Archive for April, 2011

Does Social Mobility mean going to the Pub?

Thursday, April 7th, 2011

One of the key things that David Cameron has failed to articulate about his “Big Society” is that it is primarily about strengthening communities. Instead, he has stressed volunteerism. My own view is that most people who would volunteer already do so and he is flogging a dead horse.

There are other ways that communities can (and should) be strengthened. In modern society, we often drive to work, drive the children to school, drive to the shops, drive everywhere. This has led to a diminution in the day-to-day social interactions that are the foundation of community spirit and this loss has led to the sense of isolation many people feel.

Hence we should be looking for ways to reverse this trend and increase social interactions, particularly those where people from all walks of life interact.

There are limited places where this can happen: immediate neighbours, the pub, local sports, the local fete (and other local events) and local shops. I’ve deliberately excluded religion as we should not be in the business of promoting it.

Local planning and national regulation can help increase these opportunities for interaction and help ensure that people interact with a wide cross-section of classes:

  • By ensuring housing developments include a range of prices
  • By regulating the minimum unit price of alcohol we can encourage people to meet at the pub instead of binge-drinking at home
  • By funding sporting facilities and encouraging local teams
  • By funding village halls, though it isn’t clear to me what the urban equivalent would be
  • By ensuring local shops can thrive
  • By ensuring local banking and post offices are available

“Who-you-know” certainly helps with social mobility as your social network often determines the opportunites that are open to you. So the wider a person’s social network the more opportunities exist for social mobility.

In a real sense, that bloke you know down the pub can help you get along in life. Of course there are other things that matter, most obviously education.

PS “Big Society” has to be the worst articulated good idea ever. If you consider it – as I think DC intended it to be – as a tool for strengthening communities, then it is an idea we should support.

#Yes2AV tweets

Wednesday, April 6th, 2011

For fun, I thought I’d see if I could come up with a list of tweets that are either funny (or not given how bad I am at jokes) or explain something about AV:

  • #Yes2AV To vote, rank them in order. To count, successively re-allocate the smallest pile until you have a winner. A simple as 1-2-3!
  • #Yes2AV In a 4 horse race that goes 3 rounds before you get a winner, everyone gets 3 votes. But remember, a horse still wins
  • Moat cleaner required? Then just vote NO! #Yes2AV

I’m sure you can come up with better than these!

BMA response to the Bill

Tuesday, April 5th, 2011

After re-reading the BMA response, I find myself more in agreement with them than with our own list of essential amendments!

More on the conference motion

Tuesday, April 5th, 2011

In a post yesterday, I took issue with a few of the points in our conference motion, in particular 9) that talks about a “majority of councillors”.

Well, this had me wake up in the middle of the night and unable to sleep. I’ve now decided that Conference took the notion of “democratic accountability” way too far. Healthcare is as much an industry as is making paint. It is nonsense for a bunch of councillors to tell a commissioning consortium what to do as it is for a councillor to tell Dulux how to make paint. It also makes a mockery of two key goals of the legislation: to make healthcare physician-led, and to remove it from political micromanagement.

Adding a “substantial portion” of elected councillors (point 5), let alone a majority (as implied in 9) replaces national political interference with much more pervasive local interference.

However hidden in all this is the kernel of a good idea: having a councillor or two in a commissioning consortium is a good idea. It allows oversight, local representation, and a channel-of-last-resort for complaints. It also enables communications and easier integration of primary healthcare with the wider Public Health and Social Care services envisioned under the remit of local authorities.

It is also correct that the commissioning consortia need to be accountable, not just to patients but to the tax-payer who funds them and to professional bodies. However, these requirements don’t translate into a need for elected councillors. Instead, they require full transparency, patient consultation, complaints procedures, professional standards and fiduciary responsibility. And ultimately, sanctions for bad conduct.

There is also no good reason for the catchment area of a commissioning consortium to be co-terminous with a local authority. Given living and commuting patterns, in many cases I suspect that it is non-sensical. It certainly inhibits specialised commissioning consortia which may require large, regional catchment areas. It also feels deeply illiberal.

As a consequence of this midnight epiphany, I find I disagree with the thrust of points 4 to 9 inclusive. On accountability of the consortia, that is the section I’m reviewing next, so I may yet change my mind on some of this.

Improving healthcare outcomes

Monday, April 4th, 2011

The next installment of my series on the Health and Social Care Bill. I’m still ploughing my way through the white paper . . .

Improving healthcare outcomes

I think the first sentence of this section bears repeating:

“The primary purpose of the NHS is to improve the outcomes of healthcare for all: to deliver care that is safer, more effective, and that provides a better experience for patients.”

How can you argue with that? The section continues with a thoughtful discussion of targets. The key phrase on removing process-oriented targets is “These targets crowd out the bigger objectives of reducing mortality and morbidity, increasing safety and improving patient experience more broadly“. There is more on targets, but sensibly focussed on safety, outcomes and patient experience.

Another key section talks about replacing the relationship between politicians and professionals with one between patients and professionals, reinforcing the removal of political interference.

