One Stop Shops – trick or treat?

The media recently highlighted the fact that NHS England has announced:

The NHS is set to radically overhaul the way MRI, CT and other diagnostic services are delivered for patients . . . . Community diagnostic hubs or ‘one stop shops’ should be created across the country, away from hospitals, so that patients can receive life-saving checks close to their homes. The centres could be set up in free space on the high street or retail parks.”

“The need for reform of NHS diagnostics was recognised in the Long Term Plan” – so begins the recent report by Professor Sir Mike Richards, ‘Diagnostics. Recovery and Renewal’.

The key recommendations are:

  • Acute and elective diagnostics should be separated wherever possible to increase efficiency.
  • Acute diagnostic services (for A&E and inpatient care) should be improved so that patients who require CT scanning or ultrasound from A&E can be imaged without delay. Inpatients needing CT or MRI should be able to be scanned on the day of request.
  • Community diagnostic hubs should be established away from acute hospital sites and kept as clear of Covid-19 as possible.
  • Diagnostic services should be organised so that as far as possible patients only have to attend once and, where appropriate, they should be tested for Covid-19 before diagnostic tests are undertaken.
  • Community phlebotomy services should be improved, so that all patients can have blood samples taken close to their homes, at least six days a week, without needing to come to acute hospitals.

Motherhood and apple pie

On the surface of it, these are laudable aims that have been welcomed by hospital bosses. The COVID-19 pandemic has had a devastating effect on management of non-covid conditions with, for example, a 75% reduction in cancer referrals and a reduction in 210,000 imaging procedures each week. Before the pandemic there were 30,000 patients who had waited longer than 6 weeks for a diagnostic test, a figure that has now increased to 580,000. Urgent consideration must be given both to how the NHS is put back on its feet and how it addresses the huge backlog of problems as well as the ongoing pandemic. There is logic in separating acute and non-acute service provision into covid and covid free areas, and who could object to patients having convenient and rapid access to the best available technology? This does of course depend on many factors, not least having an efficient coronavirus testing system at some point in the future, but raises other crucial issues.

Where will the staff be found?

The plan as set out requires the recruitment of around 11,000 staff including 2000 radiologists, 500 Advanced Practitioner radiographers, 3,500 radiographers, 2,500 assistant practitioners, 2,670 administrative staff and 220 physicists. Bear in mind the current staffing crisis on the NHS, with around 140,000 vacancies across the board exacerbated by low pay and workplace stress. Cancer Research estimated that staff would need to double by 2027 to meet demand, with one in ten posts in diagnostics unfilled at the start of the pandemic. Furthermore, massive investment in equipment will be needed. The report points out that in relation to the 20 other countries making up the Organisation for Economic Cooperation and Development, the UK ranks bottom for CT and 3rd from last for MRI scanners. The Clinical Imaging Board claims that nearly 30 per cent of the UK’s MRI stock is at least ten years old, with no replacement plans for almost 40 per cent of systems more than seven years old.

All that’s left to find – money and staff

The last settlement for the NHS was £20.5 bn, which over a five year period amounted to an annual increase in budget of 3.4%. This did not include funding for training and employing the staff of the future. Most commentators thought a minimum 4% increase in funding was needed, and the Office for Budget Responsibility put the figure at 4.3% in order to meet increasing demand. COVID-19 has now blown all these estimates out of the water with the additional costs of restarting and sustaining the service, dealing with COVID-19 long term and developing and implementing a workforce transformation.

Private sector – the spectre lurking in the wings

In Simon Stevens’s letter to health care providers in July this year, he mandated:

Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres”.

As pointed out in The Lowdown in a comment on diagnostic hubs:

“References . . . to high street and retail park sites are possibly of no real concern – perhaps they’re more about exploiting cheap-to-rent locations during the pandemic-driven economic recession than a push to link-up with high-profile brand sponsors – but the well-established presence of private sector interests operating in the diagnostic and pathology arena suggests there may be rich pickings on offer somewhere in the hub programme, if only until the backlog is cleared”.

