Health secretary Andrew Lansley is expected to announce today that local authorities will be given £2bn funding to promote breastfeeding and action on tooth decay under the public health improvement plan. In other NHS spending news, the Daily Mail’s Clare Bates reported that injections will be carried out at a clinic in North London run by the Tavistock and Portman NHS Foundation Trust as part of an NHS trial on gender-identity disorder (GID).

Parliament invites the public to participate in ‘Parliament Talks…Science,’ taking place from 6.30pm to 8.30pm on Thursday, 15 March, during National Science and Engineering Week. This event will be hosted in partnership with the University of Leeds and is an opportunity to find out how the work of Parliament contributes to the debate on science issues and scrutinises Government science policy.

Unreasonable reporting has arisen with the Health and Social Care Bill to an extent that has played a role in turning both members of the Pubic and medical professionals against the Bill.  Normally responsible newspapers and broadcasters, including the BBC, have sometimes been misleading and have contributed to prejudice against the reforms. In this blog I do not have space to consider every case. I therefore focus here on one example that provides a flavour of what I mean. Taken as a one-off situation the implications of this one example are not enormous but the overall pattern is disturbing.

If at the time of writing the words “BBC Health Bill” are fed into Google the first search result listed is:

BBC News – ‘Planned 49% limit’ for NHS private patients in England

The relevant BBC story was released on 27^th December 2011 and was featured prominently on BBC Television News. The first three paragraphs of the BBC summary reached through the above link read:

“NHS hospitals in England will be free to use almost half their hospital beds and theatre time for private patients under government plans.

A recent revision to the ongoing health bill will allow foundation hospitals to raise 49% of funds through non-NHS work if the bill gets through Parliament.

Most foundation trusts are now limited to a private income of about 2%.”

These opening paragraphs gave the impression that the Government had just proposed a new increase in the limits for non-NHS income in NHS hospitals. In fact, the Bill as passed by the House of Commons to the Lords included no limit at all. The new proposal was therefore to introduce a safeguard ensuring that no NHS hospital will end up principally servicing the non-NHS sector.

The proposed limit of 49% (or, to be precise, below 50%) does not in fact relate directly to hospital beds or theatre time but rather to total non-NHS income in each hospital.   Some potential non-NHS income derives from services not relating directly to medical care and should be strongly encouraged as a way of raising funds for the NHS. Certain other non-NHS medical income relates to services that would not be available to NHS patients without the contribution from private patients (e.g. by helping to fund facilities that would otherwise be unavailable such as costly diagnostic equipment). On the basis that hospitals are likely to charge more to private patients than the funding received per NHS patient, it is mathematically hard to see how a hospital can get anywhere near to 49% of hospital beds or theatre time going to private patients unless the hospital provides other important non-NHS services (e.g. for the pharmaceutical industry or in research contracts or as discussed  on pages 10-12 of my submission to the Department of Health downloadable here ).

The BBC article goes on to say (paragraphs 4-9):

“The Health Secretary says the move will benefit NHS patients but Labour claimed it could lead to longer waiting lists.

The amendment to a clause of the Health and Social Care Bill was made shortly before Christmas by Health Minister Earl Howe.

Commenting on the move, Health Secretary Andrew Lansley said lifting the private income cap for foundation hospitals would directly benefit NHS patients.

‘If these hospitals earn additional income from private work that means there will be more money available to invest in NHS services,’ he said in a statement.

‘Furthermore services for NHS patients will be safeguarded because foundation hospitals’ core legal duty will be to care for them.

‘But Labour’s shadow Health Secretary Andy Burnham claimed the move could mean longer waits for NHS patients.’ “

Under the Government’s proposals hospitals are required to ensure that NHS patients benefit from non-NHS income and to explain why they do so. It would therefore be illegal for NHS hospitals to increase waiting lists as a result of the provision of non-NHS services unless there were some greater benefit to NHS patients in other ways.

