Scottish Independence – What’s Your Plan for Vaccination Alex?

Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist

Screen Shot 2014-08-19 at 23.46.02In under a month’s time, the Scottish people will decide their fate: stay within the United Kingdom or go it alone as an independent country and carve up the Act of Union of 1707.  As we saw from the first TV debate (regrettably, only highlights due to STV prohibiting ITV and Sky from broadcasting across the rest of the UK), it is increasingly possible to distinguish between SNP stated policy (romantic fluff and guff) and the consequences of that policy (the real world perspective).  Apart from having no currency Plan A, no currency Plan B, no currency Plan C (yes, there is a trend emerging here around no currency plan full stop!), no “independent” monetary policy, no influence over Bank of England interest rates, no clue on financial regulation, no membership of the EU and no NATO, the case for Scottish independence is in a full flow (I obviously say this with some irony!).  Alistair Darling 1, Alex Salmond 0 at half time.  Indeed, Scottish independence makes about as much sense as Del Boy speaking French.  Bonnet de douche Alex!!

However, there is a long way still to go and the “Better Together” campaign should avoid hubris as this referendum is as much about emotion as it could ever be about the hard, cold and real world facts.  Moreover, Salmond is a strong communicator despite alleged briefings against him by his deputy, Nicola Sturgeon.  His Horlicks of a performance the other night, although fundamentally a consequence of bad and, quite literally, unbelievable policy, is likely to improve in coming weeks, and underestimating the SNP would be foolish.

To be fair to the Scottish First Minister, one area where there is no particular need for an “independence plan” per se is health policy.  Following devolution in 1999, Scotland has had its own fully politically independent NHS.  Holyrood is already responsible for legislative and operational matters with its own Cabinet Secretary for Health and Wellbeing, Alex Neil, and other organisational arrangements.  However, there is one area of health policy, or more to the point public health policy, that remains unclear and ill-considered should Scotland vote for independence.  That is, the business of vaccination policy.

In the case of other health technologies, namely drugs, medicines and medical devices, it is the Scottish Medicines Consortium (SMC) that handles decisions pertaining to their approval and recommendation for use on the Scottish NHS.  Following assessment criteria analogous, albeit not exactly the same, to that of the National Institute for Health and Care Excellence (NICE) in England, including assessments of cost-effectiveness and budget impact, the SMC has become a widely respected health technology assessment (HTA) body.

However, recommendation decisions for vaccinations still sits with the UK-wide Joint Committee on Vaccination and Immunisation (JCVI); an executive expert advisory body whose secretariat is Public Health England (PHE) and, despite nowhere near the same levels of transparency and process of NICE (more blogs on this topic to come), a committee that broadly speaking follows the same HTA criteria as that of the Institute. The JCVI makes it recommendations to the Secretary of State for Health (currently Jeremy Hunt) based on clinical review and cost-effectiveness, which are then subject to, in most cases, national tenders.  Some vaccines such as flu and pnuemo are procured locally by Clinical Commissioning Groups (CCGs) and follow slightly different arrangements in the devolved nations.  National tenders, however, are conducted on behalf of the whole UK and procured by the Department of Health with assistance from the Commercial Medicines Unit (CMU), which is considered favourable for “bulk purchasing” and negotiating better price and volume agreements with manufacturers versus higher official list prices.  The devolved nations then agree to payback the Exchequer in proportion to their populations and the numbers receiving vaccines.

Technically, the devolved nations of Scotland, Wales and Northern Ireland can do their own thing, reject JCVI advice, make their own recommendations and, in theory, run their own tenders.  However, this has so far never happened and can be considered most unlikely under current arrangements.  It would make little sense to duplicate the work of the JCVI and would add an extra unnecessary expense in terms of procurement.   Representatives of the SMC often appear on JCVI minutes as “observers” and have so far been happy to follow JCVI recommendation decisions in their entirety.   Moreover, given that vaccination is a population wide intervention designed to control infectious disease, cross nation coordination and a consistent vaccination policy are desirable, particularly in light of equity considerations and cross border movements.  In short, and arguably for very sensible reasons, Scotland does not have an “independent” vaccination policy.