The NHS Outcomes Framework

This section states the intent to provide separate frameworks for the NHS and for Public Health (and Social Care) and then outlines the NHS Outcomes framework and how it translates in to a commissioning outcomes framework for consortia.

This framework will cover effectiveness (i.e. outcome), safetly and patient experience. The consulting process and the goals and focus (outcomes, safety, and experience) of the framework seem sensible.

Developing and implementing quality standards

This section outlines what quality standards for care will be implemented, the expectations on these standards, and the timescale for rolling them out. It envisions some 150 quality standards over the next five years. At the time of publication, three had been implemented (on stroke, dementia, and prevention of venous thromboembolism). The example shown (on the prevention of thromboembolism) has seven quality statements and looks sensible (but really I’ve not that much idea as I avoid most medical stuff as it is just too icky and I’m rather squeamish).

Overall, the goals and timescale look reasonable, though I can’t assess what fraction of common clinical pathways are covered by 150 or so individual standards.

Research

A short section on the importance of research. While the statements here are admirable, the brevity of the section highlights the woeful lack of scientific knowledge within government! I would really have expected an outline of a framework and some tentative goals (though this is always tricky with research – you never know quite what you’ll find).

Incentives for quality improvement

A complex section on development of payment systems, currencies, and tariffs. I’m not sure I fully understand this yet, and need to read it carefully. On first reading, it seems to promote payment for quality over mere cost but I’m unclear how the payment systems work and whether this intent to provide quality of outcome incentives will or can work. I’ll revisit this after talking to a few who may know!

Overall: Looks sensible, and other than what I think is my own lack of understanding, I can’t find much to quibble about. Oh, yes I can: we need more people with at least a basic understanding of science in government!

On the conference motion

Monday, April 4th, 2011

A quick aside. In my previous post, I said I disagreed with some of the points in our conference motion. Here’s the list, and my reasoning:

3. Secretary of State to remain responsible for the final decision, if needed, when major service changes are opposed by local democratic scrutiny bodies on behalf of their community.

If we are serious about devolving decision-making to local bodies, this seems odd. The whole point of localism is to allow local decisions. The point might be okay if it defined “major service changes”.

8. The commissioning function (i.e. not back office functions) to be carried out directly by public authorities rather than subcontracted to non-public bodies; using public sector staff and employing the skills of existing PCT staff

Why? The commissioning function should surely be carried out by the Commissioning Consortia, otherwise what are they for?

9. Unless Commissioning bodies have a majority of councillors, there must be scrutiny of all commissioning decisions by local elected councillors either through the local authority, Overview and Scrutiny Committees, or Health and Wellbeing boards (which must have a majority of councillors to fulfill this role)

My concern here is that commissioning bodies remain clinician-driven, not local political entities – one clear goal of the legislation is to remove political interference. It is fine for commissioning bodies to include councillors but the majority should be clinicians.

16. Complete ruling out of any competition based on price for tariff-based services (and not just at the point of referral or the point of patient choice);

Why? If all else is equal (e.g. quality, timeliness, etc), why rule out price?

Liberating the NHS

Monday, April 4th, 2011

Continuing my look at the White Paper. I’m slowly arriving at similar conclusions to our conference motion (though I disagree with several of the points in that motion; more on that in another post). I’m also looking at this in the context of the BMA response, which also makes sensible suggestions.

Anyway, let’s look at the first section: “Liberating the NHS”.

Our Values

Not much to argue with here. This section makes it plain that the vision is a service that is fair, equal, and free at the point-of-use. It also identifies the following necessary improvements: removal of political interference, additional autonomy, transparency and accountability.

The NHS today

Stripped of the seemingly mandatory praise for the NHS, this section is fairly damning of its performance:

“Compared to other countries, however, the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world”

“… the NHS has high rates of acute complications of diabetes and avoidable asthma admissions; the incidence of MRSA infection has been worse than the European average; and venous thromboembolism causes 25,000 avoidable deaths each year”

“The NHS also scores relatively poorly on being responsive to the patients it serves. It lacks a genuinely patient-centred approach in which services are designed around individual needs, lifestyles and aspirations. Too often, patients are expected to fit around services, rather than services around patients.”

To me, this section highlights two things. First, the national myth of the NHS, which surrounds it in a rosy glow and isolates it and its staff from criticism, is deeply flawed. Second, the NHS desperately needs reform. By some measures I’ve seen, we’ve underinvested over the last 25 or so years by >£250bn! [Grr, where did I read that? I'll link to the source if I can find it!]

Our vision for the NHS

The callout box is great, highlighting the need for a service that is patient-centric, clinician-driven, with quality and outcome targets, reduced inequalities, better geographic (localised) organisation and sustainability.

I have concerns over the reality of cost-savings from the restructuring proposed. In the past, these have often been illusory, with serious failings in the implementation of well-intentioned reforms. On the plus side, the proposed legislation is radical and the restructuring profound, so cost-savings may well be real.

Improving public health and reforming social care

Another good idea, addressing a deep lack in the NHS: overall public health. It also covers the need to integrate this with social care (it sets out a timetable for reform of social care).