The article from the BBC then quotes Andy Burnham as saying:

 ”This surprise move, sneaked out just before Christmas, is the clearest sign yet of David Cameron’s determination to turn our precious NHS into a US-style commercial system, where hospitals are more interested in profits than people.

“With NHS hospitals able to devote half of their beds to private patients, people will begin to see how our hospitals will never be the same again if Cameron’s Health Bill gets through Parliament.”

We have no criticism of Andy Burnham at a personal level. He is simply doing what politicians often do in showing political bias. However, the impartiality of the BBC can be criticised because of the prominence to given to his remarks without providing the information necessary to put them in context. The only surprise was in the Government restricting non-NHS income at all. The prime directive of the NHS is to achieve the best clinical outcomes for NHS patients and is not to make a profit. As explained above, hospitals will not normally be free to devote anything like half of their beds to private patients, because to do so would generally breech the total non-NHS income limit and also not be in the interests of NHS patients. In addition, the Government’s proposals will not directly increase the number of private patients. Far too few private patients exist to fill half of NHS hospital beds.

The proposed Government amendment was announced on 15^th December 2011 but not reported by the BBC until 27^th December. The amendment was agreed by the relevant House of Lords Committee on 15^th December after considerable debate involving Shirley Williams (Liberal Democrat). If the Labour Party truly felt the proposal to be as harmful as Andy Burnham has implied, press coverage would have been obtained well before Christmas. A Labour plot to sneak out biased criticism between Christmas and New Year fits the facts better than a Conservative plot to release the news shortly before Christmas, although we have no strong evidence that either has occurred.

The House of Commons debated the non-NHS income limit on 16^th January 2012 when Andy Burnham (Labour) moved the following motion:

“That this House believes there is an important role for the private sector in supporting the delivery of NHS care; welcomes the contribution made by private providers to the delivery of the historic 18-week maximum wait for NHS patients; recognises a need, however, for agreed limits on private sector involvement in the NHS; notes with concern the Government’s plans to open up the NHS as a regulated market, increasing private sector involvement in both commissioning and provision of NHS services; urges the Government to revisit its plans, learning from the recent problems with PIP implants and the private cosmetic surgery industry; believes its plan for a 49 per cent. private income cap for Foundation Trusts, in the context of the hospitals as autonomous business units and a ‘no bail-outs’ culture, signals a fundamental departure from established practice in NHS hospitals; fears that the Government’s plans will lead to longer waiting times, will increase health inequalities and risk putting profits before patients; is concerned that this House has not been given an opportunity to consider such a significant policy change; and calls on the Government to revise significantly downwards its proposed cap on the level of private income that can be generated by NHS hospitals.”

The wording of this motion is much more accurate and precise than the media coverage. The Labour Party supports a role for the private sector in the NHS. The debate is about how large that role should be and what limits should be imposed.  The motion refrains from repeating the false claim that the Government proposals would allow most hospitals to allocate 49% of beds and theatre time to private patients. The Bill clearly makes it illegal for non-NHS income to be accepted that would be expected to lead to an increase in NHS waiting times or NHS health inequalities or to a move towards putting profits before patients. However, Andy Burnham is entitled to fear that the law will be broken. The Conservative view is that the non-NHS income cap is a “belt and braces” safeguard and not something that will in practice affect many hospitals.  I do not propose to cover this topic here but the true debate between the three major UK political parties is about more subtle matters than the media appear at times to recognise.

Andy Burnham previewed his attack theme for today’s health debate with a piece in the Guardian on Sunday highlighting that NHS hospitals will be allowed to use up to 49% of their capacity for private patients. There are several stories on memory but this one also in the Guardian allows you to test yours! Not before time the House of Commons Health Select Committee will be looking into the regulation, guidelines and practices of private cosmetic clinics. Finally we knew that many hospitals don’t check the standard of English spoken by nurses from abroad, now we know how many. According to the Mail 90% of NHS Trusts don’t check.