Having read through “Scotland’s Future” – the SNP’s “plan” for an independent Scotland – there is no mention of vaccination and what Scotland would do in the event of a UK divorce.  As with everything else, the SNP would be wrong to assume that in the case of independence, JCVI advice would automatically be “handed over”, SMC representatives would still be invited in as “observers”, or the English taxpayer would happily go on paying for the administration of national tenders; the results from which go on to form vaccination policy and UK wide immunisation schedules.  After all, when you divorce you divorce.

So, would Scotland have its own JCVI?  Would responsibility for policy shift to the SMC?  Who would conduct the tendering process?  Would Health Protection Scotland undertake the very complicated and intricate infectious disease modelling to ascertain epidemiological trends and cost-effectiveness?  If so, what is the “human resource” plan to recruit people from what is already a very limited pool of experts?  All of this is on top of questions concerning how Scotland would handle the licensing of healthcare technologies given that the Medicines and Healthcare product Regulatory Agency (MHRA) is also a UK body.  Even the European Medicines Agency (EMA), which supersedes the MHRA, belongs to the EU and, regardless of SNP rhetoric, membership is not a “slam dunk” raising additional uncertainties regarding independence. There might be reasonably practical and straightforward answers to all these questions, but as with so many other things around Scottish independence nobody in the “Yes” campaign has properly thought it through.  Fluff and guff might be contagious, but it is also potently dangerous in the context of infectious disease and advancing a serious vaccination policy.

This might not be the foremost consideration, or immediate area of policy, that Scottish citizens may cogitate over, worry about or indeed lose sleep over when contemplating the merits of independence.  Also, against the backdrop of gargantuan questions such as the entire fate of the Scottish economy, its membership of the EU and future defence policy, there are obviously bigger political fish to fry.  Nonetheless, public health is important in its own right.  It is something the SNP has sought to emphasise in government and its blueprint for independence (Scotland’s Future) when considering obesity, alcoholism, drug addiction and smoking cessation (admittedly, only in six pages of largely rhetorical prose and pseudo English NHS bashing!).  More pertinently, it is another area of policy which the “Yes” campaign has completely neglected to consider.  Despite his bluster and guster and extraordinary “Braveheart” rhetoric, not even Mr. Salmond is “immune” from these small but important details.  #Better Together.

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World Humanitarian Day 2014 is today and there are many continuing risks Globally for humanitarian health workers.

Guest blog by Dr Iseult Roche

Global action is needed to help protect humanirtarian health workers attempting to deliver aid in areas of conflict and crises.

World Humanitarian Day 2014 is set among some of the most difficult and dangerous range of humanitarian crises and conflicts. Although many people will automatically reflect in the plight of those naturally caught up in the problems, not everyone will consider the dangerous circumstances Humanitarian Health workers place themselves in, to provide aid and attempt to help those in desperate need.

Screen Shot 2014-08-19 at 16.48.42Today, the World Health Organisation raised awareness of the dangers humanitarian health workers encounter,  by saying health workers had been “threatened , shunned and stigmatized ,” during aid work in Ebola areas.

In other areas, health workers, clinics and hospitals had been attacked.

The director-general of WHO, Dr Margaret Chan has said : “Doctors, nurses and other health workers must be allowed to carry out their life-saving humanitarian work free of threat of violence and insecurity.”

While Dr Richard Brennan, humanitarian response department director at WHO, said: “Assaults on health workers and facilities seriously affect access to health care, depriving patients of treatment and interrupting measures to prevent and control contagious diseases.

The World seems to be getting smaller and increasing global travel, can result in global transmission of disease. The vitally important work humanitarian health workers carry out is important to everyone, and, not only those in immediate direct need of aid.

