Book review: Hunt’s dreary, well-informed, well-meaning book about the NHS will make not one jot of difference

24 Jun

ZERO: Eliminating unnecessary deaths in a post-pandemic NHS by Jeremy Hunt

“He who would do good to another must do it in Minute Particulars,” William Blake wrote. “General good is the plea of the scoundrel, hypocrite and flatterer.”

Yet politicians find themselves obliged to talk about the general good. They have to make speeches and issue manifestos about what they will do to make things better for the whole country, or even the whole world.

Although they often have no real idea about how to solve or ameliorate some problem, they have to pretend that they do. How easy, in these circumstances, to degenerate into a scoundrel, hypocrite and flatterer.

Once a politician aspires to, say, the presidency or the prime ministership, speeches and manifestos are no longer enough. A book is required.

Words like “future” and “hope” often appear in the title of this volume, which is unreadable.

Jeremy Hunt is aware of these pitfalls, and has sought with immense conscientiousness to avoid them. He knows that particular cases are more interesting than general moralising.

At the start of the book, he relates a thought which occurred to him a year into his six years as Health Secretary, at Margaret Thatcher’s funeral in 2013, as he listened to the eulogy delivered by Richard Chartres, the Bishop of London:

“He read out a letter she had received from a nine-year-old boy called David, to which she had replied personally. I sat there, and thought: In my seven months as Health Secretary I haven’t read a single letter from an NHS patient. If Margaret Thatcher had found the time to do personal replies as Prime Minister, couldn’t I?”

The Department of Health received more letters than any other government department. It employed 50 officials in the correspondence unit to draft replies, and to protect ministers “from the highly personal and emotional missives received from people who had experienced problems with their care”.

Hunt asked to see one letter a day to which he would write a personal reply:

“I didn’t know it at the time, but this request sent the department into a spin. Sir Humphrey-like meetings were held behind my back to work out if they could dissuade me from such a thoroughly dangerous idea. They saw their job as shielding me from such letters, not exposing me to them.”

He at length received a letter which said: “I am just writing to thank you for the fantastic NHS care I received…”

This, of course, was not the point, and at length he started getting some proper letters of complaint, which were “eye-opening and sometimes horrifying”.

Hunt reckons the problem is that when error is admitted, a search begins for someone to blame. This means mistakes are covered up, nothing is learned from them, and often the same mistake is repeated over and over again before anyone does anything about it.

Hence the horror of the Mid Staffs hospital scandal, which continued unchecked for four years. The whole system is designed to pretend things are better than they actually are.

All this can be stated quite briefly, and is already generally accepted. Atul Gawande, mentioned by Hunt, and others have written about the need, as in the airline industry, for mistakes to be reported, not hushed up.

Once Hunt manages to get a letter a day of complaint presented to him by the department, he drafts a personal reply to it. And he uses some of these letters to introduce each of the 15 chapters in his book: his method is to recount some monstrous case of neglect, before drawing some general conclusions about the need for a culture change within the NHS.

No normal reader is likely to have the stamina to read through all these cases. One soon feels one has supped too full of horrors, and has also had enough of clunky, inconclusive passages like this one:

“I put in place an ambition to halve neonatal deaths, stillbirths, maternal deaths and severe injuries which was very ably led by leading obstetrician Matthew Jolly and chief midwife Jacqueline Dunkley-Bent, which contributed to neonatal deaths dropping by over a third and stillbirths by a quarter over the last decade. I also set up a maternity scheme modelled on what happens in Sweden, to allow instant access to a settlement in maternity cases where the NHS knows a mistake has been made. It was designed to bring faster closure for families and prevent the frustration of long court processes. To my frustration, it was not up and running before I left my role and ended up being cancelled, presumably on cost grounds.”

When I was a child in the 1960s, I knew who my NHS doctor was, and he would visit me at home when I was ill. Dr Price was a comfort both to me and to my parents.