In fact the privatisation of diagnostic and laboratory facilities is already well underway. There is no comfort here in Professor Richard’s report which even cites as a case study:

The East Midlands Radiology Consortium (EMRAD) was launched in 2013 to create a common digital radiology system. Pioneering work led to the development of a Cloud-based image-sharing system through which the seven NHS trusts involved in the partnership could share diagnostic images, such as X-rays and scans. In 2018, EMRAD formed a partnership with two UK-based AI companies, Faculty and Kheiron Medical, to help develop and test AI tools in the breast cancer screening programme in the East Midlands.”

There is no mention of the fact that EMRAD paid £30m for the picture archiving and communication system from GE Healthcare but refused to pay full service costs until GE sorted out chronic problems causing a dangerous backlog of CT and MRI images.

Like many of the aspirational service developments contained within the Long Term Plan, ‘one stop shops’ could offer real value to patients. As the report by Professor Richards recognises:

These new services will require major investment in facilities, equipment and workforce, alongside replacement of obsolete equipment. Training of additional highly skilled staff will take time but should start as soon as possible. International recruitment should be prioritized.”  

This is no small ask and needs to be part of a generous new funding settlement for the NHS by government.  This should be an investment in the NHS as a public service rather than a source of rich pickings for private companies.

This article was written by John Puntis for Keep Our NHS Public

Policy statement on a National Care Service.

Doctors in Unite believe that the current model for social care is not working and that this has been brought into sharp focus during the COVID 19 Pandemic. Care homes bore a huge burden of deaths during the first wave, for many reasons, but not least due to the fragmentation that privatisation has imposed on that sector. This has led to a lack of local capacity and national coordination of care for some of the most frail and vulnerable in society.

Social Care at home is in a similarly parlous state. Domiciliary care is also largely outsourced to the commercial sector and provided by a workforce on extremely low pay, poor conditions and zero hours contracts. Many workers are not paid for the time they spend travelling between clients. Workers have too little time to spend with clients and it is difficult for them to build trusting relationships.

We do not wish to reinvent the wheel. Keep Our NHS Public and the Socialist Health Association are launching National Care Support and Independent Living Service on 10th October, The TUC and the Labour Party, through Reclaim Social Care, have good policy on how social care should be organised which Doctors in Unite would be able to broadly align with. These are set out in the appendices at the end of this statement.

We believe that:

  1. Care is a basic human right and is good for society as a whole. There must be a national care service which is publicly funded, publicly provided and free at point of need. It should be paid for out of general taxation and years of underfunding must be reversed. The Keynesian Multiplier for care service is substantially higher than the 2.5 figure at which spending is self-funding because for every £1 spent on the service the economy benefits by £2.50 which generates £1 in taxation. Within reason, spending on services with a multiplier above 2.5, such as health, care, environments, education and welfare actually reduces the deficit and so is money well spent.
  • Private/for profit care services should be brought back into public control.
  • The national care service must be subject to local democratic control. Users, their families and workers, through their trade unions, must have a strong voice and local councils must be accountable. Neighbourhood health committees should be set up as we suggest in our earlier paper “Public Health and Primary Care”.  https://medicalpractitionersunion.files.wordpress.com/2020/05/public-health-and-primary-care.pdf   The service should be funded centrally but organised locally.
  • Users and their families must be at the centre of their care, which should be personally directed and flexible, but not through personal budgets. We acknowledge that users are usually best placed to determine the care that they need but we are concerned that personal budgets can be unnecessarily expensive and bureaucratic to administer and will give some an economic advantage over others with equal need. Everyone should be able to access the care that they require in the way which is most suitable for them as individuals without the need for personal independence payments. We would like to work with disability action groups to develop personally directed care while taking the economic inequalities out of the system. There must be proper funding and support in place to enable users to access the system and find services that meet their needs.
  • There is a broad spectrum and continuum in social care needs Doctors in Unite believe that the natural home of social care is within the local authority not the health service. Nevertheless, where necessary, a National Care Service and the NHS should work collaboratively for the needs of a user. There is no need to merge the two services.  It is unhelpful to classify a need as either social or medical, a need is a need. Services must be properly funded so that if someone needs a bath they get help with a bath without the historical arguments as to whether the need for that bath is social or medical.
  • The National Care Service should be funded sufficiently so that people can be supported to live independently if they wish. People should not be pressured to go into a care home because services, such as night sitting, are not available in the community or deemed too expensive. Similarly, residential care home options should be available if this is what people prefer and need.
  • Care must be dignified and both residential and domiciliary care should be comfortable, homelike and run by the local authority. Many small locally run services strive to provide this though often they struggle to remain viable. Bringing these providers into public ownership whilst maintaining their ethos would provide stability for staff and clients. Proper service planning would also end the geographic perversity such that residential care homes are set up not where they are needed but where the real estate is cheapest, meaning long journeys for relatives to visit their loved ones distant from where they live.
  • Domiciliary care should be brought back into social ownership under Local Authority control immediately. As already stated, users and their families must have a strong voice as well as fully engaging with care providers.Existing small locally run businesses could be organised to work collectively as not for profit cooperatives. Current owner managers could be employed by the publicly owned National Care Service with a national wage structure rather than owning the businesses. We think that many might prefer this as their jobs would be less precarious. A national care service should capture the ethos of the smaller organisations, providing comfortable homely care but relinquish the current commercial economic model. Smaller providers often aren’t able to respond to crises and weren’t prepared for the pandemic, for example, they had totally inadequate supplies of PPE. A national care service should take the best of all the models, be properly funded and brought back into public ownership.
  • Under a National Care Service care workers must be properly paid, we support an immediate 35% pay increase. Care workers must have a proper career structure with progression and training which must be funded and transferable, including into the NHS. These must be nationally agreed, along with terms and conditions, as is the case with Agenda for Change in the NHS. We would like to see an end to all zero hours contracts, though acknowledge that some workers do find their flexibility helpful. We therefore would support an opt in to a zero hours contract after three months of working, as is currently available in Wales.
  • All social care vacancies must be filled within a year.

