A NATIONAL OCCUPATIONAL HEALTH SERVICE

Doctors in Unite Policy Paper, September 2021

SUMMARY

Up to a third of UK social class differences in health was probably caused by work 50 years ago. Since then, many hazardous jobs have been exported but new types of unhealthy work have emerged.

Work can be bad for health but so is unemployment. The most disadvantaged suffer unemployment in recessions and poor-quality work during economic growth. Work in a safe and supportive environment benefits health.

Chronic illness and disability often prevent obtaining such work, or lead to its loss. People with impairments should be employed for their abilities. Punitive ‘welfare to work’ policies damage health, cause stress and diminish self-respect.

Profit-driven economic activity can damage health through pollution, environmental harm, unhealthy products and unhealthy lifestyles.

Comprehensive occupational health services provide biological monitoring, employment rehabilitation, workplace clinical services and health promotion. They support workplace health and safety systems, identifying hazards, assessing risk, preventing occupational disease and supportively managing disability and sickness. They should also work with trade union health and safety representatives in the workplace.

About a third of the workforce had a comprehensive occupational health service in the 1980s, a third had a partial service and a third had no service. 

Most of the workforce today have no direct access to occupational health services.

Occupational health services in the UK have never been statutory, but mostly employer-provided services. There have been campaigns to incorporate occupational health into the NHS, but by 1980 this was seen as medicalising the issue.

But with no statutory duty on employers, occupational health services declined and were commercialised. Public ownership is essential to ensure accountability to workers’ health rather than to corporate interests.

DiU (MPU) has often provided medical support to trade unions. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Network. We also liaise with the H&S representatives of other unions and the TUC.

Doctors in UNITE (the Medical Practitioners’ Union) believes there should be national occupational health services (NOHS) for England and devolved nations, including the following criteria:

  • Cover all workers, paid or unpaid.
  • Address occupational, environmental and commercial determinants of health.
  • Provide biological monitoring, employment rehabilitation health promotion and support safety management.
  • Normally be publicly provided
  • Be accountable to Parliament and devolved Assemblies.
  • NOHS should be part of the statutory health service.
  • Existing national organisations for health and safety and control of pollution should be redesignated as part of the statutory comprehensive health service. This does not imply any suggestion for reorganisation of them.
  • Locally, NOHS should be democratically controlled by workers (preferably through their trade unions), the appropriate regulatory agency, consumer representatives and local communities.
  • Professional independence is central.
  • Funding from general taxation to enhance independence.
  • Be provided on a group basis to small and medium-sized enterprises.
  • Stress at work must be addressed.
  • Certain types of health care should be provided in the workplace.
  • Linked to a Work and Health Service taking over DWP’s disability functions, as part of the NHS and providing employment-focused rehabilitation.
  • Linked to the public health system.
  • Have access to all levels of management and of regulation.
  • Have specialist support.

THE IMPACT OF WORK ON HEALTH

By comparing variance between industries in age/sex standardised mortality and in age/sex/social class standardised mortality, Fox & Adelstein showed in the 1970s that between a quarter and a third of UK social class variance in health was caused by work, rather than by lifestyles, housing, geography or general economic and social conditions. The 20,000 annual UK occupational deaths implied by this was far more than have ever been recognised as occupational deaths, suggesting unrecognised or unquantified work-related causes of common diseases. The study has not been repeated, and some data is no longer routinely collected. In the ensuing four and a half decades a shift from manufacturing to service industries has exported some of former occupational causes of disease to countries with weaker regulation and weaker trade unions. However new forms of unhealthy work have emerged, whilst trade unions and regulation have both been weakened. The figure may not have changed, especially as the proportion of the variance which it explains by work is similar to the proportion of adult life spent at the workplace.

Work can be bad for health but so is unemployment. Good quality work is needed– safe work in which people are trained and resourced for the responsibilities they carry and have control of their own work and work/life balance. Poor quality work and worklessness both damage health. The most disadvantaged suffer unemployment in recessions and poor-quality work in economic growth, never experiencing good quality work and suffering two different health-damaging situations successively.

Employment, through its impact on well-being, is central to both physical and mental health. Social networks help protect against a wide range of physical conditions including cancer and complications of pregnancy. Lack of autonomy harms cardiovascular health. Threats hanging over people that they cannot influence cause a stress reaction which contributes to heart disease, cancer and infections. This is also caused by people carrying responsibilities that they are not trained or resourced to carry (although responsibilities which they are able to discharge are a healthy challenge rather than a stressor). Pleasant green environments are of sufficient importance that people recover faster from surgical operations if they can see a tree from their hospital window. Work/life balance and understanding of family roles are important to avoiding the stress of role-conflict.

THE IMPACT OF HEALTH ON WORK

Work in a safe and supportive environment has a positive effect on health. The consequences of long-term unemployment are well known. Work can be an important contributor to health resilience. Unfortunately, sickness and impairment can often prevent the obtaining of this essential support.

People with impairments should be employed for their abilities not viewed through the lens of their impairment. Most people with impairments can work in an appropriate setting. However, this doesn’t routinely happen. If people become sick, they may well lose their job. The welfare to work policy is stigmatising and punitive in approach, itself damaging health by causing stress and diminishing self-respect.

OTHER IMPACTS OF WORK AND ECONOMIC ACTIVITY ON HEALTH

As well as occupational ill-health, economic activity can damage health in other ways. It may cause pollution, harm the environment, produce products that are less safe and healthy than they could be, or market unhealthy lifestyles encouraging people to harm themselves.

OCCUPATIONAL HEALTH SERVICES

It was said in 1980 that a comprehensive occupational health service would provide biological monitoring, employment rehabilitation, clinical services at the workplace and health promotion, and feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supportively managed disability and sickness.

At that time about a third of the workforce had a comprehensive occupational health service, about a third had a partial service and about a third had no occupational health service at all.  Large employers were more likely to have a comprehensive service and smaller workplaces more likely to have a partial or non-existent service.

Since 1980, the closure of large sectors of manufacturing and heavy industries, privatisation of nationalised industries, and growth of service industries perceived as less hazardous, has led to outsourcing of most occupational health services to commercial companies. Insecure contracts and separation from the workplace culture mean they have less independence than the old-style services.

 Comprehensive services as defined in 1980 are now virtually unknown, limited to some especially hazardous and regulated industries like the NHS, nuclear industry and armed forces. The majority of the workforce now have no access to occupational health services. For many who do have access, it is not a direct access.

HISTORY OF ORGANISATION OF OCCUPATIONAL HEALTH SERVICES

Occupational health services in this country have never been a statutory service. Some public bodies provided occupational health services for their own staff (although they have often now been outsourced) and some NHS bodies have contracted to provide occupational health services to private companies. However, the context has been employer-provided services rather than a public duty.

Nye Bevan wanted occupational health (including the Factories Inspectorate) as a fourth wing of his NHS, and was supported by the BMA, but opposed successfully by others. What Nye called “the NHS” was broader than what has been called the NHS since 1974, and meant what since 2013 has been called “the statutory health service” (or, as Andrew Lansley called it “the comprehensive health service”) i.e. health care and public health. Between 1948 and 1974 the environmental health services of local authorities were part of one of the three wings of the NHS and this wing of the NHS cleaned the air, cleared the slums and eradicated polio and diphtheria. Between 1974 and 2013 these services were not part of the NHS, or of the statutory health service established under the NHS Acts. Since 2013 they have been restored to the statutory health service but continue to be excluded from the term “the NHS”. Doctors in UNITE believes in restoring the pre-1974 terminology.

Throughout the 1950s and 1960s there was a campaign to incorporate occupational health into the NHS. This can be misunderstood if interpreted in the light of the current terminology rather than that current at the time. The Health & Safety at Work Act, 1974 occurred in parallel with the reforms of the NHS which redefined it so as no longer to include environmental health. Thus the possibility of the new health and safety bodies being part of the NHS was never considered.

In 1980 occupational health again came to the fore of political debate but by 1980 the new definition of the NHS had bedded in so the debate about occupational health being part of the NHS had come to be seen as a quaint, reactionary, medicalisation of the issue. The MPU did articulate the case for restoring the old definition of the NHS and adding occupational health to it, but this required two separate reforms to take place together. The TUC shared the general consensus that occupational health was working well in large workplaces and group services were needed for smaller workplaces. However radical GPs in Sheffield were also trialling accessible focused primary care services supporting workers with occupational health problems. These spread at the time to a number of other cities but, following years of austerity cuts, only the Sheffield one remains.