He behaved, so far as I can tell at this distance and through a cloud of the usual childhood ailments, as he would have done before 1948, when the NHS was founded. That was the tradition in which he had been trained.

Does anyone now know the name of their doctor? Hunt works round to this question, and on page 173 states:

“we need a decisive change in the model of care offered by the NHS, so that patients always have one doctor or nurse clearly responsible for their care. In normal circumstances that should be a patient’s GP, although for frail elderly patients it might be a district nurse.”

How right he is, but can such an outcome be attained by Hunt, or some other well-intentioned Health Secretary, declaring that it ought to be attained?

In the absence of a single doctor or nurse who takes responsibility for a patient’s care, the family try to act as champions, desperately trying to see that relevant notes from the past are presented to doctors new to the case, and to provide whatever the harassed nurses are unable to provide in the way of care.

But what a supplicant one feels as one goes about this task of asking the nurses whether they could possibly provide this or that, or simply tell one, on the telephone, what sort of a night the patient has had.

The melancholy paradox must be stated that to survive a stay in hospital, one needs to be feeling more than usually fit, even though one has been taken in because one is more than usually weak.

Hunt is full of good intentions. If he appeared at one’s bedside, he would be marvellously sympathetic. It would do one good to see his furrowed brow. One would be sure he really cares. One might even think that if he was in charge, the world would be a better place.

But as Health Secretary, he too was reduced to the role of supplicant. And his dreary, well-informed, well-meaning book will make not one jot of difference to anything.

The post Book review: Hunt’s dreary, well-informed, well-meaning book about the NHS will make not one jot of difference first appeared on Conservative Home.

Noshaba Khiljee: The Government is making big strides towards addressing health inequalities post-Covid

29 Apr

Dr Noshaba Khiljee is a Consultant Nephrologist and Physician at Dartford and Gravesham NHS Trust, and was a parliamentary candidate in 2019.

In March 2021, the Commission on Race and Ethnic Disparities, chaired by Dr Tony Sewell, published its long-awaited report. It looked at four main areas: education and training; employment; crime and policing; and health.

In terms of health, the release of the Government’s response to the report has mostly been welcomed by healthcare professionals in the UK like myself. It is greatly appreciated to see the Government addressing such issues within ethnic minority groups.

The Covid-19 pandemic has disproportionately affected ethnic minority groups, with higher death rates in Black and Asian communities. On top of this, minority groups have historically tended to be worse affected by chronic medical conditions and have lower access to healthcare services.

Furthermore, minority communities are more likely to experience living and working conditions that predispose them to worse healthcare outcomes.

Data from the Office of National Statistics (ONS) showed that deaths from Covid-19 in the black and Bangladeshi communities was over four times that of the white population.

In addition, intensive care data also revealed an alarming picture. Although ethnic groups constitute 17 per cent of the UK population, they made up to a third of patients admitted to intensive care units during the pandemic.

Similar trends were also seen amongst staff working in the NHS. Some reports showed over 50 per cent of all deaths were from health workers born outside the UK, who represent less than 18 per cent of the workforce.

Furthermore, doctors from ethnic communities make up 44 per cent of doctors working in the NHS, yet 95 per cent of Covid-19 deaths occurred in this group. The first 11 deaths all belonged to ethnic groups, sadly including a prominent senior consultant working in my own hospital.

Amongst nursing staff, 60 per cent of all deaths occurred in ethnic minority groups who make up only 20 per cent of the workforce.

The Government’s report, Inclusive Britain, is looking to identify the causes of such health outcome differences, and to focus on prevention by looking into ethnicity, socioeconomic background, and geographical factors.

This report, launched by Kemi Badenoch, the Equalities Minister, outlines a solid plan of action on how to address these issues on health, education, employment, crime, and policing as well as enterprise.

This is something many healthcare professionals like myself have been campaigning about – to understand the cause of such disparities and finding solutions – I am pleased to see this report address these issues.

