Proposed a more humane way of executing people during the French Revolution

Proposed a more humane way of executing people during the French Revolution
Lady Mary Wortley Montagu 1689-1762 (see Isobel Grundy, ‘Lady Mary Wortley Montagu – Comet of the Enlightenment’; Oxford University Press, Oxford 1999) came from an aristocratic family, largely self educated through having access to family library, and determined to be a woman of letters. Her brother died from smallpox in 1713 and she herself was infected in 1715. Lady Mary went to Istanbul for two years when her husband was appointed ambassador to the Sublime Porte. She wrote extensively on Turkish society from mixing with Turkish women and can be credited with producing the first secular work by a woman about the orient.
Open to the idea of learning from a foreign culture, she enquired into the lack of smallpox in Istanbul and investigated the widely employed process of ‘engrafting’ (inoculation; variolation), which protected against the infection. This involved taking a small amount of matter from an infected pustule in a mild case and scratching this into the skin of an uninfected person. She had her son treated in this way, and then her daughter on returning to England and during another outbreak of smallpox. Caroline, Princess of Wales had her two daughters inoculated but only after 7 prisoners in Newgate Prison and 11 London orphans survived the process. The practice was adopted by Catherine the Great in Russia.
Some physicians in the Britain were supportive but others incredulous that there was anything they could learn from a woman/a non-professional/a non-Christian country. Some who used it failed to observe the Turkish practice of taking extreme care over the process, with the result that their patients became ill with smallpox. Lady Mary lived a long time away from England, in Venice Florence, Rome, Genoa, Geneva and Avignon. Her writings challenged social attitudes towards women and their intellectual and social growth. Eighty years after her promotion of variolation, Edward Jenner introduced the much safer vaccination with cowpox. Six years later, James Gillray’s cartoon made a powerful anti-vaccination statement (https://www.britishmuseum.org/collection/object/P_1851-0901-1091).
Soviet Russia introduced mandatory smallpox vaccination in 1919 to great effect. The World Health Organisation launched its worldwide eradication campaign in 1967, with success coming ten years later. In 1978, Birmingham medical photographer and ASTMS member Janet Parker tragically died from smallpox, presumably from the medical school laboratory. Sheila McKechnie, a regional officer for ASTMS, was very active in representing the interests of staff union members. The whole affair is well documented in Mark Pallen’s fascinating book ‘Last Days of Smallpox’, although marred by anti-union posturing (https://www.amazon.co.uk/product-reviews//1980455228/ref=acr_dpx_hist_4?ie=UTF8&filterByStar=four_star&reviewerType=all_reviews#reviews-filter-bar).
John Puntis
NHSE/I recently published a consultation document on the “Next steps to building strong and effective integrated care systems across England”. This response exposes the fundamental problems of a market based health care system in trying to deliver integrated care.
1. Overview
Publication of the next steps document during the covid-19 pandemic comes at a remarkable moment. Significant shortcomings have been exposed in the NHS1, in the systems for communicable disease control and public health,2 in the procurement system3 and in the social care system.4 The lack of hospital and ICU capacity have been major drivers of national lockdowns in March 2020 and January 2021 and the causes of severe winter pressures in previous years.
At the same time, the pandemic has demonstrated the obstacles created by market bureaucracy and heavy-handed and centralised market regulation which have developed over decades in the NHS.
The document hints at positive effects of the pandemic (paragraph 2.1) and refers in general terms to some of them (e.g., 2.72), which have played a part in “increas[ing] the appetite for statutory ‘clarity’ for ICSs and the organisations within them.” (3.8). It also recognises “the persistent complexity and fragmentation” which is rightly complained about (1.3).
This is largely the product of reforms premised on competitive relations and contracting among health bodies. Finally a new anti-competition consensus appears to have emerged in NHS reform5 which has found its way, though problematically, into the document.