  • Last but by no means least we must note that a large proportion of care workers are overseas migrants, many with precarious residency in the UK. Without these people a National Care Service could not function. We demand that they are all granted permanent status immediately and that care workers are regarded as essential workers for immigration purposes.

APPENDIX 1

KONP/SHA NACSIL demands:

Publicly funded, free at the point of use    Publicly provided, not for profit 

  • Nationally mandated but designed and delivered locally
  • Co-produced with service users and democratically accountable
  • Underpinned by staff whose pay and  conditions reflect true value & skills
  •  Meets needs of informal carers   Sets up an independent living task force

APPENDIX 2

Reclaim Social Care policy and demands:

https://www.reclaimsocialcare.co.uk/policy/

Reclaim Social Care is clear that the country requires social care to be:

  • based on supporting independent living for all
  • free at the point of use
  • paid for, like the NHS, through central taxation
  • brought into the public sector
  • staffed by people well supported and with a positive career structure
  • with financial support for voluntary carers 

Reclaim Social Care composited the below motion which is now Labour Party Policy:

SOCIAL CARE COMPOSITE RESOLUTION PASSED AT LABOUR PARTY CONFERENCE SEPTEMBER 2019

This was brought together from motions from across the country, many based on Reclaim Social Care’s text. It is now Labour Party policy.

Conference notes the current postcode lottery of Social Care funding and the real hardship and unfairness this causes, impacting on the most vulnerable within our society reducing life expectancy, health outcomes and wellbeing. 

Labour to develop a universal care and support service working with user groups, in collaboration with a national independent living support service and available to all on basis of need, based on Article 19 of the UNCRPD. 

England’s social care system is broken. Local Authorities face £700million cuts in 2018-19. With £7billion slashed since 2010. 26% fewer older people receive support, while demand grows. Most care is privatised, doesn’t reflect users’ needs and wishes, whilst charges increase. 

Disabled and elderly people face barriers to inclusion and independent living, thousands feel neglected. 8 million unpaid, overworked family carers, including children and elderly relatives, provide vital support. 

Make the provision of all social care free to recipients as is the case for health care under the NHS. 

A service:

  • That provides a new universal right to independent living
  • Enshrined in law and delivered through a new National Independent Living Service co-created between government and service users.

Consequences of marrying social care to the NHS include medicalisation, isolation, indignity, maltreatment, bringing social care under a struggling NHS umbrella is not the answer. 