The transfer of local health responsibilities from PCTs to local authorities makes a lot of sense! Public health covers not just primary and social care, but environmental and infrastructure issues (for example: refuse, education, communications, housing, sports facilities, etc) which necessarily belong to local authorities.

The financial position

Not much to say . . . this section reiterates the need for structural reform and cost savings in administration, but sets this against a backdrop of increased (real terms) spending. It also calls for much increased productivity. Let’s wait and see how this translates into reality. Call me cynical.

In summary: the vision outlined here accords well with liberal principles, though as always, the devil will be in the details of the implementation. Next up: “Putting patients and the public first”.

The Health and Social Care Bill

Monday, April 4th, 2011

After someone on the Liberal Democrats Facebook page asked what my view was on pushing ahead with the cuts to and the reform of the NHS, I decided to read the whitepaper Equity and Excellence: Liberating the NHS and the Health and Social Care Bill.

My first impression is that the whitepaper shows none of the weasel words and compromise often seen where there is serious disagreement and feels like a coherent whole. So I think Andrew Lansley and Paul Burstow share a common vision for the NHS. As a consequence of this, the bill is far more radical than anything in either party’s manifesto!

This will be a series of posts, as there is a lot of material to digest. In this first post, I’m going to focus on the intent of the legislation, drawn largely from the summary of the white paper.

Putting patients and public first

It’s difficult to argue with any of this. What I think is noteworthy:

  • Strengthens localism, based around local authorities
  • Clear intent to reduce inequalities

Improving healthcare outcomes

  • Great shift from process oriented targets to outcomes!
  • Nice focus on openness, responsibility, and above all outcomes

Autonomy, accountability and democratic legitimacy

This feels like one of the key sections to me. It seems clear there has been a meeting of minds over the need to remove the NHS from political interference and put healthcare into the hands of patients and clinicians.

  • Devolution to commissioning consortia. This is great in principle but I have concerns that finance isn’t a core skill of clinicians. However, addressing this is a question about mechanisms – the intent is great.
  • Intent on legitimacy is good, but the single statement on the responsibilities of local authorities feels a bit weak. There is no statement on legitimacy of consortia, which is an issue: patients must have an input.
  • It’s not clear that making all NHS trusts become foundations is either good or bad. However, I’ll roll with this for now as simplification feels good.
  • The clause on the Monitor has a problem: the duty to promote competition must make it clear that quality of outcome is prime not cost. I’m also slightly worried about the mention of “efficiency” though it is subsidiary to “effective”

Cutting bureaucracy and improving efficiency

This section feels like standard stuff that every government paper includes, but the intent is correct. In particular, it feels like there is a good shift towards localism versus centralised Whitehall control, which might for once translate to real savings.

Overall, I like the intent of the white paper, with the caveats given above. That is, I’m concerned that:

  • Financial management isn’t a core skill of clinicians so they’ll need financial advice.
  • It feels like there is too little on democratic accountability. In particular, there is no statement on the accountability of the commissioning consortia.
  • While promotion of competition is good, at present there is nothing that makes it clear that competition over quality of outcome is more important than cost.

In summary: apart from the caveats above, I like the intent of the bill: patients-first, clinician-run, devolved from Whitehall, with patient choice. My gut feel is that my caveats will be (at least partially) addressed in the next few weeks during the “natural break” in the legislative process!

Transition to a Green Economy – revisited

Saturday, April 2nd, 2011

After the terrible earthquake and tsunami in Japan and, in particular, the ongoing events at Fukushima, I’m going to briefly revisit the topic of zero-carbon energy.

Have these events changed my opinion that nuclear power should play a significant role in our future energy supply? No. To quote Lewis Page of The Register “Operating nuclear power stations is not just very safe, or safer than other methods of generating power. It has to be one of the safest forms of activity undertaken by the human race.”.

This may be a controversial view, but when you look at the outcome of the Tōhoku earthquake, some 28,000 people are estimated to have died. In comparison, any deaths from Fukushima would pale into insignificance (not that I expect any). It should also be remembered that no modern design would have ANY of the problems experienced at Fukushima, which is a 1960′s design, built on a site with fundamental weaknesses (seawall too low, no provision for site inundation, no provision for regional infrastructure collapse). Again, no modern design would have these flaws.

In fairness to TEPCO and the Japanese authorities, the site WAS prepared for both earthquakes and tsunamis. But it was designed in the 1970s before plate tectonics and megathrust earthquakes were properly understood . . . I’ll be very interested to see over the next months and years whether they had had plans in place to upgrade (or close) the site.

The main thing Fukushima highlights for me is the woeful lack of understanding of science within the media. ALL the early coverage of the events was riddled with sensational alarmist reporting which even a minimal understanding of science and a bit of googling would have quashed.

It’s Official!

Saturday, April 2nd, 2011

I am now the Liberal Democrat candidate for the Somersham Ward of Huntingdonshire District Council. Expect to hear more about this and about Yes2AV over the next few weeks.