The hope in 1980 was that the system would grow and ways would be found to make it universal. Public ownership was seen as a distraction.

These hopes were not met. Without any statutory service, and without even any duty on employers to provide a service, it gradually declined. Far from being a distraction, public ownership is essential to ensuring a primary accountability to the health of the people rather than to corporate interests.

SUPPORTING WORKERS ON OCCUPATIONAL HEALTH ISSUES

As the medical organisation of the social movements of the people DiU (MPU) has always sought to provide medical support to the trade union movement. In the 1950s the union’s full time Medical Secretary did this. In the 1970s we made a medical input into the work of the ASTMS Health & Safety Office. In the 1980s volunteers from within our membership, called “medical safety representatives” aimed to provide such advice to workers engaged in health-related collective bargaining, and we also contributed to the training of safety representatives in what was then the GMWU at its national college. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Committee. The trade union movement needs access to medical advice which is sympathetic to grass roots collective bargaining. We have a role in that, although we do not claim any exclusivity.

A FUTURE OCCUPATIONAL HEALTH SERVICE.

The term “occupational health service” is time-honoured with no obvious alternative, but, especially if it is outsourced rather than integral, implies excessive professionalisation of issues which should be integral to workplace cultures. It must be an independent source of expert advice to a workplace health and safety service and to an employment rehabilitation and resettlement service.  It should also contribute to addressing the environmental and commercial determinants of health as well as the occupational determinants. “Occupational health” has not traditionally done this. If the new occupational health is to do so it needs links to public health.

Doctors in UNITE (the Medical Practitioners’ Union) believes there should be a national occupational health service (NOHS) meeting the following criteria.

  • NOHS should cover all workers, paid or unpaid.
  • NOHS should address occupational, environmental and commercial determinants of health.
  • NOHS would provide biological monitoring, employment rehabilitation, and health promotion, and support safety management. We will discuss later whether it should also provide clinical services at the workplace.
  • NOHS should normally be publicly provided, although where a satisfactory comprehensive occupational health service already exists in a particular workplace, and has the confidence of the trade unions, it could be publicly licensed and its role extended.
  • NOHS should be accountable to Parliament through a Minister for Industrial Health shared between DHSC, DWP and DBEIS.
  • They should also be accountable to devolved Assemblies
  • The existing national organisations for health and safety, employment of sick and disabled people, or control of pollution should be redesignated as part of the statutory comprehensive health service and should review ways to work together and fill gaps. This does not imply any major reorganisation.
  • Locally NOHS should be controlled by workers (preferably through their trade unions), the appropriate regulatory agency (be that HSE or the local authority), consumer representatives and local communities. In a previous policy statement some years ago, we advocated joint control by employers, expert regulators and trade unions/ communities/ consumers, as that fitted with the tripartite model of health and safety current at the time. However, that model has not proved robust so we now feel NOHS must be controlled by those it serves.
  • Professional independence is central.
  • The issue of funding will be raised. In a previous statement we said this needs to come from employers, but funding from general taxation would enhance independence so increases in corporate tax would be better. As health services have a Keynesian multiplier in excess of the figure at which they become self-funding, it may actually not be an issue. At a Keynesian multiplier of 2.5, £1 spent generates £2.50 of growth which generates £1 of tax. Keynesian multipliers for health, education, welfare, recreation and cultural services, care, and social protection are significantly in excess of that – about 4.32 for health – implying that spending reduces the Government deficit.
  • In smaller and medium sized workplaces, NOHS would be provided on a group basis. For the smallest workplaces (such as a corner shop) it might be provided by the kind of neighbourhood public health system which we have advocated in our paper “Public Health and Primary Care”.
  • In creating safe and healthy systems of work and in biological monitoring NOHS would feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supported a supportive management of disability and sickness. This system must extend to contractors and volunteers as well as employees.
  • NOHS and the workplace health and safety system must address stress at work not by victim-blaming “stress management” terms but through the factors in the workplace environment which we described earlier such as autonomy, social networking, training and resourcing of responsibilities, pleasant environments and work/life balance.
  • There has been much debate about whether occupational health should also provide clinical services at the workplace. This must not dominate and take occupational health staff away from other roles. Many services described as “partial” in 1980 consisted of a factory nurse providing mainly clinical care. This led to doubts about the appropriateness of a clinical role. However, the workplace is a convenient place to provide certain types of health care, including screening, blood pressure measurement, stress counselling and treatment of minor injuries or minor illnesses manifesting at work. There needs to be a system for providing the simple front-line healthcare that in many countries would be provided by a “barefoot doctor” or “community health worker”. This should be planned on a universal basis, so as not to exclude retired or unemployed people, but for those who spend time at a workplace, either as an employee, a contractor or a voluntary worker, clinical care at the workplace could sensibly be a part. In providing such clinical services at the workplace NOHS would be linked to the NHS.
  • In employment rehabilitation, NOHS would be linked to a Work and Health Service which would take over the disability functions of the DWP, would be part of the NHS (New Zealand is an interesting model here) and would offer employment-focused rehabilitation. Such services were previously operated by EMAS, by Employment Rehabilitation Centres and by Remploy but were inadequately resourced and only operated for the most severely disabled people – at the time we described it as “an excellent icing on a mouldy cake”. Government then shifted the function into a “welfare to work” model which operated too late in the process, missing the opportunity to retain people in work. Both of these systems were separate from the NHS clinical care of the patient, in which work needs to be a central factor.
  • In addressing the environmental and commercial determinants of health NOHS would be linked to the public health system
  • NOHS would have access to all levels of management and of regulation.
  • NOHS needs specialist support from the NHS, laboratory services, environmental services, HSE, public health and academic institutions.
  • NOHS should be part of the statutory health service. The 1948-74 terminology in which the statutory health service was called “the NHS” should be restored. Even with current terminology there are services NOHS should provide for the NHS, especially front-line health advice, health promotion and employment rehabilitation. NHS bodies may act as local providers of NOHS in some areas.

KONP submission to Health and Care Bill 2021

Written evidence opposing the Health and Care Bill, submitted by John Puntis co-chair of Keep Our NHS Public, a national campaigning organisation seeking to maintain a publicly funded and provided universal healthcare system across the UK.

Executive Summary

This Bill will be highly damaging to the NHS as a national health service based on social solidarity. It will:

  • fragment the NHS into 42 Integrated Care Systems (ICSs or ‘systems’) each containing an Integrated Care Board (ICB)  (‘body corporate’) and associated ‘Partners’ and, by funding each system separately with its own Whole Population Annual Payment (WPAP)[1], remove universal pooling of risk to the detriment of the poorest in society;
  • enable the deregulation of procurement and so increase the potential for abuse in the giving of contracts, and in the reduction of social and environmental protections and rights for workers;
  • introduce new concepts of ‘core’ and ‘key’ services to the systems – the reason for this terminology, similar to that used by US Health Maintenance Organisations, is unclear;
  • remove the duty for the systems to provide secondary medical services and then, pushed by imposed funding limits, the systems can attempt to contain costs by developing ‘new models of care’ to replace the need for secondary care referral, and ration or deny other specific types of secondary elective care[2],[3] deemed either to be unnecessary or of lesser ‘value’, forcing people to pay for this care and creating a ‘two tier’ service;
  • develop an infrastructure run by ICBs that, as well as enabling the inclusion of private companies, will reduce the representation and powers of Local Authorities (LAs) while committing them to the strict capitated financial regime, and reduce their power to influence reconfigurations of local NHS services;
  • increase the use of digital technology in place of clinical judgement while deregulating the professions, to create a workforce which is ‘mobile’, ‘flexible’ and ‘agile’ for the sake of cost efficiency, so reducing the benefits of team work and the continuity and quality of relationships with patients;
  • create a dependence on multiple transnational corporations to drive the creation of vast health and social care data sets – an invaluable research and planning resource but one that will be open to commercial exploitation;
  • from the development of systems and data banks through to care management and provision, increase opportunities for private corporate profit making while NHS services remain underfunded.