Transfer responsibility for funding social care from the LA to the national exchequer through progressive taxation. 

Distribute funding to the LAs for social care on the basis of the population served (age, sex and deprivation) and the cost of care. 

Locally democratic and designed by service users and carers in partnership with LAs and the NHS, delivered as far as possible by service users. 

Publicly, democratically run services, designed and delivered locally, co-productively involving local authorities, the NHS and service users, disabled people and carers. 

Providing staff with nationally agreed training qualifications, career structure, pay and conditions. 

Fund social care to provide a pay rise of at least 35% to all care workers. 

Giving informal carers the rights and support they need. 

Conference resolves that within the first term of a new Labour government to provide a universal system of social care and support based on a universal right to independent living. 

https://www.reclaimsocialcare.co.uk/a/40563951-40565561

Summary

  1. Social care is in a deep crisis created by severe cuts enforced on local government by central government and the failure of the system to defend itself from these attacks.
  2. Integrated care is now proposed as a solution to the social care crisis, but not only is it not the answer, but it will harm, both social care and the NHS itself.
  3. Social care is a distinct public good state and it needs to be organised in ways that recognise its strengths and its role as an agent of citizenship for all.
  4. The problems facing social care today are the result of decades of poor policy-making and the refusal to put social care on a level footing with the NHS and other services.
  5. The resources necessary to transform social care into a universal public service are modest and can easily be achieved with the necessary political will.
  6. Universal social care should be implemented alongside a range of other reforms, including the reintegration of social care for children and adults.
  7. Creating the case for a decent social care system also demands the creation of a wider alliance for change and systems that can protect the system in the future.
  8. Better coordination of health and social care services will only occur if the NHS itself begins to work more effectively with citizens, families and communities.

APPENDIX 3

TUC Key recommendations:

https://www.tuc.org.uk/research-analysis/reports/fixing-social-care

Key recommendations

  • A new funding settlement: This year’s spending review should fully offset the cuts of the previous decade and establish future rises at a level that will allow local authorities to meet rising demand and improve pay and conditions for staff. 
  • Immediate funding to fill all social care vacancies: In a time of rising unemployment, social care could provide a steady source of new decent jobs. The government could act now to unlock 120,000 existing vacancies, to help those losing their jobs.  
  • Fair pay and conditions for care workers: To provide sustainable livelihoods and an attractive career, all social care workers must get a sector minimum wage of at least £10 per hour. There must be an end to the zero-hours contracts, and poor or non-existent sick pay that put social care workers at risk during the pandemic. And all social care workers must have guaranteed opportunities for training and progression. 
  • A national Social Care Forum: A new body is needed to bring together government, unions, employers, commissioners and providers to coordinate the delivery and development of services, including the negotiation of a workforce strategy. 
  • A reduced private sector role: The government should strengthen rules to prevent financial extraction in the care sector and should phase out the for-profit model of delivery, so that all public funding is used to deliver high-quality services with fair pay and conditions for staff. 
  • A universal service free at the point of use: The changes above can be made quickly. Longer-term, the government should make social care a universal service, paid for through general taxation to ensure high-quality social care can be quickly accessed by everyone who needs it, in every part of England, without any variation in cost and qualifying rules. 

Matt Hancock offered to auction his football shirt for the NHS – we need proper funding, not charity gimmicks

Doctors in Unite would like to remind the Secretary of State for Health and Social Care that the NHS is not a charity but a government funded health service, set up in 1948 with the specific intention to remove health care from the precarious state of reliance on income or beneficence.

Matt Hancock has his hands on the levers of government, he should be using his time and influence to bring investment in the NHS and Social Care up to the levels needed to redress the years of systematic underfunding, fragmentation and privatisation which have contributed hugely to the failures we now see in the government’s ability to cope with the challenges of COVID-19, not trivialising matters by suggesting that all of the problems can be solved with the sale of a football shirt.

Dr Jackie Applebee is the chair of Doctors in Unite

The government can’t hide behind grateful applause: they must now fund the NHS properly

The solidarity expressed through weekly applause for the NHS, carers and key workers has been truly inspiring, and a great source of support for all staff. 