But as David Lock QC has said in 2019: “The big picture is that you have a market system. If you do not want a market system and you want to run a public service, you need a different form of legal structure.” And this obvious truth raises fundamental questions, which the document seems to glimpse, but which it is unwilling to grasp.
Why, for example, continue to insist on running health organisations as businesses if the aim is collaboration instead of competition? How should needs-assessment and population planning be undertaken if the aim is to secure comprehensive health and social care for geographic areas? Where should they be located and on which bodies does the statutory duty of universality fall? How can major political questions surrounding resource distribution be undertaken consensually outside established political processes? Equitable access and solidarity require risk-pooling and a community response.
Rather than rising to the challenge of these questions in ways which could reliably “provide[] the right foundation for the NHS over the next decade” (page 31), the document puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market-based framework and undermine risk-pooling, even when proposing legislative change; much essential detail is omitted.
As they stand, the proposals seek to achieve integration by focussing on increasing freedoms of the various bodies involved in commissioning and contracting. They rely on general exhortations to counter deregulation. Laudable “fundamental purposes” inform an “aim” of “a progressively deepening relationship between the NHS and local authorities”. Three “important observations” which may or may not be aims relate to more local decision-making, more collaboration and economies of scale. A “triple aim” duty of unspecified strength relates to “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer” (1.3, 1.8, 1.9, 3.3).
The approach however leaves substantially unchanged the legal powers of the many incorporated bodies active in the health care market among which collaboration is expected but from which disintegration has spread. If the aim is “rebalancing the focus on competition” (3.3) a concrete.
administrative alternative is required. None is offered. Seeking to promote greater integration whilst retaining commercial autonomy will not work.
In summary, the proposals:
We discuss the details in the following two sections.
2. ICSs during 2021/22 and before legislation
The document seems to have two purposes: to further progress ICSs and the merger of CCGs ahead of legislation; and to explain changes to the NHSE/I’s legislative proposals published in September 2019.
Our understanding of what an ICS will be and do, before legislation, is set out in the below.
What will an ICS be and do before legislation – as far as we can make out?
An ICS will not have legal form and will consist of:
We make a number of key points under the following headings:
(1) Strategic needs assessment
The emphasis on strategic needs-based assessment and planning is welcome, yet there will be no single body which has the responsibility to carry it out and no legal mandating of it. This is likely to lead to buck-passing. Perhaps more importantly, it is also likely to lead to needs-based planning being overridden by increasingly powerful monopoly providers having pivotal influence over a single budget, and over its allocation both for non-secondary care services to undefined “places” with no statutory identity, and for secondary (and tertiary) care.
Moreover, it seems highly unlikely that services provided would be based on the needs assessment, because clinical networks are expected to carry out “clinical service strategy reviews on behalf of the ICS” and “develop proposals and recommendations” which providers will agree. Indeed, “[c]linical networks and provider collaborations will drive…service change” (2.26, 2.11, 2.72). No tie-in to the strategic needs assessment is proposed, let alone a requirement for it to frame provision.
Public health experts have traditionally performed the functions of needs assessment, facilitating service development and service planning. However, public health sits outside of health services and is further fragmented between local authorities and the Secretary of State (Public Health England, to be replaced by another non-statutory body, the National Institute for Health Protection) as a result of the 2012 Act.
Clinical Support Units provide information and support for commercial contracting. They are not substitutes for public health, are not integrated into CCGs or local public health departments, and do not inform strategic needs assessment and service planning.
(2) The single pot budget
It appears – certainly before, and perhaps after, legislation – that ICSs will not be responsible for all people within an ICS area. That term – an ICS area – is conspicuously absent from the proposals. The CCG membership model (‘persons for whom they are responsible’) cannot be changed without legislation and so will presumably be ‘scaled-up’ to cover all the CCGs involved.
We have previously expressed6 concern about how Accountable Care Organisations would have been able to integrate health and social care services because their funding would have been for a different population (GP lists versus local authority), and would not have health service funding allocated for unregistered CCG residents who might be eligible for local authority social services. This concern still applies in relation to ICSs, including provider collaboratives and place-based partnerships, both with and without legislation, and with and without integrated provider care contracts.