Fragmenting the National NHS and controlling system budgets

  1. The Bill provides statutory authority for 42 Integrated Care Systems (ICSs), modelled on Accountable Care[4] specifically designed to reduce state expenditure on healthcare. Each ICS will be funded by its own Whole Population Annual Payment, with a legal duty placed on ICBs and eventually all their associated Partners, not to overspend their own and the system revenue and capital budgets[5]
  1. A key aim is to replace the national tariff system in which treatments have a fixed price for all patients, and replace it with a Payment Scheme. This may make different provision for the same service depending on local circumstances, areas, types of provider, other factors related to provision or arrangements for the service, different populations, and the range of services provided.[6] Each ICS will have different costs, and disparities between ICSs are likely to develop. Among our concerns is the possibility that, in this context, the national scheme for staff pay, terms and conditions will be undermined – especially in the situation where there are strong pressures to cut costs. One outcome could be that staff migrate from poorly funded areas. Explanatory Note EN 27 makes it explicit that the private sector can influence the details of the payment scheme rules of how commissioners establish prices to pay providers.[7]

Deregulation of Procurement

  1. The Bill proposes repealing Section 75 of the Health & Social Care Act 2012; revoking the NHS (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013, and reducing the Competition and Markets Authority’s (CMA) competition duties (EN121-122). It provides a power to create a separate procurement regime for clinical services, and remove the procurement of health care services from the scope of the Public Contracts Regulations (PCR) 2015 (EN-114). The power provides for mixed procurements in the regime,[8] so non-clinical services can be exempted from PCR 2015 if they are bundled with clinical services.
  1. The removal from PCR 2015 will deregulate the market with the loss of the labour and environmental protections that enable contracting authorities to incorporate social, ethical and environmental aspects in their contract conditions and award criteria. These protections include specificrules to manage abnormally low tenders, and suppliers who have previously violated certain social, labour[9] and environmental laws. There is strong evidence that all NHSE’s ‘integrated care’ ambitions could be achieved without removal from PCR 2015 and loss of its protections.[10]  However, as PCR 2015 restricts procurement without tendering to our public services[11], deregulation is only specifically required if there is a wish to give contracts to private providers without tendering.   
  1. Clause 68 of the Bill provides for new regulations on procurement[12] under which private provider companies may be able to extend their contracts or even be awarded new contracts without competition. This, along with less opportunity for contracts to be contested or scrutinised (only 4-6 weeks from announcement of intention to completion) and with contest only being allowed based on issues with the stated regime criteria[13], makes it much easier for private companies to gain contracts. Judicial Review may be the only way to challenge the lawfulness of any decision.

The absence of a statutory duty to provide secondary medical services and the creation of ‘sustainable’ healthcare.

  1. There will be no statutory duty on any body to arrange the provision of secondary (i.e. hospital) medical services. The government had a qualified legal duty to provide hospital medical services ‘throughout England’ from 1946 until 2012. Under the H&SC Act 2012, this duty was repealed and clinical commissioning groups (CCGs) were given a duty to arrange provision of medical, and other key services and facilities (under s.3 of the 2006 NHS Act). This duty will now pass to 42 ICBs, but excluding medical services. The reasons for this are not given. If enacted, an ICB will be under no obligation to arrange such services. This is particularly concerning in the light of the new payment rules (see above) allowing categories of services not to be paid for. The possibility that has always existed for patients to challenge legally the non-provision of NHS services will be significantly reduced.
  1. The systems are expected to meet their local needs and reduce spend by innovating and developing ‘new models of care’[14]. The absence of any legal duty to provide medical services creates a new ‘freedom’ for systems to provide alternatives to replace, and also delay or deny the need for elective secondary care. There is no robust evidence that the models, developed and trialled to prevent referral, work in terms of improving outcomes or saving money.[15] Rationing[16] and refusal to offer the ever growing list of Procedures of Limited Clinical Value (PoLCVs)[17] will increase the number of people pressurised to seek care either privately or as ‘NHS paying patients’, creating systems with different spending priorities and ‘two-tiers’ for elective procedures.
  1. Also the whole range of ‘cost-efficiency’ measures, which have already begun,[18] can be fully used to try to reduce secondary care costs. An attempt to do this included in the Bill is ‘discharge to assess’[19] developed to clear hospital beds as quickly as possible, but which has caused great concern because of ‘dangerous’ discharges to depleted social services[20] that may increase if new ‘eligibility to reside’ criteria are enforced[21].

Integrated Care Boards (ICBs) and Integrated Care Partnership committees (ICP) and the private sector.

  1. An ICB must draw up its own constitution and specify its name (Clause 13 and Schedule 2). Under the NHS Act, the name of CCGs had to begin with ‘NHS’: for ICB’s, there are no requirements for this – yet another indication that the Bill, and the ICSs it legitimises, are serving to dissolve the NHS. Further, an ICB constitution does not have to specify its members, and can include representatives from private companies.
  1. In Schedule 2 Part 2 the ICB is pronounced as a ‘body corporate’ and as such ‘all members will have shared corporate accountability for delivery of the functions and duties’. If representatives of private companies are members of ICBs, this accountability will conflict with their other legal duties as company directors, in particular the duty to ‘act in the way he (sic) considers, in good faith, would be most likely to promote the success of the company for the benefit of its members as a whole.’
  1. The constitution must specify arrangements for exercising the ICB’s functions (Schedule 2 (10)), and this may include through the creation of committees and sub-committees which will carry out its functions, including accountability for NHS spend and performance within the system (EN38). These committees may consist entirely of, or include, persons who are not members or employees of the ICB – with the potential to include representatives from private companies.
  1. Under Clause 20 (4) an ICP joint committee must be set up by each ICB and each responsible LA whose area coincides with, or falls partly within, the ICB area (new section 116ZA). The ICP committee will have one member appointed by the ICB, one by each LA, and others appointed by the ICP. It will bring together health, social care, public health and necessary others such as social care providers or housing providers (EN 40). Social care providers are overwhelmingly private, and the open-ended description is explicit in the Bill where, when appointing its members, ‘an ICP may determine its own procedure (including quorum)’.
  1. Throughout the Bill there are no details at all on how the public will influence decisions of the ICB. The only reference to ICB transparency is at Schedule 2 (11) (2): ‘The constitution must also specify the arrangements to be made by the ICB for securing that there is transparency about the decisions of the board and the manner in which they are made.’ The Freedom of Information Act will apply (Schedule 4 (60)) but that will have its exclusions for commercial activities and legal advice.

Diminished powers of Local Authorities (LAs) in meeting local needs and NHS reconfigurations

  1. LAs and ICBs (in their role as replacing CCGs) must undertake a joint strategic needs assessment (JSNA) of the health and social care needs for each authority’s area to ‘determine what will be needed in terms of the discharge of health and social care functions’ [22]. Under Clause 20 116ZB an ICP must use the JSNA to prepare its ‘integrated care strategy’ and then send this to the ICB(s) and the LAs who may supplement it if necessary as a ‘a joint local health and wellbeing strategy’. After all this local effort however, NHSE, LAs and importantly the ICB will only need to ‘have regard to’ the strategies when making decisions ‘so far as relevant’[23].
  1. In Schedule 6 of the Bill, the retained LA powers to refer NHS reconfigurations to the Secretary of State (SoS) could be diminished because of new powers the SoS has to initiate plans for reconfigurations, ‘call in’ plans at any time, and retake any decision made by an NHS body. Commissioning bodies will have a duty to report current and possible future decisions that require or may require reconfiguration[24]. This suggests the possibility of intervention in support of a reconfiguration before local scrutiny can act, pre-empting challenges to plans, and public scrutiny.

Professional deregulation and workforce restructuring

  1. In the NHSE’s Integrated Care Systems: Design Framework[25] it is stated that providers are to ensure services are arranged in a way that is ‘sustainable and in the best interests of the population’, and in the People Plan[26] to achieve this ICSs are felt to require a ‘flexible’, ‘agile’ workforce able to move rapidly between disciplines and providers, with staff potentially ‘passported’ between organisations across and beyond a system. Such changes will depend upon the use of similar digital technologies in clinical activities across services, and while they may be cost-efficient, they are likely to impact on teamwork and continuity of care, affecting the quality of patient care as well as staff morale. They may also place unreasonable demands on staff, given the geographical size of ICSs and extra travel involved.
  1. There is a further ambition that technology, including algorithmic decision-making tools, will allow the professional deregulation of various groups of staff,[27] while Clause 123 gives the SoS the power to use secondary legislation to remove a healthcare profession from regulation and abolish its regulatory body. Our concern is that this will weaken standards of training and competence, allow the down-banding of staff and put patients at risk[28].  Firstly, a growing dependence on algorithms ignores that these are not value free but subject in their development to human error and bias, as was so dramatically shown in the ‘biased school exam results’ in 2020[29]. Secondly, without sufficient learned clinical judgement, the health workers using these systems may be unaware of computer decision errors or when they should seek advice. Computer systems can crash, from power failures, viruses and software bugs, and under-qualified workers may be unable to cope when this happens.

