxed demeanour usually only seen in a top class politician.

The speed with which Stevens has begun to set out his policy agenda has also been striking, reflecting perhaps the modern political consensus that you only get one honeymoon in office and it pays to make the most of it.  Doubtless, an appearance before the Health Select Committee demanded some more hard-edged thinking but use of elbows in relation to the scope of specialised commissioning (a ministerial decision) and CCGs’ involvement in primary care commissioning (immediately raising Labour hackles) demonstrates striking confidence.

Similarly, he has grasped the importance of the cultural issues that can so easily turn nasty, taking a 10% pay cut on appointment and moving swiftly to introduce greater transparency around NHS England’s dealings with external stakeholders.

So a very different type of Chief Executive for what is acknowledged to be a very different type of role to that taken on by his predecessors.  The big things that Simon Stevens needs to do will get done as much by charm, persuasion and political positioning as by much diminished executive power.

The NHS has been fortunate to secure a very talented man for a knock-down price.  Whether that will be enough, and how it will wash with the real politicians in Westminster, remains to be seen and will be fascinating to watch.


Partnership working in NHS procurement reform – the way forward

- March 24, 2014 posted by Dorothy ChenDorothy Chen

There is a clear financial crisis looming over the NHS.  65 out of the 245 hospital trusts are predicting a deficit for 2013/14, the highest proportion observed in NHS history.  34 of these are Foundation Trusts, whose very license with Monitor stipulates financial sustainability.

The Department of Health (DH) has attributed much of the financial crisis to inefficiencies in NHS procurement.  Data on NHS expenditure for the last three years shows that non-pay spend in the NHS has been increasing at about £2billion (or 10%) a year.  No doubt, some of this can be attributed to the reorganisation and increasing demand for NHS services.  However, with total activity over the same period only reporting a 2.9% growth per year, the Department is certainly right to be concerned.

To those familiar with NHS procurement, these figures may hardly seem surprising.  Procurement practices have been variable ever since hospital trusts were set up as stand-alone entities, each looking after its own purchasing and supply chains.  This has led to providers paying vastly different sums for the same supplies.  Without bulk buying, the NHS as a whole is failing to negotiate best prices and get the best value for money.

DH’s solution to this problem is the “key supplier programme”.  The programme aims to engage with the NHS’s top suppliers (those that have the most business) to see what can be done to reduce costs.  The idea is for the NHS to act as a “single customer” rather than having each provider negotiate their own prices and setting up multiple small contracts with the same suppliers.

As part of this programme, DH is seeking data from key clinical suppliers on how medical technology is currently procured and used across the NHS.  This is difficult for a variety of reasons, including confidentiality agreements and logistical issues around the release of pricing data from individual companies.  Industry has also expressed concerns around the impact of such schemes on innovation, particularly in relation to the government’s commitments set out in “Innovation, Health and Wealth”.  Comparing apples with apples can be more challenging than first appears in healthcare.

Meanwhile, DH and Monitor have written to individual providers, advising them to stop signing confidentiality agreements with suppliers in line with transparency guidance which is due to be introduced in April 2014.  The guidance will include an additional clause in the Standard Contract which mandates trusts to make their procurement information publicly available, including the prices they pay for goods and services.  DH’s message to industry is clear – we will sort out NHS procurement, with or without your help.

Realistically, however, DH is unlikely to make its target of £2billion savings in NHS procurement by 2015/16 on its own.  Even if all providers stop signing confidentiality agreements with suppliers today, the multi-year terms of industry-standard agreements mean that pricing information on some products will not become available until after 2015/16.  Further complicating matters, medical products are often sold as part of different services bundles, leading to wide price discrepancies.  These cannot be properly accounted for unless DH knows how much service level support is included in each price – information that industry is best placed to provide.

Regardless of its good intentions, the Department’s approach risks alienating key industry players at a time when their data and expertise are indispensable to achieving targeted savings.  It also seems out of kilter with the NHS’s role as commissioner and the emphasis in policy on procuring for outcomes rather than by price alone.  A better approach may be to recognise mutual benefits, jointly identifying waste, with the possibility of sharing potential savings.  As is often the case in partnership working, this will require as much of a commitment from industry as from DH, working closely with the NHS itself.