In addition, the bases upon which resources will be allocated to secondary (and tertiary) care and to place-based partnerships, and within those partnerships are entirely unclear. This is presumably deliberate. Already there has been a marked decrease in administrative accountability for spending, and multiple contracts and subcontracts – which will continue – make it increasingly impossible to ‘follow the money’, let alone to assess the costs of contract administration. Detailed financial reporting to NHSE/I is obviously essential and may be provided for, but public transparency in funding as between primary care, community and mental health services, and acute, secondary and specialist care, including sub-contracting, is also essential.
(3) Provider collaboratives
No control is proposed over the composition of these collaboratives. They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services. The potential inclusion, for example, of large private hospitals, which have been contracted during the pandemic, needs to be clarified immediately. No control is proposed over the granting of contracts to providers within thesecollaboratives, who may in fact be distant from and have no connection with the local community and be subject to commercially-driven mergers, acquisitions and closures that threaten patient care.7
Full integrated care provider contracts can be awarded, though there is no reference to the House of Commons Health and Social Care Committee in June 2019 having “strongly recommend[ed] that legislation should rule out the option of non-statutory providers holding an ICP contract [in order to] allay fears that ICP contracts provide a vehicle for extending the scope of privatisation in the English NHS”. In September 2019, NHSE/I acknowledged this and stated that it supported the recommendation. If private companies are not likely to be awarded such contracts, then what is lost by legislating to that effect? And what prevented a clear statement to that effect being made in this document?
Neither is there any reference to the HSC Committee’s recommendation that “ICP contracts should be piloted only in a small number of local areas and subject to careful evaluation”.
(4) ICS membership
There are two potential aspects in this regard.
The document proposes for legislative change Option 2 that the ICS body should be able to appoint such members to the ICS body as it deems appropriate “allowing for maximum flexibility for systems to shape their membership to suit the needs of their populations” (3.19). It seems that this will be possible de facto before legislation, e.g., via the unspecified provider collaboratives. This risks giving private companies influence over the allocation of NHS funding: “they are there to make money from the NHS” in the words of Dr Graham Winyard – and should not be admitted as members. Yet the document is silent on this point.
As for patients, the document is silent on whether individuals on GP lists will transfer to any provider (e.g. under an integrated care provider contract), or even to a provider collaborative – or, after legislation based on Option 2, to an ICS body; and, if so, how that would be achieved and whether individuals would have any choice in the matter. In addition, will individuals be able to move from one ICS to another? And what happens, for example, if an individual is on the list of a GP (or provider or provider collaborative) within the ICS, but lives in a local authority area within another ICS and requires social care?
NHSE/I should clarify these issues as soon as possible.
(5) Public accountability
ICSs will be making major resource allocation decisions, which will often be controversial. Transparency and scrutiny will be critical. However, the document says nothing about how current public accountability requirements and mechanisms will work in an ICS context. These mechanisms are based mainly around CCGs and local authorities, but in reality these bodies will no longer be the decision-makers. Actual decision-making will be de-coupled from legal functions and the effectiveness of public accountability will be diminished in the process.
(6) Competition and contracting
Proposals to remove market competition, compulsory contracting and the commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 – which are welcome – cannot happen without statutory change; the rights of private providers and the purchaser-provider split remain in place. The work-arounds continue.
(7) Social care
Adult social services are means-tested. Health services are not. Providers of social care and support are said to be included in place-based partnerships, but the allocation of resources to and within the partnerships is entirely unclear. There is no mention of any safeguards to prevent services which are currently free from being re-designated as social care and so subject to means-testing and possible charges.
(8) Public health
Local authority public health will fall within place-based partnerships. As for other services covered by these non-statutory partnerships, there is no mention of how protecting public health funding will be achieved in the face of the power of provider collaboratives and clinical networks operating at the level of the ICS and beyond. Representation by DPHs and other local authorities is unlikely to be enough.