Data, the use of analytics, and other concerns

  1. Clinical activity, costs and ‘outcomes’ will be monitored in real time and data stored for planning and analytics. As accountable care requires  ‘best value for the system’ to be the primary measure to decide where to spend a limited budget[30], all health conditions need to be developed as ‘currencies’[31] so that they can be compared ‘as in a market’ using health and social care data and analytics. In this way lesser ‘value’ can be used to explain individual decisions not to provide care.
  1. Clause 81 of the Bill concerns an amendment on ‘dissemination of information’ which appears to want to put beyond doubt NHS Digital’s power to share huge amounts of health or adult social care data, including that for commissioning, planning, policy and development, population health management, and developing innovative approaches and technologies for service delivery. Widely expressed concerns about growing commercial access to data[32] can only unfortunately be strengthened by reading clause 81 while glancing at NHS England’s ‘Health Systems Support Framework’. This includes some 200 organisations – almost all of them private, many based abroad and at least 30 from the US – all accredited to support the widespread development and use of IT in Integrated Care Systems and so with unprecedented access to patient data. Our concerns include that NHS data, once uploaded, may well find its way abroad where it may not have the same privacy protections that the UK currently requires.

Conclusion

  1. KONP finds the problems identified with the Bill are substantial, with serious implications for the future of the NHS as a comprehensive, universal healthcare system that is publicly funded and publicly accountable. There are also serious concerns for patient safety with the proposed future deregulation of the professions and the ‘flexible’ working it endorses that will only serve to undermine further the morale of staff.
  • At the same time, the Bill does nothing to address: the serious inadequacy of local, primary medical services, community, mental health and hospital services (e.g. staffing and beds) after years of underfunding, service closures and cuts; the corporate take-overs of GP services; the broken social care system; the failings of the centralised communicable disease control system, and the wider public health system.

Recommendations

  • There should be: an immediate halt to the progress of the Health and Care Bill and the rollout of ICSs; an extended and meaningful consultation with the public and Parliament to decide how health and social care services are provided in England; the introduction of legislation to bring about a universal, comprehensive and publicly provided NHS, fit for the 21st century as set out in the NHS Bill [33].

References


[1] https://www.england.nhs.uk/wp-content/uploads/2019/08/13-Whole-Population-Budget-Overview.pdf

[2] https://www.bmj.com/content/365/bmj.l2326

[3] https://inews.co.uk/news/health/nhs-routine-surgery-hip-knee-replacements-savings-76769

[4] Fisher, Elliott S.; Staiger, Douglas O.; Bynum, Julie P. W.; Gottlieb, Daniel J. (2007-01-01). Creating Accountable Care Organizations: The Extended Hospital Medical Staff. A new approach to organizing care and ensuring accountability https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2131738/

[5] Clause 23 – inserting new sections 223C, 223GB, 233N and 223LA into the 2006 Act: Power to impose financial requirements on ICBs

[6] Schedule 10 of the Bill. At 114A (3) (e), 114A (6), the Rules for the Payment Scheme which are set by NHS England

[7] At 114C Private firms can qualify under (8) (a) as licence holders include ‘independent providers’ or under (b) (i) which is a catch-all for services provided ‘for the purposes of the NHS’ or under (b) (ii).

[8] for example a health service has some social care services commissioned as part of a mixed procurement in the interests of providing joined up care

[9]Labour laws lost are the International Labour Organisation conventions including Freedom of Assembly and the Right to Strike. 

[10]http://data.parliament.uk/WrittenEvidence/CommitteeEvidence.svc/EvidenceDocument/Health%20and%20Social%20Care/NHS%20Longterm%20Plan%20legislative%20proposals/written/97675.html

[11] NHS. Reg.12(2) PCR2015

[12] https://www.england.nhs.uk/wp-content/uploads/2021/02/B0135-provider-selection-regime-consultation.pdf

[13] Quality (safety, effectiveness and experience) and innovation, Value, Integration and collaboration, Access, inequalities and choice, and Service sustainability and social value.

[14] https://www.england.nhs.uk/new-care-models/

[15] https://www.nao.org.uk/wp-content/uploads/2017/02/Health-and-social-care-integration.pdf

[16] https://www.bmj.com/content/365/bmj.l4375

[17] These used to be called Procedures of Limited Clinical Effectiveness (PoLCEs) but the immaterial nature of ‘value’ broadens the scope of what can be rationed and allows comparison with activities across the system when decisions are to be made about where not to spend the limited budget.

[18] https://www.healthemergency.org.uk/pdf/McKinsey%20report%20on%20efficiency%20in%20NHS.pdf

[19] EN (156-157)

[20]https://www.ombudsman.org.uk/sites/default/files/page/A%20report%20of%20investigations%20into%20unsafe%20discharge%20from%20hospital.pdf

[21] https://www.bmj.com/content/370/bmj.m3747

[22] ss.116, 116A and 116B of the Local Government and Public Involvement in Health Act 2007

[23] Clause 20 116B

[24] Clause 38 & Schedule 6; NHS Act 2006, new s.68A & Schedule 10A

[25] https://www.england.nhs.uk/wp-content/uploads/2021/06/B0642-ics-design-framework-june-2021.pdf

[26] https://www.england.nhs.uk/wp-content/uploads/2020/07/We-Are-The-NHS-Action-For-All-Of-Us-FINAL-March-21.pdf

[27] White paper 5.150 “over time and with changing technology the risk profile of a given profession may change and while regulation may be necessary now to protect the public, this may not be the case in the future.”

[28] EN-168 calls this ‘the development of a flexible workforce that is better able to meet the challenges of delivering healthcare in the future’.

[29] https://www.aiimi.com/insights/2020-grading-algorithm-understanding-what-went-wrong

[30] https://www.kingsfund.org.uk/sites/default/files/2018-10/approaches-to-better-value-october2018_0.pdf

[31] https://www.england.nhs.uk/wp-content/uploads/2019/05/a-new-approach-to-community-healthcare-funding-testing-and-guidance.pdf

[32] https://www.digitalhealth.net/2014/02/care-data-a-media-disaster/

[33] http://www.nhsbillnow.org

Solidarity with Florence House Medical Centre Openshaw and staff in general practices everywhere.

At our meeting last weekend, Doctors in Unite passed the following resolution in solidarity with the staff at Florence House Medical Centre, and general practices across the country:

“This branch is horrified at the brutal attack on staff at the Florence House Medical Practice in Openshaw on Friday 17th September 2021  

Health workers across the NHS and social care have gone way beyond the call of duty to keep the public safe during the COVID 19 pandemic. Despite this General Practice is being vilified by the right wing media such as the Daily Mail. The Government and NHSE have sat on their hands, failing to come to the support of hard working staff in surgeries, instead they are allowing dedicated staff to be used as scapegoats for their own abysmal failings.

The reality is that General Practice provided 29.7 million appointments in July alone, 45.4% of which were same day appointments.

Telephone and digital first models of providing General Practice care rapidly increased in April 2020, on instruction from NHS England, in order to reduce viral transmission, keep patients safe and away from overcrowded waiting rooms and to keep staff well so that surgeries could still provide a service. Coronavirus is still with us and the need to minimise transmission has not gone away.

We acknowledge that some patients mourn the loss of an automatic face to face appointment and many GPs share this feeling, preferring to see patients in person.  In part this is a consequence of Covid, but even more so reflects serious under-investment in primary care over recent decades. We believe that patients need longer time with their GPs but this will only be possible by dramatically increasing GP numbers and reducing patient list sizes, both of which require Government investment which has been seriously lacking.

Telephone and Digital appointments can be as effective as face to face appointments for some problems. Many patients like them and feel that their GP is much more accessible. Of course, we must be aware of the digital divide but most practices have measures in place to accommodate patients who, for whatever reason, do not use the internet. Face to face appointments are, despite what the Daily Mail say, still provided regularly when GP and patient agree that this is necessary.

General Practice staff, especially receptionists are right on the front line, more so than most, and are particularly vulnerable. Levels of stress and burnout amongst GPs area at an all-time high with many leaving the profession.

It is despicable that the media have been allowed to whip people into such a frenzy that someone felt emboldened to attack General Practice staff so violently as has happened at Florence House.

We stand in solidarity with the staff at Florence House Medical Practice and call on the Government and NHS England to condemn the attacks and to tell the truth that the whole of the NHS, including General Practice, is working extremely hard to care for patients.