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Threats to Mankind from Drug Resistant Bacteria and Viruses

The risk of an end to the human race may sound like science fiction. However, there are only a small number of threats that could theoretically lead to the extinction of mankind. The four main concerns that most experts share are:

1. Nuclear war.

2. Deadly plague that cannot be treated by drugs or prevented by vaccines.

3. A potent poison being widely disseminated.

4. Earth being struck by a large meteor.

Drug-resistant plague poses one of the most serious, potential challenges to mankind. The final responsibility for coordinating a response rests with governments. The dangers are being increasingly recognised by politicians with the British Prime Minister helping to lead the way and a far-reaching British enquiry planned. All Infections are caused by “pathogens”, which are usually bacteria, viruses, tiny fungi or other microscopic parasites. Bacteria are a specific type of one-cell living organism and can be seen with an optical microscope. Viruses are much smaller and comprise largely genetic material that enters human cells and tricks them into making more viruses. Fungal infections are relatively rare but do arise e.g. thrush. Malaria is an example of a microscopic parasite that does not fall into the other categories. All pathogens mutate so that their properties gradually change. As the reproductive cycle is short many generations can occur in a small period of time. Pathogens that have mutated in a way that makes them more able to resist the actions of drugs are more likely to survive in patients being treated with the products. Growing drug resistance in the community and hospitals results.

Resistant viruses are probably a greater threat to mankind than resistant bacteria, fungi or microscopic parasites. Viruses are necessarily harmful because they take over healthy human cells and use them to produce new viruses. They are often transmitted between people in specific ways e.g. by sneezing and absorbing viruses through the nose in the case of ‘flu or the common cold; through blood or sexual activity in the case of AIDS; through animal bites with rabies. Once viruses have entered the body they frequently target a particular organ or class of cell e.g. a type of white blood cell for AIDS; the liver for hepatitis. New viruses generally require the discovery of new drugs or vaccines to treat or prevent infections whereas a new strain of bacteria is generally treatable by existing antibiotics (antibacterials). Bacterial infections are normally curable whilst viral infections vary in this respect. Fortunately, viral infections that are easy to transmit and mutate rapidly tend to cause less serious infections (e.g. the common cold, ‘flu). However, there is no reason as to why this pattern will continue. The risk for mankind is the evolution of a virus that is as easy to transmit and that mutates as readily as the common cold or ‘flu but is also invariably deadly. There is no reason why such a virus will not emerge and why drug development might not turn out to be too slow to provide an effective response.

Resistance to existing drugs is growing in the case of all pathogens. The problem is arguably potentially more serious for antiviral drugs than for antibiotics because there are far fewer of the former from which to choose in practical clinical situations. Nevertheless, antibiotic resistance is a growing and serious problem that can lead to deaths when hygiene has proved inadequate and the right combination of antibiotics is not found in time for a specific patient’s infection.

What should governments, doctors and regulators do?

In my experience drug companies have not become more reluctant to research potential breakthrough antibiotics. The reasons why the pace of antibiotic drug discovery has slowed are partly the increased bureaucracy within drug companies affecting R&D productivity in all drug classes and partly a big reduction in the number of good ideas for new antibiotics for reasons relating to antibiotic science. Most antibiotics including all penicillins, cephalosporins, monobactams and carbapenems have what is known as a beta-lactam ring in their chemical structure. Such antibiotics are collectively known as beta-lactams. The commonest way in which bacteria become resistant to beta-lactams is by starting to make a substance belonging to a chemical family known as “beta-lactamases”, which destroy the beta-lactam ring in beta-lactam antibiotics and so render them useless. Antibiotic R&D since the 1950’s has been largely about testing many different beta-lactams with the object of finding chemical structures whose beta-lactam ring is more stable in the presence of beta-lactamases. Most possible structures have been considered so that discovering new antibiotics is now much harder. In addition, many beta-lactams have been subject to resistance from the beginning because they can be destroyed by beta-lactamases that are already encountered. Antibiotics that are not beta-lactams typically see just as much resistance develop in other ways, have higher side effects and work in a narrower range of bacteria.

Incentivising drug companies to develop new antibiotics would have limited effect since the industry is running out of good ideas for designing new antibiotics. Policies in the UK for rewarding drug companies cannot alone be of great importance on the world stage. It would certainly be fair and helpful to compensate companies for lost sales of any drugs that are held in reserve in case resistance to presently used products becomes unmanageable. However, this idea is not a solution in itself because of the limitations of current ideas for new antibiotics, although coordinated support from other countries would help.