(9) Workforce planning
The next steps document is silent about work force planning. Lack of doctors and staff is already a serious issue after years of fragmentation, lack of investment and, appallingly, absence of a strategy: the Kings Fund described it recently as “a workforce crisis”. NHSE/I need to be clear about how attempts to improve this critical function would operate in the ICS context.
(10) Moving staff and their terms and conditions
It is proposed that there should be “frictionless movement of staff across organisational boundaries” (bizarrely in the context of data and digital technology, page 20). This is capable of different meanings across a spectrum, but nothing more is said about this, nor on the terms and conditions of staff in the ICS context. Much more information should be provided.
3. ICSs after legislation
There is much less information on legislative changes in the next steps document than was contained in NHSE/I’s September 2019 document entitled The NHS’s recommendations to Government and Parliament for an NHS Bill. The next steps document lists some of thoserecommendations and states, oddly, “We believe these proposals still stand” (3.3, 3.4). This statement makes it unclear whether they continue to be proposals.
The next steps document proposes two options for legislation.
Option 1 would establish the ICS as a mandatory statutory ICS Board in the form of a jointcommittee of NHS commissioners, providers and local authorities with an Accountable Officer, and with one CCG only per ICS footprint which would be able to delegate “many of its population health functions to providers” (page 29).
Option 2 would set up a new statutory ICS body asan NHS body by “repurposing” CCGs, taking ontheir commissioning functions, plus additional duties and powers, and having “the primary duty…to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations”. It would have “flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers”. It would have a board of representatives of system partners (NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer as a minimum) with the ability to appoint such other members as the ICS deems appropriate “for maximum flexibility for systems to shape their membership to suit the needs of their populations” (page 30).
NHSE/I prefer Option 2.
Most of the points we have made pre-legislation continue to apply. We expand on some of those and add to them as follows:
(1) Major reorganisation
It is striking that despite the apparent opportunity for primary legislation following the Queen’s Speech neither Option grapples with the fundamental questions posed in the Overview above, which flow from the anti-competitive consensus (if such there be). This might be because NHSE/I wish to avoid being seen to be proposing a major reorganisation. But this is exactly what is happening, even without legislation.
In September 2019, NHSE/I stated:
“The Select Committee [in July 2019] agreed that NHS commissioners and providers should be newly allowed to form joint decision-making committees on a voluntary basis, rather than the alternative of creating Integrated Care Systems (ICS) as new statutory bodies, which would necessitate a major NHS reorganisation.” (emphasis added)
(2) Competition and contracting
No legislative changes are proposed to the purchaser-provider split. Whilst repeal of procurement rules under section 75 of the 2012 Act and removal of commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 are welcome, the document is silent on safeguards against corruption and conflicts of interest.
It is also important to recall that in September 2019 NHSE/I stated that it would retain a number of the provisions of the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 – commonly referred to as the ‘section 75 regulations’. Of particular worry, exacerbated by the covid-19 pandemic, is retention of “the requirement to put in place arrangements to ensure that patients are offered a choice of alternative providers in certain circumstances where they will not receive treatment within maximum waiting times”. The possibility of the use of private providers in these circumstances, rather than increasing NHS capacity, is obvious.
(3) Fate of CCGs
NHSE/I still seem undecided about the fate of CCGs in Option 2. Under both Options, the document states that “current CCG functions would subsequently be absorbed to become core ICS business” (2.64). Yet the document only proposes, in relation to Option 2, to replace the CCG governing body and GP membership, but for some unknown reason does not state that CCGs will be abolished, which presumably they must be, under Option 2, with no replacement.
(4) ICS membership
The document proposes in Option 2 – though we are not clear why this is not a possibility in Option 1 nor de facto from now onwards (see section 2(4) above) – that the ICS body should be able to appoint such members as it deems appropriate. This would be a blatant undermining of the ICS as an NHS body.