We also stand in solidarity with patients who deserve an NHS that is adequately funded to provide for their needs. This Government are a far cry from providing such a health service.

Government and NHSE must suspend all non-patient facing tasks in General Practice including CQC inspections and appraisals, to allow overstretched practices to concentrate on patient care.

We call for the NHS to be restored as a comprehensive, cradle to the grave health system, publicly funded, publicly provided and free at the point of use for all.”

Medical activism

John Launer

This article is reproduced from the Postgraduate Medical Journal 25 August 2021.  Please click on link for references.

Medicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7 years for females.)2 However, the teachers who impart these facts are equally unlikely to have come from deprived backgrounds themselves, or to imbue them with the sense of outrage that such figures should evoke.

Once qualified, most doctors will begin to understand that some of the frustrations they encounter at work arise from political decisions rather than ones made by clinicians and service managers. These decisions may include limitations on budgets, and performance targets. Many will complain about politicians, but they may be unaware how far their own practice, including the use of hi-tech investigative technologies and expensive medicines, has been massively influenced by political lobbying. (In 2020, the pharmaceuticals and health products industry in the United States spent more than any other sector on lobbying efforts, totalling around 306.23 million US dollars)3 Few will campaign for government funds to be spent outside the health sector altogether—on social care, nutritional support and housing assistance—where these would demonstrably have more impact.4 They will probably not question the structural inequalities which lead to their earning incomes that may be ten times the median income of their patients.5 6

Campaigning doctors

To set against this, there is also a long and distinguished history of individual doctors (and nurses) who have chosen to be political campaigners. Such people have seen their vocation as not only treating patients but fighting on the political front for the welfare of under-privileged groups, communities or society as a whole. Famous activists from the past in the United Kingdom include Thomas Wakley, John Snow, Florence Nightingale and Elizabeth Garrett Anderson. More recently, the physician Sir Douglas Black and the socialist general practitioner Julian Tudor Hart had a considerable influence in orienting the profession towards population and community health as well as individual care.7 8 (For over 20 years I had the privilege of practising alongside Ron Singer, an ally of Tudor Hart, a fierce campaigner for the original values of the National Health Service, and a role model for combining clinical and political commitment).9 Across the world, notable activist doctors have included Franz Fanon, a guiding light of the Algerian independence movement, who wrote of how the medical profession were complicit in the oppression that colonialism brought about. Che Guevara became a revolutionary in Cuba after being profoundly affected by his experiences as a medical student. Sun Yat-Sen was instrumental in bringing down the last imperial dynasty in China and became first president of the republic.

While such activism is not new, there has been a notable upsurge recently in the number of influential voices from within the medical profession arguing that every doctor has a duty to move beyond their clinical work and challenge the current political realities. In an essay entitled ‘The moral determinants of health’, the leading US physician Don Berwick has pointed out: ‘No scientific doubt exists that, mostly, circumstances outside healthcare nurture or impair health.’10 He makes a passionate plea for doctors, nurses and their professional organisations to become involved in campaigning on issues such as racial discrimination, women’s equality, human rights, climate change, the criminal justice system, hunger and homelessness. Countering objections that this campaign list might seem out of character for many health professionals, he argues bluntly: ‘Healers are called to heal. When the fabric of communities on which health depends is torn, then healers are called to mend it. The moral law within insists so.’

In a similar vein, David Kopacz of the University of Washington writes of medical activism as ‘a foundation of professionalism.’11 He quotes Robert Jay Lifton, who studied how U.S. soldiers could participate in war atrocities and how German doctors participated in the Holocaust: ‘As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it… That inevitably includes entering into social and political struggles against expressions of malignant normality.’12 Kopacz also cites educator Parker Palmer, who speaks of a new kind of professional: ‘a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.’13

Failings of governments

Doctors are also speaking out with growing urgency and frankness about the failings of governments to address the health and social needs of their citizens. Kamran Abbasi, executive editor of the BMJ, has written a blistering attack on the British government’s ‘politicisation, corruption and suppression of science’ during the COVID-19 pandemic.14 Rachel Clarke, a palliative care doctor, has become a bestselling writer and contributor to social media, drawing attention to government mismanagement of the pandemic, and the human consequences. While occasional voices are still raised in support of the notion that doctors should only treat patients and keep their noses out of everything else,15 such views are increasingly likely to seem blinkered and outdated.

As health and social inequalities widen, and we learn more about the power held over human lives by an ever-diminishing number of individuals and corporations,16 I predict that more doctors around the world will be drawn inescapably into political campaigning. Doctors who believe that medicine and politics are entirely separate will be seen as fundamentally out of touch with medicine or politics, or both.

Briefing on Privatisation within the NHS in London -examples based on reports from members of London KONP groups over the last few months 2021. [1]

Martin Blanchard July 2021

This briefing is not a detailed report of recent privatisation of healthcare in London, but rather examples of the type of privatisation that is occurring with links to details about the companies involved. If these examples are occurring in all five incipient ICSs (North West London -NWL, North Central London-NCL, North East London-NEL, South East London-SEL, and South West London-SWL) then they represent major changes in provision.

Private hospitals, Private Patient Units (PPUs) and hospitals developed through Private Finance Initiatives (PFIs) are generally well known and dealt with towards the end of this document. Less well known are the low-key private interests in community services and partnerships hidden behind the NHS brand.

The overriding wish to develop choice in health care provision in the Health Bill and the Provider selection regime will make it easier for ‘Any Qualified Providers’ to gain contracts- see also APMS contracts below. It seems very likely that private companies will continue to strengthen their roles in medical diagnostic services, community services, elective care, new models of primary care, and informatics- areas where investments are less risky and there are track records for making profit- see Centene below.

Examples of private company involvement in ICSs

1.Public Private Partnerships

North East London

Johnson & Johnson Managed Services, part of Johnson & Johnson Finance Limited2, and Guy’s and St Thomas’ NHS Foundation Trust have entered into a 15-year partnership to deliver an Orthopaedic Centre of Excellence at Guy’s Hospital’3.

North Central London

Hospital Corporation of America (HCA) at UCLH is HCA’s first joint venture, a partnership between HCA Healthcare UK and University College London Hospital which seems to be continuing to develop. HCA was founded in 1968 in Nashville, Tennessee. It has 186 hospitals, and approximately 2,000 sites of care located in 21 states and the United Kingdom. Its Revenue increased to $51.53 billion (2020) with a net income of $3.759 billion (2020). It has 280,000 employees (2020).

Health Services Laboratories LLP was set up as a partnership between UCLH NHS Foundation Trust, RFL NHS Foundation Trust and The Doctors Laboratory. The latter is owned by Sonic Healthcare, Australia4 a multinational corporation with a A$6.2 billion revenue.

South East London

From 1 April 2021, SYNLAB UK & Ireland became responsible for the delivery of Viapath’s day-to-day pathology services, which are at the core of the new partnership. Colleagues across SYNLAB5, Viapath and the NHS will work together over the next few months to develop plans to achieve the shared vision of developing an integrated, world-leading hub-and-spoke pathology network across South East London to be completed by 2024.

SYNLAB laboratories was founded in 2010. It’s headquarters are in Munich Germany and it produces 500 million tests per year in diagnostics services for human and veterinary medicine, environmental analysis and pharmaceutical industry. It’s revenue in 2018 was € 1.9 billion. It is owned by Cinven, a global private equity firm founded in 1977, with offices in nine international locations that acquires Europe and United States based corporations, and emerging market firms that fit with their core businesses. It purchased SYNLAB6 in 2015 as part of the €10.6 billion of assets it had under management.

2.Primary Care

Operose take over

The facts surrounding the take- over by Centene Corporation of some four dozen GP surgeries and hubs in London from AT medics and the associated lack of openness and transparency, and even misrepresentation, under cover of the pandemic, has been widely reported, locally and nationally. For more information see the letters sent to the Secretary of State by NHS campaigning organisations on 22 February 20217 and by leading councillors from 12 London boroughs on 19 March 20218. Both letters call for the Secretary of State to require the Care Quality Commission to investigate as provided by section 489 of the Health and Social Care Act 2008.

Centene’s takeover of the 49 GP locations across London10, their UK subsidiary Operose’s ex CEO Samantha Jones’ move to be the adviser on NHS integration for the Prime Minister11 (note that for some reason the Guardian forgets to mention that she is moving from Centene), and Centene’s purchasing control of Circle Health12 indicates their ambitions to become a major presence in the transformed health service and to be in a strong position to offer services to care manage ICSs.13 Please see the deputation by Dr Brant Mittler JD MD to Camden Health and Adult Social Care Scrutiny Committee April 2021 on the matter of corporate American healthcare management14.