The most constructive way in which governments can help in the discovery of antibiotics and antivirals is by funding academic research and courses relating to bacteria, viruses and microbiology in the hope of generating ideas that the industry can pursue and increasing the number of appropriately skilled scientists. In the meantime governments, doctors and managers should work to minimise resistance in the following ways:

1. Detailed, high-level, expert guidance is required on the best prescribing practice to provide the most appropriate treatment for patients with the least development of resistance.

Many doctors and scientists have opinions about what constitutes wise and responsible prescribing of antibiotics and antivirals. Nearly all experts agree that antibiotics should not normally be given to patients whose infection is obviously viral since antibiotics are not effective against viruses. The only exception arises when an antibiotic is needed as a preventative measure. Opinions vary considerably over more detailed matters where there is often little hard data and practice varies from country to country, region to region and doctor to doctor. Some of these differences reflect different types of infection and varying patterns of resistance. However, most differences reflect the impressions of doctors in the absence of conclusive evidence. For example, a standard course of most antibiotics in the UK lasts five days. In Spain the same drugs are usually taken for four days (i.e. a day less) but at double the daily dose. Which practice carries the lower risk of resistance developing and whether the position is the same for all antibiotics is simply not known reliably.

The assumption is often made that resistance will build up more slowly if antibiotics are used less. Certainly if they are never used resistance will be held in check. However, it is not true that the lowest dose will cause the least resistance. The dose must be high enough for relatively resistant bacteria to be unlikely to survive and patients should complete the course, once started.

The initial choice of drug given to a patient is important. If the original therapy works poorly the patient will benefit little from it and the scope for increasing resistance is high.

The consequences of using combinations of antibiotics or of antivirals require detailed modelling. Bacteria and viruses find it harder to become resistant to two drugs at the same time than one but if resistance does develop more than one drug stands to be compromised.

Certain combinations represent special cases. For example, in both AIDS and infections caused by a class of bacteria known as Pseudomonas a combination has always been needed to achieve high levels of effectiveness.

An interesting debate is ongoing about whether Augmentin should generally be prescribed in preference to amoxicillin. Augmentin is a mixture of amoxicillin, the most widely prescribed antibiotic in General Practice, and a substance known as a “beta-lactamase inhibitor”. The latter product has minimal antibiotic activity of its own but neutralises beta-lactamases and can therefore restore the lost potency of amoxicillin. Resistance to amoxicillin can only develop from the use of Augmentin if the beta-lactamase inhibitor fails to do its job. Use of Augmentin rather than amoxicillin alone should slow down the development of resistance to amoxicillin but risks introducing resistance to the beta-lactamase inhibitor.

Much work needs to be done, preferably at national level. New studies need to be carried out. The NHS needs to supply whatever data is reasonably required. A suitable agency to coordinate the necessary work might be NICE. This national responsibility could transform NICE from an organisation that carries out unnecessary studies relating to drug pricing with no effect on the NHS drug bill to a body at the forefront of helping mankind.

2. Development of quicker tests for identifying bacterial susceptibility to antibiotics

At present it usually takes at least 48 hours to test bacterial samples from a patient to determine what antibiotics will work against a patient’s infection. As a result the patient may initially be given ineffective medication with little benefit and a high risk of adding to resistance. Side effects may also result from combinations of antibiotics designed to increase the chance that an effective product may be included.

Whilst good ideas for promising new antibiotics are rare, the reasons for diagnostic companies not developing much quicker tests to determine the choice of antibiotic are commercial. Improved, very quick, accurate tests have the potential to have a significant impact on the development of resistance. A major drive to develop such tests and get them accepted is appropriate with either public funding or special arrangements to ensure an attractive financial return. The arrangements could be self-financing because of the reduced use of ineffective, expensive products and shorter stays in hospital.

3. Hospital Hygiene

Although viruses often enter the patient’s body in specific ways (e.g. through someone else sneezing) bacteria are often transferred through lapses in hygiene. Resistant bacteria are found most frequently in hospitals because vulnerable patients may be in close proximity, potent antibiotics are widely used and some facilities require to be sterile (e.g. operating theatres). Every case of suspected poor hospital hygiene should be independently investigated and recommendations made.