Getting the balance right: self-management for long-term conditions in the new NHS

- March 17, 2014 posted by Tessa HughesTessa Hughes

Long-term conditions affect 15.4 million people, more than a quarter of the population, and NHS England expects this to rise by almost a third by 2018.  In a recent blog post Martin McShane, NHS England’s Director for long-term conditions, set out his three part plan for meeting the increasing demands on NHS services: understanding the needs of the population and tailoring services accordingly, person-centred care planning and team work.

Most importantly, McShane states that “people want and need to be involved in planning their own care.  They want to have support and care that gives them as much control as they want”.  This is in line with the current trend for patient-centred care, rather than paternalistic approaches.  Central to this is ensuring that patients have the information and support to self-manage their condition.  The benefits of self-management are significant – it has been found to improve health outcomes, patient experience and improve adherence to treatment and medication.

Self-management was a key theme during my time at Diabetes UK and remains a priority for them today.  Diabetes, like many other long-term conditions, is with people every day.  Small and large adjustments will be required to keep diabetes under control and avoid both short-term and long-term complications of the condition.  It is therefore not surprising that it was a Diabetes UK expert patient programme that outgoing NHS England Chief Executive, Sir David Nicholson, chose to attend undercover recently, trying to get a better understanding of the needs of people with long-term conditions.

Diabetes UK is always clear that effective diabetes management should be in partnership with the healthcare team.  People need access to appropriate training and support to even start to understand about self-management and will still have questions along the way that require the input of healthcare professionals.  There is still a long way to go until NHS commissioners fully understand what is required to support effective self-management.  Access to structured education programmes for newly diagnosed people with diabetes is just 50% in some of the best performing areas of the country.  In the worst areas, no one is offered this support.

Last week, Arthritis Care and NRAS chose to withdraw from a winning bid with Circle Health to provide supportive self-management services in Bedfordshire because they did not believe that sufficient resources had been made available for them to provide the necessary support.

Effective self-management requires investment.  Empowering people to understand and manage their conditions may lead to happier patients with better health outcomes but it won’t necessarily save the NHS lots of money in the short term.  Perhaps most acutely aware of this is Sir David himself who spoke last week of the billions of extra funding that will be required to support much needed NHS reforms.

Bringing lobbying into the open

- February 11, 2014 posted by John MurrayJohn Murray

JMC Partners has recently been the subject of press interest in relation to the ethics of lobbying.  This is something we welcome, providing it is accurate and informed.  Indeed, the ethics of lobbying formed the subject of a blog in March 2012.  This reflects our consistent interest in the  subject and is reproduced below.  In particular, we stand by the importance of well informed lobbying, transparently declared, as an essential contribution to good government.

Lobbying – is the government proposing a solution to the wrong problem?

Sadly lobbying has become a pejorative word which we usually apply to those putting a case with which we disagree. A prominent public figure and journalist regularly sounds off about the iniquities of lobbying and lobbyists, conveniently forgetting that he himself constantly lobbies through that most privileged of channels – a weekly column in a national newspaper.

JMC Partners has an interest to declare – lobbying is a significant part of what we do – but far from being ashamed we take great pride in our ability to help inform policy development, believing that it is better as a result. In particular, our focus is on supporting clients who have an interest which coincides with the public interest. Conversely, the role of politicians and civil servants is to distinguish between that which is genuinely in the public interest, while giving short shrift to special pleading.

This competition of ideas at the heart of lobbying is important to good government and happily recognised as such in Westminster. It must however be supported by free access and complete transparency. In other words, anyone must have the opportunity to raise legitimate issues of public interest with policy-makers regardless of party affiliation and, crucially, without the exchange of money. In doing so, they must be clear about who they represent and such transparency should be a precondition of engagement on the part of politicians and civil servants.

Over the years, there have been examples of professional lobbyists behaving unethically, for example by offering cash for parliamentary questions in the 1980s. Any such behaviour is anathema to the majority of lobbyists and explicitly forbidden by the likes of the Association of Professional Political Consultants. The majority of problems tend to arise on the side of the lobbied rather than those lobbying, often when the dividing line between personal relationships and political access becomes blurred, with the proximity of money making for a more toxic mix.

The government’s current proposal to introduce a statutory register of lobbyists is in many ways a response to these other problems. Lobbyists seem unlikely to object on business grounds but without insupportable bureaucracy a register seems unlikely to capture the kind of contacts which have attracted most criticism in recent years. Only ministers and civil servants can ultimately ensure an ethical approach to access and transparency, mindful of the need to put themselves above suspicion.

Views expressed are those of the author, not JMC Partners.