In Parliament this week, the Science and Technology  Committee report on Alcohol Guidelines are now available. The Treasury Select Committee published the Government’s response to its report into Private Finance Initiative (PFI) funding, alongside a short report commenting on recent progress and highlighting ongoing areas of concern. Also, today the Health Committee has its fifth oral evidence session on Social Care, taking evidence today from a number of key stakeholders on this challenging subject. 

This is definitely a step in the right direction, as often clinicians forget what a key role community pharmacy plays in supporting hospital and GP services.  Conveniently located in high traffic shopping areas, community pharmacies are easily accessible and frequently visited.  For many individuals, the pharmacist is their first point of contact, which is particularly key for patients who manage long term conditions or those just leaving hospital.

2020health is currently providing programme design and evaluation support for the Wells Challenge, a unique year-long programme sponsored by Sainsbury’s that will see ten families across the country with the surname Wells challenged to improve their health by taking advantage of the services available to them at their local Sainsbury’s pharmacy.  The project aims to show how community pharmacists can improve public health by providing advice and support in areas such as diet/lifestyle management, smoking cessation, and alcohol.  Community pharmacy is a vastly underused resource, and by taking advantage of all of the services that community pharmacists can provide, hospitals and GPs can in turn provide better care and support for their patients.

It has been noted by experts that productivity in English hospitals needs significant improvement.  The NHS have been instructed to save £20bn, an annual saving of 4 percent, by 2015. The Nuffield Trust has released a report that revealed numerous areas where changes in productivity could result  in gains for hospitals.  One of the areas mentioned was decreasing the amount of time patients spend in hospital.  Currently, patients are spending an average of 7.2 days in hospital. This could be decreased by amending the discharge contract, especially over weekends, and providing more day case surgeries for minor procedures such as cataract surgeries and ear, nose and throat operations. Finding a more effective way of purchasing goods could also save an estimated £500m. Additionally, changes could be made behind the scenes to include human resources and finance, saving £600m annually.  Staffing, which currently consists of 70% of the total costs, should also be reviewed, as it is important to limit the amount of time that is given for overtime and the use of agency staff.  Hospitals have to find a balance between the skill sets of employees to reduce replication and maximize efficiency.  Hospitals would be wise to heed these recommendations to cut costs and achieve their savings targets.

We like to think that we are in control of our lives and as we declaim our autonomy it’s convenient to ignore all the different social, environmental and historical influences on us and our choices, not to mention our dependency tendencies!

The House of Commons Science and Technology Committee have published their report today on Alcohol Guidelines, which reviewed the attempt to influence our drinking through the current advice given by government on safe limits. Notably they say, “We have heard sufficient concerns from experts to suggest that a thorough review of the evidence on alcohol and health risks is due.”

It also reiterates points that was made in 2020health’s report, From one to many (October 2011) that people don’t realise how much they are drinking, that we don’t understand what a unit is or how many units there are in a bottle of wine or beer and there is a need for more education, especially as guidelines are too generalised. We all respond differently to alcohol and 14 units a week may be all right for a 55 year old 5’10″ woman weighing 10 1/2 stone but not for a 21 year old of 5’1″ and 7 stone.

The Commons report is only looking at the unit guidelines, which is important, but it makes me wonder if the Behavioural Change Unit at the heart of government are also doing their bit? Because if we really are going to stem the flow of millions of pounds haemorrhaging out of the economy due to alcohol misuse, we need to take a serious look at the other influences on us. Our GP, our family, our friends, our work are the obvious ones, but what about advertising by the alcohol industry?

More than any other country in Europe we are bombarded with alcohol advertising as we have no laws to restrict their assault. Whether it’s the football league, ordering from Amazon, watching TV or going to the cinema we cannot avoid it and are subjected to attempts to brainwash us into thinking that alcohol is a pre-requisite to having a good time (are we that boring when sober?), it’s refreshing (it dehydrates), it makes you more sexy (really?!) or that you need more! Young people of course are especially vulnerable to these messages. Going to the pub with friends is fun and part of our culture, but if we are going to regain control over our drinking, then an important step towards this is out-lawing the propaganda.