4. Isolation of sufferers from deadly new viruses

Robust plans are needed to put sufferers from new deadly viruses into isolation quickly and efficiently. Doctors must record details relevant to learning about the virus and send them to a national monitoring and coordinating centre. Scientists should start immediate work to see whether there is the potential to develop a useful vaccine rapidly.

ebolaThe new virus currently posing the greatest threat is Ebola, which was first identified in 1976 and was very rare until this year. From 1976 to 2013 fewer than 1,000 people per year have been infected. The World Health Organization (WHO) has now declared an International Public Health Emergency and ruled that it is ethical to make untested vaccines available to patients. Checking whether an antiviral or antibiotic is active against the intended pathogens can be tested relatively quickly in early-stage laboratory research before work is done to confirm that the product can be safely used in humans and reaches the required parts of the body.

Whilst few good ideas for new antibiotics exist, antiviral R&D is thriving. Since the emergence of AIDS in the 1980’s drugs have been found that in combination make life expectancy in HIV positive patients fairly normal. Strong progress has been made in the treatment of Hepatitis B and Hepatitis C. Gilead’s Sovaldi, also known as sofosbuvir,  for Hepatitis C was provisionally recommended for use in the UK by NICE last week at a cost of approximately £30,000 for a 12-week course. The drug is set to become the best-selling medicine ever.

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To Get Healthy, Embrace Imperfection

Guest Blog by  Sandy Getzky,  Associate Editor at ProveMyMeds

What’s the secret to successfully reaching health and fitness goals? Stop striving for perfection. Aiming to be be perfect might seem like a noble cause, but it’s ultimately a frustrating one that can lead to major setbacks. There are several good reasons to accept imperfection instead.

Maintain Realistic Goals
Setting goals that are focused on achieving perfection can backfire quickly. These are unattainable goals that most people won’t bother following through on. It’s more important to focus on setting realistic goals that take physical limitations or time constraints into consideration. This allows people to slowly and steadily work toward accomplishing their goals instead of giving up on them. It also prevents them from setting goals that they can’t achieve, like developing and maintaining an unrealistic body shape or following an exercise routine that’s too strenuous.

Accept Setbacks and Move On
Those with realistic health and fitness goals should realize that no one is perfect. Indulging in one unhealthy meal or snack every so often or missing a workout routine on occasion are bound to happen, even with those who pride themselves on having a lot of self-control. People who manage to achieve their goals don’t let setbacks deter them. Instead, they embrace these imperfections, shrug them off and move on with working toward their goals.

Use Rewards for Motivation
It’s ok for people to have a vice or two that they can use to motivate themselves. For example, watching a mindless show on TV or enjoying a small serving of fries or a sugary dessert as a reward for reaching one of their goals can help keep them going. The key to doing this is moderation. Watching TV or eating an unhealthy food isn’t going to do much harm, as long as it’s done once in awhile instead of becoming a regular habit. Being perfect doesn’t have to mean giving up every questionable yet enjoyable activity.

Don’t Try to Be Physically Perfecten_a06fig01  Those who are working on health and fitness goals might have an image of what they consider physical perfection in mind. While this might provide some motivation, it’s also a good way to get discouraged. Everyone has physical flaws of some type, whether it’s a nasty case of nail fungus or discolored teeth. Some of these flaws can be corrected, but things like a person’s normal body shape or natural hip size, can’t really be changed.

ProveMyMeds is a public health and education startup focused on producing helpful resources concerning the treatment of common ailments.


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There’s nothing small about a mini-stroke

Guest Blog by Dr Shamim Quadir, Research Communications Manager, Stroke Association

???????????????????????????????In May, the Stroke Association came together with many of the top researchers in the field of mini-stroke and stroke, stroke policy makers, and people who had first-hand experience of mini-strokes. A mini-stroke is also known as a transient ischaemic attack (TIA). We all took part in a round-table discussion and debate, which covered the many aspects of mini-stroke, and established what the emerging priorities are for research and prevention of this condition.

Despite mini-stroke affecting over 46,000 people every year, many people still misunderstand what a mini-stroke actually is. For example, we heard about patients who had experienced a mini-stroke on a weekend and thought they could wait until the following weekday to get themselves checked out, oblivious to their immediate danger. We also heard that 90% of all mini-strokes are spotted by bystanders, and not the person themselves. It’s clear that increased knowledge and understanding of mini-stroke amongst the general public could help to save lives.