We had seen a low uptake of the Covid-19 vaccine amongst the black and Asian community, including healthcare professionals. This may have been caused by a legacy of deep-rooted mistrust in vaccines and health services because of historic discrimination.

Recognising this, the Government has worked with key stakeholders, such as in collaboration community leaders, to halve the rate of vaccine hesitancy in black adults.

Coming from an ethnic group myself, I was pleased to see the Government, with the help of many trusted voices such as local faith leaders, influencers, social media and many volunteers, turn this into one of the most successful vaccines rollouts in the world.

We should also not forget that Britain was the first country in the world to administer the first dose. To date, 141 million doses have been administered, equivalent to more than 70 per cent of people fully vaccinated in the UK.

The Government has used extensive communication campaigns, both at local and national levels, to build trust and hence increase the vaccine uptake in ethnic minority groups markedly. Such efforts have been welcomed by medical experts, who themselves have campaigned vigorously to address such concerns.

The levelling-up agenda has also addressed the unacceptable health inequalities in society, particularly amongst ethnic minorities. This includes inequalities in areas such as housing deprivation, tobacco and alcohol use, diet, and physical activity.

The report also looks at the need for ethnic minority groups to participate in clinical trials and research, such as promoting the INCLUDE Ethnicity Framework. The Department of Health and Social Care (DHSC), is looking at the potential bias caused by the design of medical devices and its impact on patients from different ethnic groups.

This could potentially affect diagnosis and treatment in such patients but awaits the findings of Professor Dame Margaret Whitehead’s report in 2023.

The Government’s report has also put in place how the health and social care regulators will measure workforce diversity and inclusion in all their inspections. For instance, the Care Quality Commission (CQC) will look at how hospitals are addressing the experiences, progression, and disciplinary actions in respect of ethnic minority staff in their workforce.

The pandemic has helped the government to learn lessons regarding ethnic minority groups. Their report has been welcomed and will help to build trust in our health institutions.

This will be vital in tackling the stark disparities in health outcomes across the UK, to ensure everyone can have the opportunity to live long, healthy lives wherever they live.

Although I can’t say this will tackle all inequalities, the Government has definitely taken some steps taken in the right direction and only time will tell.

Miriam Cates MP: The re-introduction of key abortion safeguards is a step towards tackling domestic abuse

18 Feb

Miriam Cates is MP for Penistone and Stocksbridge

Almost two years ago, suddenly and without scrutiny, the Department of Health and Social Care (DHSC) announced the biggest change to abortion law in this country since 1967.

At the start of the pandemic and ensuing lockdown, the DHSC granted emergency measures to allow medical abortions to be self-administered at home without any in-person consultation. Now, the Government is mulling over whether to end this temporary policy in line with the cessation of other Covid emergency measures.

In practical terms, the changes in March 2020 have meant that a single phonecall currently suffices for women and girls to be sent abortion pills. This was no small alteration to abortion provision. The knock-on effects of this ill-judged change have since emerged, with the experiences of women revealing concerning issues.

In removing the requirement for an in-person consultation prior to abortion, there is no guarantee that the woman requesting the pills is doing so for her own legal use within the medically accepted time limit (10 weeks gestation in England and Wales). Nor is there any guarantee that she is doing so freely, without coercion. There is no way to ensure that the patient is alone. Without a face to face consultation, there are fewer or no visual markers (such as eye contact or body language). This disjuncture of care is exacerbated in cases where the woman has limited English-speaking abilities and poor computer access.

The circumstances that surround a woman’s reasons to seek abortion are complex and individual. Often victims of domestic abuse do not even realise that what they are experiencing is, in fact, coercion. For example, pressure from well-meaning parents to abort so that a student finishes her studies, a partner citing economic pressures or threatening to walk out, or teenagers encouraging their friend to just do it and swallow the pills are all instances of pregnancy coercion. How can a healthcare professional possibly certify over the phone that a woman is making the decision to abort freely?