Alternative Provider Medical Services (APMS) contracts

APMS contract numbers in primary care are set to grow. NHSE welcomes ‘digital priority’ private companies as Alternative Providers into underserved (deprived) areas (see NHS APMS Digital First New Market Entry Engagement Pack 2020). The increased entry of private providers into the NHS is felt to be necessary to promote patient choice. It will be mandatory for the Secretary of State, via regulations to impose standing rules on NHS England and ICBs about the arrangements they must make for enabling people receiving certain treatments to exercise choice in the Health and Social Care Bill 2021.

Further help for private specialist digital primary care has been provided as Babylon GP at Hand is able to gain access to local facilities if they recruit 1000 or more users in a CCG area/locality. They also state that NHSE have agreed that forty minutes travel to local primary care facilities is acceptable, so facilities for their service may not be required in every CCG area/borough.15

3.Community services

South West London

Wandsworth podiatry is provided by Healthshare16. They are owned by the BGF Group plc currently owned by Uberior Investments Ltd, RBS SME Investments Ltd, HSBC Investments Ltd and Barclays Funds Investments Ltd.17 Diabetic retinal screening is provided by Northgate Public Services18 which is owned by the Nippon Electric Company19 with a revenue of ¥2.9 trillion (2021), and which is owned by AT&T20via Western Electric with a revenue of $171.76 billion.

North West London

The Adult hearing service providers in Ealing are Specsavers, Scrivens and Hearbase. Specsavers Optical Group Ltd is a British multinational optical retail chain, which operates mainly in the UK, Ireland, Australasia and the Nordic countries with an annual revenue of £1.7bn. It is owned by the Perkins family.

Scrivens is a Birmingham based company with 113 branches across the midlands and SE England owned by the Georgevic family.

Hearbase is a growing Kent-based hearing company with 25 years experience. It recently obtained a contract from the NHS and has 50 stores across Kent and London.

Ealing Pharmacy IT and Ealing, Brent Central, West London and Hammersmith General Practices have support provided by First Data Bank (FDB) group21 which is owned by Hearst Communications22 a NY based corporation with a revenue of $11.4 billion.

Ealing, Brent, Central London, West London, and Hammersmith have GP diagnostics provided by Inhealth Ltd. This is one of sixteen diagnostic units in London. InHealth is a private company owned by The Damask Trust, the trustees of which are Ivan Bradbury and the Embleton Trust Corporation Ltd., which is in turn owned by MacFarlanes LLP with a revenue of £ 237.7million. InHealth’s services are provided from over 350 locations in the UK and Ireland and they work with a significant majority of NHS Trusts in the UK covering over 200 hospitals and over 80 community health clinics. For the financial year ending September 2019, according to Companies House, the company reported revenue of £120.6 million.23

Ealing cytology is provided by The Drs Laboratory (TDL) -see Sonic Healthcare above.

Hillingdon Teledermatology is provided by Concordia, now Omnes Healthcare ltd24.The Concordia company has had serious financial difficulties and had to withdraw from a contract with North East Essex with 5 days notice having moved its surviving assets into a new company the Omnes Group.

Ealing, Hounslow and Haringey have community ophthalmology services provided by Operose- see above.

Healthshare Ltd provide Central and West London with MSK physiotherapy and podiatry.

Clapham Junction general practice is run by Practice plus which belongs too Bridgepoint Advisers25 a London based private equity company with €18 billion of assets.

An Ealing General Practice is run by Totally PLC26 through its acquisition of Greenbrook Healthcare. Totally is headquartered in Mabledon Place, London. It has a revenue of £113.71 million.

4.Digitisation, informatics, analytics, Artificial Intelligence (AI)

Discovering what investments are being made in private corporate digital provision is important because these purchases invariably come with a promise to make our health and social care services not only better but also financially more ‘sustainable’ sometimes even with expressed ‘savings per patient’. They also come with ‘forever’ revenue costs.

The way that ‘improved’ services are usually provided is by using population data to identify people ‘at risk’ of requiring secondary care and then intervening with a less expensive , alternative provision to prevent referral or admission. The features improved services include are ease of communication and sharing of data, stratification of community clinical need, targeting of particular patient groups, standardisation of interventions that can be provided by less-skilled practitioners, ‘pull through’ of patients through a service, patient activation to increase prevention and self-care behaviours, and use of volunteers and families in caring roles. What is lost is the quality and continuity of any ‘provider -user’ relationship. From an informatics perspective there are ‘transformation’ capital costs (initial IT set up and future updates and developments) and revenue costs (software subscriptions, maintenance, training, storage, security), for the system and each of the partner organisations.

North Central London as an example

This information was obtained from North London (NL) Partner’s response to NHSEI in late 2019 re: actions taken to meet targets in the Longer Term Plan. Having found company names or systems being set up, a search for articles on company websites and in the Digital Health media, where they publicise the activity of IT corporations for interested investors, was carried out.

The NL Partners ICS investments:

  • a population health management platform: Cerner27 HealtheIntent is being deployed
  • Health Information Exchange ability provided by ATOS28 (information from a CCG meeting Chaired by the Accountable Officer)
  • an Analytics Board to lead and oversee the development and use of analytics across North Central London, ‘where it makes sense for us to work together’

Partners investments:

  • Royal Free London (RFL) Foundation Trust has fully implemented electronic patient records using Cerner Millennium at RFH, Barnet and Chase Farm Hospitals (the RF Group)

Meanwhile in other local hospitals:

  • University College London Hospitals (UCLH) Foundation Trust has implemented electronic patient records using Epic29 across all sites
  • North Middlesex University Hospital (NMUH) Trust and Whittington Health have implemented new functionality in their System C30 electronic health record. System C is owned by CVC Capital Partners a Luxembourg private equity company with $75 billion of assets.
  • Great Ormond Street Hospital NHS Foundation Trust has also implemented Epic.

From NL Partners:

‘We anticipate that as the electronic health records are developed, especially in the acute sector, this will be reflected in the overall digital maturity of NCL when a new assessment is undertaken’.

In June 2019, the NCL Chief Information Officer (CIO) Working Group took part in a London -wide initiative for assessing digital maturity on a system level, ran by Deloitte Touche Tohmatsu Limited 31. Digital maturity is an objective that has to be continuously assessed and maintained.

NL Partners data security

Data security is an ongoing concern that the entire informatics system of the ICS and all Partners will need to continually invest in and purchase from private providers. NL Partners aim to keep abreast of the latest cyber security developments and requirements. Their providers are well on their way to rollout Windows 10 and Microsoft Advanced Thread Protection, and all of the GP sites already meet these requirements. Their Trusts are well engaged and keen to be on the front foot in this regard, but progress is threatened by national capital spending reviews.

Furthermore, they use the Cyber Security Support Model (NHS SBS cyber security framework) with its list of accredited suppliers to raise their level of cyber protection. They are briefing their trust boards on cyber security awareness, implement cyber security tools, and have made significant progress towards achieving the ‘Cyber Essentials Plus certification’ with providers and primary care practitioners.

Their organisations are already making use of the Cyber Risk and Operations support package to continuously improve their cyber resilience.

Funding NCL’s Digital Transformation

‘There will be additional financial implications to connect more organisations to the HIE shared record and HealtheIntent population health management which are not included in current funding bids e.g. community pharmacists, out of hours services, dentists etc. Quality improvement support will be needed to maximise the benefits of HIE and HealtheIntent implementation across the system. We have already bid for all available funding that exists and are waiting for confirmation that we will receive funding for the projects that were originally approved’.

‘Our future challenges include the fact that the software licensing model is moving to a subscription service globally. This moves the cost from capital to revenue and may create challenges given the financial context in NCL.

Adding this to the year- on-year CIPs (Cost Improvement Programmes) trusts have to make on their revenue budgets only adds to the scale of the problem looming. NCL trusts will also need to make significant investments to maintain their current ‘level of maturity’, current operations, and to procure new licenses for out of support products and clinical systems as they reach their end of contract in the next years’.

The OneLondon programme

The OneLondon programme is enabled by Cerner32 ‘turning London into the most connected capital city from a health care perspective’ [in the world].