So what exactly is the ‘mini’ bit that makes mini-stroke different from a stroke? Is mini-stroke simply the same as a stroke but, as the common definition suggests, lasts less than 24 hours? Using that logic, would this mean that a mini-stroke lasting 25 hours automatically turns into a stroke?  And what about the symptoms of a mini-stroke? Are they just harmless, forgettable, imitations of a bona-fide stroke?

The truth is that a mini-stroke is always a medical emergency. It’s a warning sign that a person is at imminent risk of a stroke. The risk is greatest in the first few days, and within a week more than one in 12 people who have had one will go on to have a full stroke.

You see, most strokes happen when the blood flow to part of the brain is cut off by a blood clot. The blood clot blocks a blood vessel supplying the brain, and this causes brain cells to die, which will often cause permanent disability or death. In a mini-stroke the only difference is that the clot either dissolves on its own or moves. That’s all. You might say, ‘well the clot’s gone, what a relief!’ But that neglects the critical question of why the clot formed in the first place. If it has moved, where did it go? Will it be back? Could there be another one, and what can be done?

Typically, the term mini-stroke (or TIA) is used for strokes where the symptoms experienced are subtle, seem to pass within a few minutes, and have no apparent, long term effects that would be noticeable using standard check-ups. As symptoms are fleeting, many people dismiss them as ‘just a funny turn’, and not something to worry about. It may only be after they have had a mini-stroke diagnosed, or gone on to survive a full stroke, that the penny drops – many people realise that they’ve been on the same path for quite some time, and acknowledge previous ‘funny turns’ as the mini-strokes they were. It was also agreed at our round-table that a lot more is known about mini-stroke than is currently being put into practice for patient benefit  Healthcare professionals need to ensure they take on board what research has already told us about this and put it into practice consistently.

Remember, a mini-stroke (or TIA) is ‘not just a funny turn’. Don’t ignore it. Get it treated urgently.

To find out more about our round-table discussion and to read the full report, visit the Stroke Association website.

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So Dave, What is the Big Idea for the NHS in 2015?

Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist

It has been a political summer of seismic proportions. We have seen a full scale Cabinet reshuffle complete with promotions and demotions, hirings and firings, and the odd important retirement.   The egregious and woeful “election” of Jean Claude Juncker as the President of the EC Commission.  The continued persistence (I think “rise” is hardly the right word now) of the unflappable Nigel Farage’s UKIP and the continued evisceration (I think “decline” does not quite do it justice!) of the hapless Nick Clegg’s Liberal Democrats.  An escalating international crisis in Russia, Ukraine, Syria, Iraq and the Middle East to name but a few.  And, perhaps most disturbingly of all, the ongoing public meltdown of Tony Blair.  Our former Prime Minister has not only shown that delusion is most certainly the servant of ignorance as far as Iraq is concerned, but he has added some credence to Mayor Boris Johnson’s theory that Tony Blair has actually “gone mad”.  In his extraordinary role as Middle East envoy, which given his toxic legacy on Iraq makes about as much sense as employing Ryan Giggs as a marriage guidance counsellor, Blair has been telling anyone who can still be bothered to listen that the furnace of chaos, death and destruction in Iraq is all a direct consequence of the international community not firing enough guns and bombs at Assad’s Syria!  The man once touted as the JFK of British politics has rendered himself totally ludicrous and politically pie-eyed.  No wonder some people are hellbent on impeachment.

Turning to doDavid Cameronmestic matters, we are now less than a year away from the general election scheduled for May 2015.  Back in 2010, although the economic crisis naturally predominated electoral proceedings, it was the health service that remained David Cameron’s officially pledged number one priority.  Announcing in 2006 that he could surpass Tony Blair’s “número uno” in just three letters – N H S – thereby defeating the nostalgically vacuous Blarite trio of “education, education, education”, the imperative that is health policy has proven to be a rocky and exigent challenge for the Prime Minister.