We have seen an appalling rise in domestic abuse during the pandemic. Over 40,000 calls and contacts were made to the National Domestic Abuse Helpline during the first three months of the lockdown alone. The charity Refuge reported a 61 per cent increase in calls to its 24-hour helpline and online chat service in the past year, and a shocking 81 per cent of callers in 2020 described being “controlled” by their partner. As Lisa King from Refuge summarised: “Lockdown measures, where women have been isolated and confined with their perpetrators more than ever, have compounded their exposure to violence and abuse.”

Moreover, Refuge’s figures show that domestic violence worsens during pregnancy; 20 per cent of women using the organisation’s services are pregnant or recently gave birth, whilst studies show that four to nine per cent of women experience abuse during their pregnancy or afterwards. The most common age bracket contacting Refuge’s helpline were women aged 30-39. It is no coincidence that they are women of childbearing age.

As such, parliamentarians should be doing all we can to prevent domestic abuse situations from escalating, and ensure the highest level of support services for women. I am certain the Government does not want to put women at risk from coercive control nor put in place measures that risk aiding their abusers.

As a 2019 article in a leading medical journal states, “Potential for misuse and coercion is high when there is no way to verify who is consuming the medication and whether she is doing so willingly. Sex traffickers, incestuous abusers, and coercive boyfriends will all welcome more easily available medical abortion.”

Notably, polling of clinicians supports these concerns. Around six in seven GPs were found to be concerned that the “at-home” abortion policy could see more women being coerced into abortion, whilst 87 per cent were concerned that women were at risk of unwanted abortion arising from domestic abuse by partners controlling or monitoring their actions.

The Conservative Party manifesto in 2019 pledged “to fight crime against women and girls” and provide support for “individuals, most often women, trapped with coercive partners.” Indeed, Home Office Ministers have reassured us that the Government has “remained resolute in our commitment to tackling abuse that takes place behind closed doors and out of sight”; a commitment which has been evident through the passage of the Domestic Abuse Act 2021.

As the Government makes its decision about the long-term future of  the home abortion policy, I urge the DHSC to prioritise the security and welfare of women facing unplanned pregnancies. Coerced abortion is widely held to be a “brutal form” of “discrimination”. It is our duty to prevent it.

David Willetts: The case for the National Insurance increase

28 Jan

David Willetts is President of the Resolution Foundation.

Conservatives don’t like putting up taxes and voters don’t like paying them. So it is not surprising there is an energetic campaign against the National Insurance increase. Should the Chancellor give ground to the critics?

One of the arguments, set out eloquently on ConservativeHome, is that we are having to pay higher taxes because the Government has decided to increase the size of the state, and it would be far better to shrink the state and abandon the tax rises.

But the main reason for the NI increase is to finance the cost of the NHS. That, in turn, is going up just because there are more old people, so public spending rises – even without any change in policy. Old people are heavy users of the NHS. It is very different from the demographic backdrop to the 1980s and 1990s when there were many fewer pensioners because of the low birth rates of the 1930s and the war years.

But now we are facing the healthcare and pensions costs of the post-war baby boom. And, however radically the Government reformed the NHS, it is hard to see pensioners being asked to pay for it, but that is what is driving the spending increases.

The Health Foundation estimates that funding for healthcare will have to rise in the next decade by over £60 billion just to maintain services in the face of these demographic pressures. We can try to offset these pressures by cutting other Government programmes; indeed, we have been doing that for a decade.

Whitehall-controlled day-to-day spending will have gone up by £111 billion between 2010 and 2024. An extraordinary £84 billion of that will have gone to the Department of Health and Social Care. We are reshaping the state so it is above all a mechanism for extracting money from young people to finance services and payment to older people who tend to vote – and vote Conservative.

This leads on to the objection that the levy is unfair on young taxpayers, especially as an increasing proportion of the money is to go to older people to protect more of their assets, and fund their health and social care. It is indeed a big problem that NI is not paid by pensioners, so if they are still working they take home more than a younger worker doing the same job.