While such inter-connectivity of data has the clinical benefit of shared information, the huge financial significance of such accessible ‘big data’ for markets must be recognised. Creating a network of 8 million healthcare records may prove very tempting. Commentators such as Professor Shoshana Zuboff33 from the Harvard Business School believe that the use of human data for wealth creation, without clear permission for use, is theft akin to the trafficking of human organs. But until the law can catch-up with such activity it remains a frequent practice. It is the Artificial Intelligence algorithms applied to large volumes of human data that can predict behaviours, and in the context of online purchasing and marketing it has generated enormous increases in dividend returns for the giant social media corporations. These huge financial gains are seen as the main driver of ‘surveillance capitalism’. The growing ‘health markets’ are an important part of these developments- see below.

Some insights about Cerner and the growth of the Health Market

Matthew Swindells, a senior manager in the NHS, left to become the senior Vice-President of Cerner and then moved from that job back to the NHS as England’s National Director for Operations and Information from May 2016 to the end of 201934-as ICSs were developing. Cerner gained multiple contracts across NCL35, the rest of London and other areas in England, and a presence on the OneLondon database and the National Database36.

Cerner has systems in St Barts, Whipps Cross, UCL Institute of Digital Health, St George’s, Croydon Health, Imperial, Chelsea and Westminster, South London Healthcare NHS Trust at Queen Elizabeth and Princess Royal hospitals, Kingston Hospital, Newham University Hospital, London North West University Healthcare NHS Trust, The Hillingdon Hospitals NHS Foundation Trust and the list is growing….

Distie Profitt, Cerner UK Managing Director states that over the past few years Cerner has faced stiff competition in the UK from Epic, which has won a string of high -profile contracts at UCLH, GOSH, Guys and St Thomas’, and Frimely as well as big regional deals with Northern Ireland and Manchester. But Cerner has similarly high-profile clients, including Imperial, Oxford, Barts, the Royal Free and Newcastle. Additionally, they partner with a range of providers and enable whole health systems across the country. Looking ahead she says Cerner believes the future is about ‘building on baseline digitisation and integration to then enable the automation of workflows, underpinned by a commitment to interoperability’. Profitt also highlights ‘The Rise Of Consumer Healthcare’ with a high-profile example being when Oxford and Milton Keynesbecame the UK launch sites for Apple’s Health Records feature, linking data from the trust’s Millennium EPRs to people’s iPhones. In August, Cerner announced a partnership with Amazon’s new cloud linked fitness tracker Halo. The Amazon tie-up with Cerner, due to reach the UK in coming months, will enable people to share activity, sleep, body fat percentage and other important wellness data with their health and care providers. The future will be much more citizen-centric in the care process. So, it’s not just paying lip-service to the person but understanding the citizen. That’s where much bigger change will come. We will continue to experience the acceleration of consumer engagement and them being more demanding of how and where they gettheir care.

NHSX is currently bidding for up to £3 billion investment in provider digitisation. Although it would be a welcome slice of investment, Profitt says that there are still a sizeable number of trusts and social care that have not yet digitised, and £3 billion is still not a lot to complete provider digistisation.

5.Subsidiaries

In North Central London back in 2018 whilst trying to find contact details for hospital Governors of the Royal Free London NHS Foundation Trust campaigners found a brief note in the local Trust Board minutes about a subsidiary company. The Trust’s Group Strategy and Investment Committee (GSIC) that dealt with such matters did not meet in public or provide public minutes. At the same time Unison, as part of a national campaign, had sent an FOI to ask the Trust about payments to external advisors concerning subsidiaries, and the declared £400,000 bill pushed the campaigners to send in an FOI asking for information relevant to that expenditure. After refusals, complaints to the ICO, serial delays by the Trust, an appeal to the Tribunal, an Information Commissioner’s change of opinion, an agreement by the Trust to send most of the information, a recent Tribunal hearing decided that the public still could not see the legal advice to the Trust. Documents have recently been received which show that the major hospital provider group has set up a series of linked subsidiaries.

The Trust’s rationale for the creation of subsidiaries was that National funding for the NHS was forecast to grow annually at less than the 4% per annum a level that most commentators believe was required to maintain existing models of service delivery.

The trust had an underlying financial deficit of c.£94m per annum and required all departments to make significant year on year savings. The subsidiaries were aligned to the trust’s drive for continual improvement in the quality of services and were a response to the need for change so that services could be provided in a way that was sustainable going forward.

The subsidiaries reflected the national picture across the NHS, driven by the financial challenge, where trusts were reviewing how they could increase productivity and quality, whilst reducing costs to the healthcare economy. In 2018 there were 65 wholly owned NHS subsidiaries in England37.

With the subsidiaries the Trust was able to

  1. access alternative (non-NHS) capital to fund service development, to pump prime transformation, innovation and investment;
  2. develop a range of programme specific strategic partnerships with commercial partners in a corporate form more familiar to the corporate sector, including the ability to plan and deliver for multi-year budgets;
  • provide assurance and a strong governance framework to manage non-operational risk for the trust;
  • operate at scale and on a standardised manner in keeping with the trust’s intention to grow as a group of hospitals, and develop an income.
  • improve, attract and retain well qualified staff to deliver future programmes of work.

In addition, the Trust stated that the property subsidiary would allow increased opportunities for local Small and Medium Enterprises (SME) to do business with the new company. The current Standing Financial Instruction (SFI) rules used NHS criteria for doing business with SME’s and these were extremely strict and in most cases made it challenging /impossible for SME’s to tender for business. A subsidiary gave an opportunity to provide a huge boost to the local economy as well as providing potential growth in employment for other local businesses.

This turns out to be an essential ‘anchor’ activity of providers required by the ICS to use the market to try to reduce inequalities and improve Public Health. Also in the papers there was a wish for the Trust to emulate a group of subsidiaries developed just across the Thames called:

Essentia Trading Limited (SE London ICS) February 9th 2021 Controlled by Guys and St Thomas Enterprises Ltd, controlled by Guys and St Thomas FT as SSAFA GSTT Care LLP

An example of the business they are currently doing from the Business Press:

‘ETL’s Zero Carbon Delivery Framework provides a one stop shop allowing public sector entities such as hospitals, military, education, police/fire an expedited and compliant avenue for low and zero carbon infrastructure investments. And excitingly, UK Private and Listed companies are also able to utilise the ZCF to ensure best value……ETL is a subsidiary wholly owned by Guy’s and St Thomas’ NHS Foundation Trust and profits are invested back into the NHS. In 2018, ETL supported over 25 NHS Trusts with NHS Energy Efficiency Fund (NEEF) applications and the delivery of successful projects’.

Essentia is also a partner in Optimedis COBIC UK a German/British partnership accredited on the Health Systems Services Framework38. Note the HSSF now has 12 streams and nearly 200 mainly private firms accredited.

There is also a large subsidiary called Quality Trusted Solutions Ltd in the incipient NW London ICS that is wholly owned by Central North West London Trust (CNWL)39. It offers help in Asset Management, Management Information System (MIS), Soft and hard Facility Management, Capital Projects, Transport Management, Sustainability and Strategic Estate Management. If you are short of money they have access to private finance that ‘can help unlock schemes and deliver long term solutions’. From its accounts, its turnover for the year ending March 2019 was £30.9m.

6.Private hospital provision and financing in London40

There are 28 private hospitals and Private Patient Units (PPUs) in central London and 46 outside central London but within Greater London:

  • HCA has the largest presence in central London measured by number of in-patient facilities, including six hospitals it owns and one PPU it manages. It also manages one PPU in Greater London.
  • Centene/Circle owns four hospitals in central London and six hospitals in Greater London, it also manages three PPUs in Greater London.
  • Nuffield, Ramsey and Spire have no hospitals in central London. They have hospitals just outside Greater London: Nuffield Brentwood; Ramsay Ashtead and North Downs; and Spire Bushey and Hartswood.
  • Aspen has one hospital in central London (the Highgate Hospital) and one hospital in Greater London (the Parkside Hospital).
  • There are a number of independent private hospitals in central London: the BUPA Cromwell Hospital, the Hospital of St John and St Elizabeth, the King Edward VII’s Hospital Sister Agnes and The London Clinic (TLC). There are two independent private hospitals in Greater London: the New Victoria Hospital and St Anthony’s Hospital.
  • There are 11 PPUs in central London (excluding those operated by HCA and BMI). There are four PPUs in Greater London (excluding those operated by the above hospital operators).

Financial data on Private Finance Initiative (PFI) hospital/social care41

There are 29 hospital/social care PFI schemes in London with a capital value of £2.8bn.