Cue the Health and Social Care Bill (now Act); the Future Forum exercise; the appointment of Steve Field as the Ole Gunnar Solskjear of health politics;  the boos, the cries and the moans (that is being polite); and the eventual removal of Andrew Lansley as Health Secretary.   The ministerial health team, as it stands today, only retains one member from the 2006 speech and, more to the point, the 2010 Coalition Agreement: the indefatigable and much respected Lord Howe (Freddie has actually been in the Conservative Health Team since 1997; #make the Earl a Knight for all his service – what a man!).  When all the management are shipped out, that is a tell tail sign something has gone wrong.  Indeed, it is difficult to believe this is how David Cameron dreamt it when declaring his number one priority over eight years ago.   Moreover, it is noteworthy the Prime Minister cites spending on international aid as his proudest achievement since occupying Number 10; not his reforms to his “number one priority”.

Since assuming office, the politics and policy of the NHS have been a reputational thorn in Cameron’s side.  Of course, Prime Ministers should expect the former – after all, the NHS is a potently political and stirringly emotional business – but it is the latter that has reinforced the former and harmed the Cameron strategy of “detoxification” designed to put the Conservatives at the zenith of trust on the NHS and reposition the Tories as the party of the NHS.

As I have blogged previously during this Parliament (Depressed Reformers and Field vs. Gerada), the over-arching essence and general thrust of the HSCA are, I believe, sensible following sound principles of devolving local decison-making; increasing patient choice and concreting the patient voice; and seeking to reform an overly centralised and unwieldy service that was too clunky to effectively respond to rising demographic demand, ageing populations and concomitant increases in chronic long-term conditions.  When looking at the history of the NHS from 1948 onwards, many of the reforms are more evolution than the widely denunciated revolution – something governments of all colours have concluded is necessary and unavoidable  – albeit parts of the new NHS are, without question, “up in the air”.  Furthermore, the amplified emphasis granted to public health through the creation of Public Health England (PHE) and local health and wellbeing boards (HWBs) is progressive despite it being very early and hestiant days in this new system design.

Of course, there is no denying that the HSCA = a top-down reorganisation of the NHS.  Fact.  Period.  In the spirit of Daniel Pink’s YouTube summation of “Drive”, the King’s Fund’s cartoon delineation of the English NHS confirms as much.  It is quite simply a case of quod erat demonstrandum (QED).

Moreover, there is no doubt that significant parts of the system are struggling to find their feet.  One noteworthy example is the role of NHS England as a de facto “commissioning board” and how in turn it should be interacting with Monitor and the Care Quality Commission (CQC).  The size of these close concentric circles and their attendant organisational roles and responsibilities remains sketchy and unclear, as does their intersection in any notional NHS Venn diagram.  In addition, it is apparent parts of the NHS are simply not skilled and resourced to accommodate some of the changes.  Monitor is hawkishly trying to recruit as many health economists as it can in a sure-fire signal it was not prepared for what was coming, which in turn confers important questions about organisational skill mix.  This all points to an important aphorism.  As Alfred Chandler once advised, structure should follow strategy.  There are parts of the NHS that feel a bit like an architect’s wet dream lacking due consideration for the practical feasibility (and desirability) of implementation and, more to the point, the “human resource” question and skill-mix imperative.

The reforms might be following a natural historical trajectory of travel and might actually be the right thing to do, but the Prime Minister should concede that his original pledge on structural preservation and reorganisation has not been delivered. Despite initial scepticism and criticism, Cameron’s appointment of the emollient and pragmatic Jeremy Hunt has been a master stroke and much needed.  The Health Secretary, who arguably has been the quiet unsung hero of the Coalition, has done a superb political job of taking the “sting out of the tail” with many in the NHS acknowledging he has steadied the ship.  It has allowed him to get away from the Murdochs!  Having been locked sedulously in implementing his predecessor’s plan with an essential preoccupation doing the political equivalent of “crisis management”, we are yet to really know and hear what Hunt’s vision is for the future NHS.  This is also true of the Prime Minister and Conservative leadership more broadly.  As the clock ticks closer towards May 2015, the business of health policy, ideas and politics will become evermore important should the Tories harbour any real chance of winning an outright majority.  It is my intention to blog my thoughts over the next few months on what I think should feature in a Conservative manifesto.