In addition, as stated above (section 2(4)), it is unclear whether individuals on GP lists would be transferred to the ICS body.
(5) Missing proposals
4. Conclusion
These proposals are incoherent, de-regulatory and unclear, and are not equal to the existential threat that is posed by the current government to the NHS as a universal, comprehensive, publicly-provided service free at the point of delivery. This has been amply demonstrated by the government’s response to the covid-19 pandemic which has directed billions of pounds to private companies to provide services that should have been provided by the NHS, Public Health England and local authorities. The proposals allow this to continue and increase.
Neither can the ambition of providing a sound foundation for the next decade be sensibly addressed without considering the inevitable but uncertain changes that will be necessary post-pandemic to the public health and social care systems, and to the functions of local authorities.
The challenge now is much greater than it was in 2019, when the difficulties of getting major NHS legislation through the House of Commons was used as a reason/excuse for not proposing legislation equal to the task of taking the market out of NHS once and for all. We urge MPs who are committed to the NHS as a public service to support scrapping the 2012 Health and Social Care Act in its entirety and to support the NHS Reinstatement Bill which would put back the government’s duty to provide key services, delegated to Strategic Integrated Health Boards and Local Integrated Health Boards.
Footnotes
Dr Norman Bethune (1890 – 1939) was an outstanding doctor and thoracic surgeon who broke with the medical conventions of the time in his native Canada to campaign for a socialised health care service, having suffered tuberculosis himself and seeing how poor people died of the disease while rich people survived. He said of the medical profession: “We set ourselves in practice, all smug and satisfied, like tailor shops. We patch an arm, a leg, the way a tailor patches an old coat. We’re not practicing medicine, really, we’re carrying on a cash-and-carry trade. I’ll tell you what’s needed: A new medical concept of universal health protection, a new concept of the function of a doctor.“
He went to Spain during the civil war and supported the Republicans fighting against Franco’s fascists. He was the first to develop a mobile blood transsfusion service for front-line operations on the battlefield. He also invented a range of surgical instruments including rib shears, which are still in use today.
Dr Bethune joined the Communist Party of Canada and convinced his comrades to send him to China in 1938 to help organise medical care for the Mao Tse Tung’s 8th Route Army, who were fighting against the Japanese invasion. He organised mobile surgical units and blood banks for front-line troops, treating both wounded Chinese and Japanese troops. It was here that he wrote his famous text “Wounds” in the early hours of one morning in 1939, excoriating the capitalist class for the wars and suffering they unleash on the world in pursuit of profit. It concludes:
What do these enemies of the human race look like? Do they wear on their foreheads a sign so that they may be told, shunned and condemned as criminals? No. On the contrary. they are the respectable ones. They are honoured. They call themselves, and are called, gentlemen. What a travesty on the name, Gentlemen! They are the pillars of the state, of the church, of society. They support private and public charity out of the excess of their wealth. they endow institutions. In their private lives they are kind and considerate. they obey the law, their law, the law of property. But there is one sign by which these gentle gunmen can be told. Threaten a reduction on the profit of their money and the beast in them awakes with a snarl. They become ruthless as savages, brutal as madmen, remorseless as executioners. Such men as these must perish if the human race is to continue. There can be no permanent peace in the world while they live. Such an organization of human society as permits them to exist must be abolished.
These men make the wounds.
Norman Bethune died 12 November 1939 of septicaemia after he cut his finger during an operation on a wounded Chinese soldier.
A detailed account of Norman Bethune’s life can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676399/
At the start of the pandemic it was thought that spread of coronavirus was through large droplets travelling over a relatively short distance or by fomites contaminating hands and mucous membranes. The danger of aerosol spread was recognised, but thought to be limited to ‘aerosol generating procedures’ (AGP) such as intubation. For this reason, high grade face masks (FFP3 or N95) were only recommended for staff exposed to AGP (1).