Payments due to the PFI operators/companies: Unitary Payments (1992/93 – 2016/17): £5.4bn Unitary Payments (2017/18 – till end): £16.8bn

So this is a total of £22.2bn of payments (incl. services) for £2.8bn of capital over the lifetime of the contract.

Profit and tax savings

Of the 29 London PFI schemes, the Centre for Health and the Public Interest (CHPI) was able to review the financial accounts of 22. These 22 schemes had a capital value of £2.7bn and from 2008/09-2015/16 (the period for which profit data was available) they paid £3.5bn to the PFI companies.

Out of this £3.5bn the PFI operators made a profit before tax of £334.1m and on this profit made an estimated tax saving of £32.8m.

Conclusion

The amount of privatisation of healthcare provision in London is already extensive and much remains hidden from public view behind the NHS brand. With the Health and Social Care Bill 2021 it is set to grow.

Many will argue that general practice has always been privately contracted so why do the changes matter, but there is a massive difference between GP partnerships working to earn salaries, and transnational corporations or private equity companies created to extract wealth. It is surprising how many of the new providers when investigated prove to be owned by the latter. The NHS is moving from a state funded service to a public-private conglomerate, and along the way new markets and investment opportunities are being created.

This is exactly what the WEF redesign of health services called for following the 2008 crash in order to improve the global growth of capital42. The losers will be the English public and the staff of the NHS; profits and dividend payments have to come from somewhere, and it will be from our pockets, job experiences, and less access to, and poorer quality of care.

References

  1. There is no reason to believe that private companies are not gaining similar contracts in communities across the Capital.
  2. https://en.wikipedia.org/wiki/Johnson_%26_Johnson
  3. https://www.hospitalmanagement.net/news/new-orthopaedics-centre-excellence-opened-guys-hospital/
  4. https://en.wikipedia.org/wiki/Sonic_Healthcare
  5. https://sel.synlab.co.uk/laboratory-details/ https://sel.synlab.co.uk/overview/
  6. http://uk.reuters.com/article/us-cinven-m-a-idUKKBN0P51TZ20150625
  7. https://allysonpollock.com/wp-content/uploads/2021/02/Letter_SoS_HSC_Centene_22Feb2021.pdf
  8. https://twitter.com/SouthwarkLabour/status/1372973831678230530/photo/1
  9. https://www.legislation.gov.uk/ukpga/2008/14/section/48
  10. https://keepournhspublic.com/us-health-insurers-are-coming-for-the-nhs/
  11. https://www.theguardian.com/society/2021/apr/02/backlog-is-truly-frightening-former-nhs-chief-warns-of-vital-delays https://www.nhsforsale.info/conflict-of-interest/operose-ceo-moves-to-number-10-advisor-position/
  12. https://www.laingbuissonnews.com/healthcare-markets-content/circle-health-announces-major-investment-programme-as-us-centene-takes-controlling-stake/
  13. https://keepournhspublic.com/campaigns/legislative-changes/integrated-care/integrated-care-of healthcare-imperialism/ https://www.sochealth.co.uk/2021/05/10/centene-the-real-agenda/
  14. https://democracy.camden.gov.uk/documents/b27994/Supplementary%20Agenda%20-%20Deputations%2007th-Apr-2021%2018.30%20Health%20and%20Adult%20Social%20Care%20Scrutiny%20Commi.pdf?T=9
  15. https://assets.babylonhealth.com/press/20190927-Babylon-GP-at-Hand-response-to-new-NHS-policies-for-digital-first-primary-care.pdfhttps://healthshare.org.uk/about-healthshare/
  16. https://healthshare.org.uk/about-healthshare/
  17. https://find-and-update.company-information.service.gov.uk/company/10657226/persons-with-significant-control
  18. https://en.wikipedia.org/wiki/Northgate_Public_Services
  19. https://en.wikipedia.org/wiki/NEC
  20. https://en.wikipedia.org/wiki/AT%26T
  21. https://en.wikipedia.org/wiki/First_Databank
  22. https://en.wikipedia.org/wiki/Hearst_Communications
  23. https://www.nhsforsale.info/private-providers /inhealth-group-2/
  24. https://www.nhsforsale.info/private-providers/concordia-health-new/
  25. https://en.wikipedia.org/wiki/Bridgepoint_Advisers
  26. https://www.nhsforsale.info/private-providers/totally-plc-new/
  27. https://en.wikipedia.org/wiki/Cerner
  28. https://en.wikipedia.org/wiki/Atos
  29. https://www.epic.com https://en.wikipedia.org/wiki/Epic_Systems
  30. https://www.systemc.com https://en.wikipedia.org/wiki/CVC_Capital_Partners
  31. https://en.wikipedia.org/wiki/Deloitte
  32. https://www.cerner.com/gb/en/industry-perspectives/a-look-into-hie-adoption-across-england
  33. https://medium.com/iipp-blog/worker-organisation-and-the-challenge-of-shaping-markets-in-the-age-of-surveillance-capitalism-cc9dc4da37c5
  34. https://www.england.nhs.uk/author/matthew-swindells/ https://www.digitalhealth.net/2019/05/swindells-to-leave-nhs-england-private-sector/
  35. https://www.digitalhealth.net/2021/04/two-north-london-trusts-cerner-for-integrated-ehr/ https://www.digitalhealth.net/2020/11/the-challenges-of-leading-a-supplier-during-a-pandemic/
  36. https://www.digitalhealth.net/2018/03/london-csu-deliver-population-health-dashboard/
  37. Jan Savage, Marion Macalpine and Carol Saunders. How come we didn’t know about SubCos? The growing use of NHS-owned private companies. Pamphlet 2020.
  38. https://www.consultancy.uk/news/19206/the-professional-services-firms-that-are-helping-nhs-embrace-technology
  39. http://qts-llp.co.uk
  40. https://assets.publishing.service.gov.uk/media/5329dc1fed915d0e5d0000f5/130607_london.pdf
  41. https://chpi.org.uk/blog/londons-hospital-school-pfi-schemes/
  42. http://www3.weforum.org/docs/WEF_HE_SustainabilityHealthSystems_Report_2012.pdf

Bring out the dead

let’s bring out the dead
the defeated
the destitute
the isolated mind

our bodies scarred
memorial on the high street
medals for the survivors
parties for the kind ones
no dancing by eros
we endured

knightly collusion
politicians begone
in the shadow of the slaughter

we had it within us
court friends knew better
call centre illusions
our best chance
oxbridge sage
modelling murder
follow the money
eat out to help out
double or quits

bloated self-confidence
free trade in virus
haig‘s walk-over 
no-man’s land
herding the old
graves to cry by
r numbered 
bullingdon barbarism

we knew by summer
winter would come
indi_sage zoomed out
zero the virus 

mum’s phone for two plus two
frightened to play childhood 
the rich relax
the powers protect
pox on your spare bedrooms
your lofty ceilings
sourdough smugness
bring out the dead

spurt of growth 
vaccine forgiveness
all forgotten
learn the pandemic
bring out the dead

our leader rides high
mussolini by his feet
bonfire the masks
politicians on top
of rolling heads
crucify conceit
bring out the dead

eruptions of anger at our children’s stunting
renew with love
rage contained

let’s flatten the curve of the footsie one hundred
lockdown the bentley
take their front room

scream at the sky
madness
we do it with love
look the sun in the face
the heat of the heart
look death in the face
and give it new life

breath deep
smell your friend
passionate kiss for the lonely
the frightened
the mad
smile on your smile
two metres of touching
the colour of love

reach out to the victims
of torment at home
batter on batter
you made me do
hear the pain
of privatised violence
name the deed
heal the wound

payback cayman islands
they tell us now
our stocks are high
your hopes low
defeated

long
poem
long
lives
lost

death haunts the land
fear for what’s next

refuse the future they have for us
bring out the dead

our genius create
pfizer be damned
the meekest show too
beauty unbound
learn from the children
let life break through

roll up our sleeves
it’s our time now
we see kindness abound
bring out the dead

let’s house the homeless
rip the damp songs
for the frightened
care for the old
talk of the past
repair the swings
work with dignity
laugh with laugh
colour by day
love by night

let’s build a country worthy of the dead
let’s make it a country

a joyful period
of warm hearts 
and bright living rooms
of peace for the overworked
the exhausted mother
three jobs juggling
sauna and sleep
debts denied

the pandemic will pass
the shadow grey
let’s paint it red
and blue and green

but bring the dead too
to bury in our hearts

Paul O’Brien