The Treasury is very aware of his and for the first time extended this new supplementary rate of NI to pensioner earnings as well. It also covers income from dividends. But there are still other sources of income – from occupational pensions, for example – which do bear income tax but don’t pay this levy.

One obvious simplification of the tax system would be to merge NI with Income Tax, but the various exemptions from NI for pensioners have made this politically difficult. So I am relieved that at least the Chancellor has broadened the base of the new levy compared with traditional NI.

Even so there is still some validity in the argument that the Government is increasing taxes on earnings to protect old people’s assets. What we really need is a bold new Conservative programme for a property-owning democracy. We should reverse the decline in property ownership among young people. I hope to come back to this in a subsequent column.

As well as the generational problem, there is also the objection that the levy hits poor people, who are now facing the cost of living crisis. There is indeed a big hit to living standards looming. But the levy is a smaller part of this than the energy price rises. The NI rise will cost the average household £440. By contrast, average household energy bills are forecast to rise from £1,300 to £2,000. Moreover, the levy is not paid by the lowest income households. The Chancellor also increased the taper for Universal Credit so overall his budget boosted the incomes of many low income families whilst collecting more from the most affluent.

If the Chancellor has any fiscal room for manoeuvre now, he has much better means of easing the cost of living crisis than abandon the levy. Here it is. First introduce a radically improved Warm Homes Discount – increased by £300 and made available to 8.5 million families. Second, spread the costs of energy firm failure over a number of years. Third, temporarily transferring the social and environmental levies off energy bills. Combined this package would reduce energy bills by up to £545 a year at a cost of around £7.3 billion. This is much lower than the £12.7 billion cost from cancelling the rise in NI. It would also be much better targeted: more than half the benefits of postponing the NI levy accrue to the richest fifth of households.

Is it nevertheless the wrong time for any tax increases when the economy is still recovering from the enormous blow of the virus? But if anything it is bouncing back better than was feared. The better figures for public borrowing, which some are arguing show you don’t need the tax increase, are also evidence that the economy is growing fast enough to pay for this.

Borrowing is running rather lower than forecast – but it is still £147 billion this year so far and likely to come in at around £180 billion. With interest rates rising, the cost of this borrowing is going up. The Treasury always worries that if markets think the Government is never going to be able to raise taxes, the interest rates we pay would rise. There is some politics here as well – delay for a year or two and the hit is closer to the next election. Margaret Thatcher faced these arguments 40 years ago when the 364 economists warned against her tax rises in the 1981 budget, but that was the moment when the economy started to recover.

Then finally there is the most seductive argument of the lot – that tax rises actually cost revenues whereas tax cuts fund themselves by boosting economic growth and getting people to declare more of their income. It is true that there comes a point where increasing tax rates reduces totally revenues, but we are nowhere near that. The one apparent recent example is the increase in corporation tax revenues after the rate was cut, but this looks to have been driven more by the fall in business investment after the financial crash and then Brexit. The fall in investment boosted receipts as investment spend can be offset against corporation tax.

There is no prospect of funding today’s British state, shaped by Conservatives over the past decade or more, without increasing taxes. We can’t just keep on borrowing the money for our day-to-day spending on healthcare and pensions. We can certainly reform our taxes. We can also aim to reform the NHS to offset some of the costs from demographic pressures. But we cannot be the tax cutters we were in the 1980s because we are now an older country than we were then – and indeed it is older Tory voters who are the biggest beneficiaries of the reshaping of the state which has been the result.

Richard Holden: It’s time for the Government to make more of Tory MPs’ achievements and fewer errors itself

23 Nov

Richard Holden is MP for North West Durham.

BBC Studios, Newcastle-Upon-Tyne

Everyone gets that it’s the job of the Her Majesty’s Opposition is to oppose, but its leader seems to have taken this to another level in recent weeks.