I love fresh starts, and the New Year is definitely a fresh start. But specific predictions are a mugs game. The great scientist Niels Bohr was right when he said that “prediction was very difficult, especially about the future”!

So generally speaking, we know once the Lords have finished their therapy sessions on the Health and Social Care Bill, it will go through, amended, and followed by more legislation in response to the nightmare Mid-Staffs inquiry and challenging Social Care White Paper. Much heat will be generated by politicians as they discuss dealing with lifestyle issues (alcohol, obesity, diabetes) and whether they believe the communitarian, moral construct of freedom is more or less important than the individualistic, anarchic ways of license. And while Andrew Lansley is SoS, negotiations will continue on changing the way we price medicines and whose definition of ‘value’ applies (the patient, the manager, the clinician, the family?)

In the meantime, as the NHS is still taking resources for granted – still suffering with affluenza – there is little urgency evident when it comes to radically changing the way they do things and also considering what is done by the NHS. Admittedly the enormity of the upheaval to NHS organisations will continue to distract those at the front line trying to improve care and outcomes. Every re-organisation distracts. The difficulty this time is that huge amounts of money need to be saved through systems and pathway redesign in order to meet growing demands, and this is taking second place to office moves and personnel changes. Staff roles will change, and as the PM talks today about what we expect from nursing, something is going to have to give as adopting essential telehealth (remote monitoring and consultations) will require workforce changes that we cannot afford to be stifled by union protectionism.

Most importantly, the public increasingly want to know how to make things happen. Having been passive recipients of healthcare whilst taking more initiative in other areas of our lives, we are waking up to the fact that if we fund the NHS, then we should have more authority to challenge the status quo when things don’t pan out as we expect. Unreal expectations aside (another blog-post subject), if we are refused an appropriate medicine approved by NICE, we want to know how to reverse this decision; if we want a second opinion, there should be a straight-forward way of getting one; if we want to know how carefully our NHS Trust is spending our money, we should be able to see what their losses are; if we want to have copies or access to our hospital or GP health records, we should be able to.

So a sure fire prediction is that the year ahead will be eventful and challenging. What I hope will also happen is that the public will become more actively involved in their own healthcare and expectations of what the NHS can really deliver are more realistic, whether you are a patient, professional or politician.

The news has been welcomed by many groups including the Royal College of Nursing, but some question whether the new changes will solve the deeper problems in the system. Hourly ward rounds will not solve anything without the right attitude and a sense of personal responsibility for the quality of care that is provided to each patient. This basic cultural shift must be fostered within the nursing profession – only then can hospitals be truly patient centred and provide excellent standards of care.

Back in February 2010 I was asked to pen a few words About Barbara for 2020health. I have resisted temptations to change this summary. My theme has remained that I would like to see collaborations between industry, the NHS and academia strengthened in order for more benefit to be obtained from the scientific excellence within the UK. The current Government has in my view been the first in recent decades to make major political progress towards this goal.  The economic climate has made it difficult to be generous with public funds. The Health and Social Care Bill has not been handled perfectly. However, the main objectives have been right and have not been derailed. The Government has shown a willingness to listen and a level of understanding that has not been seen since the foundation of the NHS. Of course, medical professionals should have been consulted earlier. Yes, the Prime Minister should have been more visibly involved from the beginning. True, there are still pitfalls ahead to be avoided.  Indeed much work remains to be done and the way forward is not an easy one. Certainly it would help if more MPs had scientific backgrounds.

Since the General Election in 2010 the Government has been recognising at the most senior level the importance of innovation, science, the pharmaceutical industry and cooperation with academia and the NHS.