But we need those in power to do more than just clap for us. The NHS and local authorities have been starved of resources for the last ten years. The current crisis has been worsened by a decade of government hostility towards a publicly funded health service. Low staffing levels are a direct result of budget cuts and limits on pay.

We cannot go back to an NHS that lurches from winter crisis to winter crisis. The government should admit that their past approach to health and social care was wrong. There should be a review of pay for NHS and social care workers, which at minimum adds back money denied, compared to inflation, as a result of pay rises that have been capped for years at 1%. Below inflation pay rises are a cut in spending power. The public sector has been ‘awarded’ 1% for ten consecutive years; their wages have shrunk below pay growth in the private sector.

An apology and pay correction would be a starting gesture for people who are now accepted to be courageous, brave and essential to all of us. It turns the admiration shown on our streets every week into a tangible benefit, which would boost the morale of the people now working in dangerous and difficult circumstances.

We, the undersigned, acknowledge the supreme importance of NHS and social care staff. We recognise that they are indispensable.

We call on the government to:

Publicly and formally apologise to NHS and social care staff for past policies that led to a 1% limit on pay rises and cuts to the services in which they work.

Begin a review of wages and salaries for these workers that, at minimum, restores pay lost compared to inflation from 2010 to 2020, and sets above-inflation pay rises for 2021 and thereafter.

Fully fund the NHS and social care.

The only future for the NHS after COVID-19 is a return to its founding principles

The COVID-19 pandemic illustrates the vital importance of a comprehensive, publicly funded and universal health service. The choices we make during this crisis will shape the future of the NHS and our wider society.

We are already limited by poor decisions made before the virus struck. The Conservative’s ‘hostile environment’ policy, where people with a precarious immigration status risk deportation or destitution if they seek NHS services, means there may now be considerable apprehension to access necessary care. Though coronavirus treatment is exempt from charging for those without documentation, this message is likely to be lost.

When more beds were needed, rather than requisition private hospitals the government struck a deal where beds are rented for £300 each, per day. This amounts to a public sector bail out of private hospitals that the NHS should never have to pay. These beds could be utilised in the public interest; instead they are rented at public expense.

The government then wrote off £13.4bn of NHS debt. It is disingenuous to call this debt. It represents money that has been rightly spent on patient care, and the government’s actions acknowledge this with a trick of accounting. It is also only a fraction of the shortfall in NHS funding over the last ten years of austerity.

A sincere approach to the NHS’ debt would be to cancel Private Finance Initiative payments. £2bn was paid in 2016/17 in PFI debts, and repayments will continue every year until 2050. This lost wealth represents around 2% of the annual NHS budget. It could be reinvested to improve the nation’s health but instead vanishes into private hands. The same is true for private buildings used for NHS services. There is an opportunity to return these to the ownership of the public they serve.

Fragmentation, cuts and creeping privatisation have all contributed to the difficulties in our response the pandemic. More than 17,000 beds have been cut from the 144,455 that existed in 2010. The UK has a lower number of critical care beds per person than Italy, France, Spain, Germany, the USA, Japan, or South Korea. Years of underfunding led us to this moment. The PPE distribution fiasco shows the inability of the private sector to provide the service needed. Cutting warehouse capacity in order to prioritise profit means private distribution companies cannot now supply health and social care workers with the person protective equipment they need.

The hundreds of billions of pounds made instantaneously available in response to coronavirus shows the transformative power of the state to provide a crucial safety net for all of us. We can afford a far fairer society than the one we became accustomed to. Rapid changes to manufacturing capacity to produce ventilators, dialysis machines, PPE and other socially useful products demonstrates that an economy based on public ownership, planning and democratic control could meet the needs of people across the world, unlike the chaotic response of the free market.When this crisis eventually subsides, the public must not be made to pay. We must not return to more austerity.

We also cannot emerge from this pandemic and continue to ignore the harm caused by environmental destruction. The delayed, incomplete initial response to coronavirus echoes our apprehension to face the challenge presented by climate change. We should confront the runaway economic expansion that created the conditions for previous, current, and perhaps future outbreaks. We have an opportunity to live within our planetary means.