Not long ago, Keir Starmer was calling for HS2 to be scrapped. Now he’s saying it’s not going far enough. Captain Hindsight is probably wishing that he’d had a touch more foresight on this one.

At the same time, Labour deride the £96 billion investment in new rail infrastructure in the midlands and north as a ‘betrayal’. They conveniently skirt the markedly different records of the main political parties: Labour in 13 years managed 63 miles of new and electrified track. The Conservatives have managed over 1,000 miles, with hundreds of miles more of new and electrified track on the way.

All the above is important – but to my constituents feels too often like political knock-about. I endured it on BBC Politics North East this weekend up against Labour’s Ian Lavery. The record is useful for highlighting Labour’s duplicity, but not much else. And I can’t quite understand how the Government ended up wrong-footed on some of the biggest investment in the big picture in decades.

Drill down a little, and what my constituents are after is regional connectivity. Trains connecting major cities – the spine of the network – are great, but if you’d can’t plug into one of those hubs then who, in an area with no trains and a limited bus service, cares if it’s happening?

That’s the message from so many parts of the country who are interested in what’s happening to the ribs off the spine: they want to see some meat on them. For my constituents, it’s the real test on public transport delivery in our local areas – particularly in relation to buses, which the Government is doing so much work on – not the Westminster dance that the media obsess over.

This week, the Bubble has turned its collective attention towards Health and Care Bill – which delivers on another of our commitments, of the kind that governments of all shades have dodged for decades.

For this MP, the Bill also contains some important measures that I’ve been campaigning on for over a year that you won’t see splashed broadly across the mainstream media.

The Department of Health has taken up the mantle of my private members bill from the last session, and is going to ban so called virginity testing not just in England and Wales, but across our United Kingdom.

I cannot tell you what this means to campaigners from IKWRO Women’s Rights Organisation, Karna Nirvana and MEWSO – and their supporters – who have been banging the drum for change for years on women’s rights in this respect for years.

Too often, we think that issues around women’s rights have been solved, but it’s clear that there are major areas in which that just isn’t true. Banning the pseudo-science of so-called virginity testing is a good step in this area, and I have received assurances from Ministers that we’ll see hymenoplasty banned, too, in this piece of legislation – with amendments to be introduced in the Lords along the lines of my probing ones that have been backed by many MPs in the Commons.

Sajid Javid has been a true champion in this field, too, and picked up the mantle of ending under-18 marriage while on the backbenches . My colleague Pauline Latham has taken this on following Javid’s move back to the Department of Health and Social Care, and the initiative looks likely to progress soon.

With so much of the social policy debate space being taken up by arguments around trans rights in recent years, we too often forget that there are major issues around the rights of women and girls that need to be sorted out, too.

Another prime example is the campaign being led by Alex Stafford and Nick Fletcher down in the Rother Valley and Don Valley – demanding action in response widespread allegations of grooming gangs and child sexual exploitation in their towns and villages. The local Labour authorities have been, yet again, slow to act.

Time and again, when it comes to the rights of women and girls, it’s Conservative MPs leading on these battles. Fights that have been abandoned by Labour MPs (with some notable exemptions) who, long ago, became sadly too frit to take on the most socially conservative elements of British society.

On the ground in our constituencies and in Parliament, it’s backbench Conservatives leading the charge in so many areas – from levelling-up and fighting for better connectivity to the rights of women and girls.

At a national level, it feels like the Government is missing chances to highlight the good work that such Conservative MPs are doing. And that it is making a few too many unforced errors – especially when it comes to selling the positive changes we’re making for the country.

We got Brexit done. We’ve delivered the fastest and one of the most comprehensive vaccine programmes of any developed nation, and supported jobs and business through the pandemic. Employment is now higher than pre-pandemic, and we’ve got record vacancies in the economy. We are now delivering record investment in our transport infrastructure, our NHS and, at the same time, have a clear plan to get waiting lists, debt and taxes falling in the medium term. Conservative MPs are leading the way on major issues of social policy on the national level and in their communities – working day and night to deliver the investment they need.