Opinion polls consistently place the NHS within the public’s “Champion League” of priorities and, moreover, concerns.  Although an inevitable part of the Cameron health strategy will be to defend the HSCA and his Government’s record, outlining a positive vision for “Parliament 2″ is just as important.  Where does the Prime Minister see the NHS in 10 years?  What key policies are needed to deliver those values and that vision?  Does he have any further reforms up his sleeve?

Concreting a genuine promise about no more top-down reorganisations will surely need to be a keystone.  It is difficult to believe the public, or the NHS itself, could take any more major structural reform or “organisational surgery”.  The electorate will want, and need, to know where the Tories plan to take the NHS next.  A central plank will surely need to focus on funding and how to make the NHS truly sustainable; and by funding I don’t just mean ring-fencing more money from an increasingly limited national pot.  There are very tough decisions that need to be confronted.  Sooner rather than later, politicians are going to have to recalibrate what the NHS can afford to provide as a universal, comprehensive and free at the point of need service.  Regardless of what Ministers might say, there is a funding challenge – arguably crisis – that is only going to get worse due to demographic pressures, rising healthcare demand and the increase in chronic long-term conditions.  Politicians must not shy away from being upfront, candid and clear about the challenges confronting the public’s most cherished institution.  A failure to do so is tantamount to a dereliction of duty.

The Conservatives have a bit of an advantage in the form of an Opposition struggling to politically and, as we have seen so far, electorally breakthrough.  Moreover, Labour’s shaky performance on the NHS remains a problem for Ed Miliband.  Despite his human touch and accessible style, Andy Burnham has resorted to the politics of scorn, acidity and negativity.  This has been centrally epitomised by blindly opposing anything that comes out of the mouths of Ministers and playing the increasingly unconvincing “only we care about the NHS” card.  There is little sign this regressively tribal approach has positively persuaded a tired and suspicious public that Labour is best placed to run the NHS.  Moreover, some “on their watch”, and frankly outrageous, failings that occurred during the Labour and Burnham years render recent Opposition attacks politically hollow and do little to reassure weary voters that Labour has adequately rehabilitated itself during its time shadowing the Coalition.

NHS logoNonetheless, Cameron’s vision for the NHS cannot rely on Labour’s inadequacies and incompetencies, but must rather be a vision of positivity, clarity, reassurance and, this time, definitely preparation. Manifestos might not win you elections outright, but history shows us they can certainly lose you elections.  So Dave, what is the Conservative’s big idea on the NHS for 2015?

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High Five – but where is the COBRA for obesity?

So, the BBC has highlighted the BMJ report that all we need to do is eat five portions of fruit and veg a day, no more, no less. More advice for the public on what they should be doing – at least it chimes with previous recommendations and isn’t a source of confusion.

That’s the good news. The bad news is, like alcohol units, people don’t know what a portion is. Unlike alcohol where people overestimate what constitutes a unit, when it comes to eating your greens people underestimate how much they need to eat to count as a single portion. NHS choices gives guidelines, but who knew that you needed three HEAPED tablespoons of carrots to achieve one portion (and how many young people know what a tablespoon is?!)

The site barely mentions salad but that is probably because you have to eat a plateful of lettuce, rocket or spinach to get one portion.

This is of course eminently achievable apart from two significant barriers – access and cost.

Our research into nutrition and obesity has highlighted the problem of fresh-food deserts (as opposed to desserts) in some areas of the UK where there is no easy access on foot to supplies of fruit and veg.

Likewise if you compare the cost of a £1.99 takeaway ‘whole meal’ and what salad you would get for the same amount, it’s no wonder people buy the takeaway despite the fact is is less nutritious and unlikely to contain much fibre which will leave them feeling hungry again sooner than if they had eaten the salad.

It struck me again this morning as the news reported that Philip Hammond was chairing a COBRA meeting on the threat to the UK of the Ebola virus, as to when the government was going to have their Damascene awakening and realise that they desperately need COBRA meetings on UK obesity and nutrition. Successive politicians have not come anywhere near to a successful, holistic plan that will tackle our obesity crisis which is not only weighing down the NHS, but the economy and welfare state. Nothing less than participation and commitment from health, local government, devolved nations, treasury, DWP and DCMS will create the necessary cross cutting strategy to ensure we have a nation for for  future.

2020health’s report on the Obesity Crisis will be published in September.



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