An article co-authored by George Osborne and Eric Schmidt (Chairman and CEO of Google) in November 2010 commented:

“Innovation drives the modern world. It determines the success of companies, and in this century it will also determine the success of countries. For decades, we’ve been familiar with the concepts of trade and budget deficits. But today, developed economies also need to worry about the innovation deficit.”

The following quotes are taken from a speech by David Cameron earlier this month (5^th December 2011):

• “Now, this government has set a clear goal to rebalance our economy: yes, that means less borrowing and less debt, but as important it means more investment, more exports, more designing things, making new products and selling them to the rest of the world.  Innovation is the beating heart of this vision, and in this we are fortunate because Britain has something of a genius for it.”
• “But I believe that in place of the old ‘big pharma’ model, a new model is emerging.  It’s about more collaboration, more outsourcing, more early trials.”
• “you can call it experimental medicine; the fact is we see it, we recognise it, and we are determined to support it, to invest in innovation, to stoke early-stage investment, and to tear down the barriers to development.”
• “We’ve still got scientists who could be joining forces but aren’t, industry and clinicians who should be working together but don’t, and we are determined to change this.  So we have made the decision, even in these difficult times, not only to protect the science budget, but we also announced an extra £495 million capital funding for science this year.  We are creating a string of new Technology and Innovation Centres, with a high-value manufacturing centre already up and running and a cell-therapy centre to open next year.  We’re investing £800 million in Biomedical Research Centres, which are home to groundbreaking collaborations…”
• “Now next we are pulling every lever possible to make the UK a much more attractive place in which to invest.  From April 2013 there will be the new patent box offering a 10% tax rate on patent profits.  GlaxoSmithKline and AstraZeneca have already committed to new investment as a result and over the coming months we want to see more businesses follow suit.  Add to this our corporation tax rates – on course to be the lowest in the G7 – and our generous tax credits for R&D.  And I believe if you take those things together you have a compelling case for investing in research right here in the UK.  And as you look to work more and more with smaller companies it is crucial that we do more to deal with the funding gap that so many people face – the so-called Valley of Death.  So we’ve got a whole package of measures to bridge that gap – tax relief on angel investment up from 20% to 30%.  The amount that can be invested in a single company in a year up from two million to 10 million and together these mean that if you build a business worth up to £25 million and then sell it, you’re going to be better off in the UK than you would be in the US.  Now obviously last week in the autumn statement we went even further.  The Chancellor announced a new 50% tax break for the first £100,000 invested in a start-up…”

This blog is too short to cover everything but those of you who have read my blogs for 2020health and my other campaigns since the General Election will see why I am so pleased. I had no role in scripting David Cameron’s words on 5^th December but it is unusual for a politician to deliver a speech with which I agree so completely. My only disagreement is over the comment, “It could be that in just 10 or 15 years, the idea of treating disease without reference to the patient’s genetic blueprint is quite simply unthinkable.” Some diseases occur in the same way whatever a patient’s genetic blueprint and sufferers would not therefore necessarily benefit from being treated differently according to their genetic profile. Some drugs in use today are extremely effective and do not require radical improvement. In other cases (e.g. antibiotics) the genetic blueprint of the pathogen may be what matters rather than that of the patient.

For the pharmaceutical industry the main policy matter where I foresee danger is over drug pricing. The PPRS has served the UK well, although it has never been perfect. A good value-based pricing system may have academic benefits but there is no way of valuing a drug objectively because too many subjective judgements are involved. We do want to encourage innovation that leads to new medicines  fulfilling important unmet clinical needs. We also wish to support potentially valuable research skills and R&D teams for the future during the barren periods that inevitably occur from time to time. We must also remember the limitations on our ability to fix drug prices as a result of parallel importing and exporting along with other international business realities. The Government must think very carefully about the futureUK pharmaceutical pricing system, whether it is called value-based or not, because a wrong decision could undermine much of the good work that is being done to encourage pharmaceutical and biotechnology companies.