The denial of aerosol transmission of virus (2) always sat uncomfortably with the acceptance that so called AGP represented a risk. It is now known that aerosols are generated by talking, shouting, singing, coughing and sneezing and are an important form of viral transmission. Official Infection Prevention and Control (IPC) guidance [3] is now seriously lacking on the issue of AGPs: several studies [4] [5] [6] indicate that many of the “classic” AGPs (like intubation) produce little in the way of aerosols and that an actively coughing patient may be much more infectious than those undergoing various AGPs. Moreover, patients with Covid-19 requiring AGPs are likely to be sicker and later on in their illness course, and will therefore produce much less aerosolised virus than patients who have just become symptomatic, when infectiousness is known to be at its greatest.
In fact, coronavirus can be spread over large distances, for example in food processing plants (7) or in restaurant settings. Studies in health workers of SARS-CoV-2 antibody status (signifying past infection) (8) strongly suggest that high level PPE (including high grade masks) is effective in preventing infection, and that use of surgical type fluid resistant masks is inadequate in situations where staff are in close contact with symptomatic patients such as on hospital wards.
In addition, ventilation in enclosed and crowded workspaces is clearly an important risk factor in spread, yet there is little specific advice to manage this risk other than keeping windows open. This is a particular concern in workplaces and schools where maintaining social distancing is difficult; currently the highest rate of new infection is among secondary school children. The fact that a recent update of official IPC guidance does not mention aerosol spread at all (outside of AGPs) is inexplicable, given that this was after Public Health England recognised this route of transmission over two month ago. This puts tens of thousands of health and social care workers at potential risk in hospitals, primary care settings and in care homes, as well as the patients they care for.
The pandemic is far from over, with more than 600 health and care workers already having died, and an overall death toll in the UK equivalent to one international airplane crash killing all passengers every day for nine months. Although vaccine development gives some cause for hope, important unknowns remain how many people will receive/accept vaccination and how long this process will take, whether vaccination will prevent transmission and therefore achieve herd immunity, and how long protection might last. There is therefore every reason to hone non-pharmacological interventions in order to reduce further loss of life. We therefore call upon PHE and the Department of Health and Social Care to recognise an urgent need to update guidelines on COVID-19 prevention and control in the light of what is now known about aerosol transmission. This should include upgrading type of masks worn (9) and advice on how to maintain and monitor effective ventilation.
References
“Doctors in Unite are supportive of vaccination as part of a broader strategy to end the COVID 19 pandemic. In general we believe that any risks from the vaccines will be outweighed by the benefits.
However, it is difficult to say this categorically when the trial data and protocols have not been made available. We call for these to be published in full. Complete transparency should be a given and is vital in the current climate of mistrust.
We note that under usual circumstances Phase 3 trial participants are intensively followed up for six months followed by a lower level of surveillance for up to two years. We appreciate that these are unprecedented times but at the time of writing vaccines are being rolled out for mass administration within four months of the commencement of phase 3 trials with little opportunity to document medium or long term effects.
If debilitating side-effects emerge, there should be full compensation for anyone affected – including loss of pay, care and any other needs – for as long as necessary and without having to fight lengthy battles
Johnson and his government’s handling of the pandemic has been one of shocking mismanagement bordering on criminal negligence. They have lurched from one bad decision to another, have handed contracts worth billions of pounds to their friends without proper scrutiny and failed to listen to the experts. This has led to an understandable deep level of distrust amongst the public and a worrying reluctance among some sections of the community to agree to be vaccinated. This is concerning, as the very people who are at most risk of poor outcomes from COVID 19 are those who are least likely to come forward for vaccination.
We believe that until more is known about the efficacy of the vaccine in suppressing COVID 19 that vaccination can only be part of a broader strategy to combat the virus.
Robust, community based Find, Test, Trace, Isolate and Support, organised through local Public Health and Primary Care is still essential, though sadly lacking. Messaging about staying safe with frequent hand washing, mask wearing and social distancing must continue and proper attention must be paid to ventilation and indoor airborne spread.”