The Opposition hate it and are led by a central London lawyer who does not understand, never mind connect with decent working Britain. And the media are, naturally, interested in the people rather than the policy. But we’ve got a great story to tell. No one will do it for us. It’s time to regain the initiative, and relentlessly make the case for conservatism.

The GP crisis. And why it may prove that the lockdown sceptics had a point.

25 Sep

“We’re still operating under pandemic conditions” is the automatic message I receive when I phone my GP practice. Like many people in the UK, I have been bemused to find out that face to face appointments aren’t available at my surgery, even in spite of the fact that lockdown is over, and the economy has fully reopened.

Data shows that while 80 per cent of GP appointments were conducted face to face before the pandemic, in July only 57 per cent were. And far from the vaccine roll out boosting face-to-face appointments, the opposite trend appears to have happened, with GPs on course to see 80 million fewer people in person this year than in 2019.

Experts such as Professor Karol Sikora, an oncologist, are incredibly worried about the consequences of remote appointments; he tells me that “over my career I’ve probably held over 100,000 face-to-face appointments with patients and you pick up something important every single time. A patient’s body language, visual symptoms and in-person physical examination are all crucial to getting to the crux of the issue.”

The Government is concerned too; in the last few days, Boris Johnson has warned that patients must be allowed to see doctors face-to-face. Ministers will be under no illusions that the UK could be on course for a health crisis much worse than Covid; it is already estimated that 175,000 diagnoses of key conditions were missed last year.

So what exactly is going on with GP practices? Why – with the vaccine here, more PPE and better Covid treatments – are they continuing to operate in pandemic conditions? And how does the Government deal with this matter? 

When I started out this piece, I simply asked the receptionist at my GP why face-to-face appointments aren’t going ahead, and I was intrigued by her response. She had no idea, and responded as though she’d never been posed the question before.

However, reports suggest there are several big reasons for the situation.

First, GPs are feeling overstretched, due to staff shortages, which the Government has been trying to remedy with a recruitment drive. It’s unsurprising that some want to continue with the video/ digital system deployed during the pandemic, so as to get through patients quicker.

Second is that e-consults have not come out of nowhere; Coronavirus, in fact, sped up a move towards digital/phone services that was already under way. E-consults are not necessarily bad in themselves – saving time for digitally-savvy patients in a hurry.

But the main issue is one of accessibility, particularly with those who find technology or staying on the phone difficult. As Dr Ben Spencer, the MP for Runnymede and Weybridge and former psychiatrist, tells me: “Digital exclusion will disproportionately affect the most vulnerable in society”. 

The third, under-reported reason why GP surgeries aren’t fully open is to do with widespread variations in the “physical environment” of practices up and down the country. Some, for instance, are purpose-built, with ventilation and lots of space, meaning that they find it easier to see people compared to smaller surgeries. The latter will be behind the troublesome statistics.

While the Government has issued strong statements about GPs reopening – with Sajid Javid, the Health Secretary, warning that it’s “high time” for them to get back to normal – behind the scenes the Department of Health has taken a softer approach, speaking to NHS England and GP groups about the pressures they face, and how these can be alleviated.

Although the Government has invested £270 million to expand GP practice, improving things isn’t simply about throwing money at the NHS. Bureaucracy, for instance, is something that doctors have complained about; reducing it may be next on Javid’s list.

The Government will also be keen to cool tensions between the public and GPs. Yesterday Javid also held an “emergency” meeting with the BMA GP committee chair to discuss the abuse currently being suffered by GPs, in large part because the media has framed the story as “lazy doctors” against everyone else. In fact, the situation is more complicated than has been presented.