We could recreate our health and social care systems based on need not profit. We could choose to reduce inequality permanently. The reset button on society has been pushed – what happens next is up to all of us.

‘Laid-off cabin crew with resuscitation skills’ – what is the answer to the NHS staffing crisis?

Faced with an NHS and social care system ill prepared for the coronavirus pandemic, a call went out for 250,000 volunteer community support workers to help up to 1.5 million people who have been asked to shield themselves from infection because of underlying health conditions.

The response has been staggering, with more than 400,000 coming forward. The recruitment target has now been raised to 750,000. They will deliver medicines from pharmacies, drive patients to appointments and bring them home from hospital, and make regular phone calls to check on people isolating at home.

Quite how vetting, safeguarding, training and safety issues will be addressed is unclear, but that this is tapping into a strong desire on the part of many people to be helpful to their fellow humans cannot be doubted. There have also been large numbers of retired NHS workers offering to return to work and help their struggling colleagues. 

The Tories have been obsessed with getting unpaid labour to support the failing health and care systems, now wrecked by years of their austerity and underinvestment. In the process, they have also given volunteering a bad name. After Cameron’s ‘big society’ initiative sank without trace, 2018 saw the launch of a charity called helpforce. This planned to massively boost the numbers of NHS volunteers from 74,000 to “millions” and was the (as yet unrealised) ambition of merchant banker Sir Thomas Hughes-Hallet, better known to his friends as ‘Huge-Wallet’. The aim appeared to be for volunteers to do the work that hard-pressed doctors and nurses (through staff vacancies) did not have the time for. With 40,000 empty nurse posts, and bursaries that had been axed, NHS England managed to find £2.3m for helpforce in the Long Term Plan.

Currently, the NHS Nightingale nursing workforce is to be supplemented by recently laid-off air cabin crew with resuscitation skills, and first aiders from St John’s Ambulance. This unit has more than 80 wards each with 42 beds; around 16,000 members of staff could be needed should it reach full capacity. 

An unresolved question is just where the trained NHS medical and nursing staff will come from to add to the small numbers of military personnel and staff promised from the private sector. Chief nurses around the country have been asked to state their numbers of spare critical care staff – the replies are not difficult to imagine. One suggestion has been to send staff from distant parts of the country relatively behind London in the course of the pandemic and give them crucial experience before sending them back to their own hospitals. One of the objections to this is that the average length of stay for a critically ill patient is two weeks, and the surge in patient numbers likely to be maintained much longer than this. Staff sent to London would probably be kept there, greatly reducing NHS capacity in the regions just as the caseload rocketed. However, if we had a properly coordinated national response to the crisis, the possibility of NHS workers moving temporarily to hot spots might be a valuable strategy.

Of course many people still have a sense of social solidarity and want to find ways to help others. Such altruism should be both lauded and facilitated. It stands in stark contrast to the neoliberal ideology of Conservative governments – it appears there is such a thing as society after all. 

In response to the pandemic support for medical and care staff, as well as vulnerable neighbours, has been provided by members of the public all over the world, independently of the state.  This is indeed evidence of the thrilling and transformative force of mutual aid. In this context there is plenty of room for volunteers, and an energy that needs to be harnessed in the fight for universal health care in the post-covid era.

However, volunteers recruited by the government or their agencies should never be used as a substitute for trained staff. They should only ever be in supporting roles. Look to supermarkets: now in urgent need of extra hands, they have created new jobs and hired people to work. In the first instance community support staff could be recruited from those workers who have lost their jobs and livelihoods. They could be given a contract, a wage and some training. While I would prefer an experienced ICU nurse to look after me if I become ill in hospital with COVID-19, since they will be at a premium and caring for six patients rather than the usual one, I will not object to them being assisted by redeployed cabin crew with some medical skills and experience of keeping cool in emergencies. There may well also need to be willing volunteers in non-clinical support roles to keep the show on the road. 

Volunteers are not the solution to the crisis in staffing that existed pre-pandemic, and is now exacerbated by illness. But together with additional paid redeployed staff recruited with some level of skills, given basic training and afforded the usual protections of employees, they will be part of the solution until the crisis is over. Some of them may then even join the fight for restoration of a truly public, universal NHS.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.