Is this issue going away any time soon? The biggest challenge for the Government is recruiting staff. Although record numbers of people are training to be GPs, it takes years before they can actually practice. No doubt Government critics will use worker shortages to criticise Brexit, and it may come under pressure to recruit from outside the UK.

At the same time, the NHS backlog will increase, and GPs will feel even more reticent to move away from phone/digital services, particularly as flu season arrives. Expect challenging months ahead, which may leave lockdown sceptics feeling vindicated.

After all, they warned that shutting down the economy would prove more dangerous than the immediate threat of the virus. The GP debacle, and the data that’s beginning to emerge from missed appointments, may be the biggest evidence for their argument yet.

Melody Redman: Abortions at home must only be a temporary measure

17 Jul

Dr Melody Redman is a clinical genetics registrar, with a background in academic paediatrics.

In March 2020, temporary provisions were introduced to permit women in the first 9 weeks and 6 days of pregnancy to take both medical abortion pills at home. The pills are sent through the post, after a remote consultation with an abortion provider. Prior to this, the administering of the first of the two required pills for medical abortions could only take place in approved hospitals or abortion clinics.

This emergency ‘at-home’ abortion scheme was introduced because of fears about limited in-person access to clinics during the coronavirus pandemic, with the mantra at the time being ‘Stay Home and Protect the NHS’. The UK, Welsh, and Scottish Governments have recently undertaken consultations on whether to end these measures or make them permanent, and the publication of their respective decisions is imminent.

Unsurprisingly, this push to permanently permit ‘at-home’ abortion has been spearheaded by the UK’s two largest abortion providers: MSI Reproductive Choices (formerly Marie Stopes) and the British Pregnancy Advisory Service, who are lobbying for the scheme to be made permanent. Given that 59.3% of UK abortion clinics are rated by the Care Quality Commission as ‘Requires Improvement for Safety’, how then can we trust them to ensure the safety of women ‘at-home’?

Last month, I along with over 600 other medics signed an open letter demanding an end to the scheme. Our letter expressed grave concerns over examples of the pills being used beyond the 10-week limit for home medical abortions, and in some cases after the 24-week legal limit for surgical terminations. The letter also highlighted a string of other safety and safeguarding issues related to issuing abortion pills without a face-to-face consultation.

Indeed, ‘at-home’ abortions rely on women accurately remembering the first day of their last period, which only around 50% of us do. This date is then used to estimate how far through the pregnancy the woman is. The Department of Health & Social Care has confirmed that pregnancies beyond the legal limit for ‘at-home’ abortions are being terminated at home, putting women at higher risk of complications.

It appears that data on the effects of ‘at-home’ abortions is being significantly and systemically under-reported. A Freedom of Information (FOI) request to the Care Quality Commission revealed that between April and November 2020, 11 women using the scheme, who had a gestational date beyond the legal limit for early medical abortion, required hospital treatment for complications. FOI requests have similarly since shown women suffering from serious issues (including sepsis, haemorrhage, and trauma to pelvic organs) after taking the pills.

Worryingly, an undercover investigation (led by a former director of MSI Reproductive Choices) revealed the lack of basic checks carried out by abortion providers before issuing pills-by-post. The investigation saw volunteer clients being sent abortion pills despite using false identities and gestational dates, including a date that could only have led to an abortion beyond the legal limit for ‘at-home’ abortions.

The removal of a mandatory in-person consultation also hinders clinicians’ abilities to flag up signs of coercion and abuse. An alarming seven per cent of British women have been pressured into an abortion by their partner or husband, a figure that likely increased under lockdown, during which there was a 49% increase in calls to domestic abuse services.  This is a serious concern; 87% of GPs are worried about ‘unwanted abortion arising from domestic abuse’ when no in-person consultation is required.

As a doctor, I know that telephone consultations can work well for some things, but there are huge limitations. I cannot control the environment on the other side of the phone, unlike in a safe clinic space. I cannot tell if my patient is next to an intimidating partner. I cannot ‘eyeball’ them to see if they appear frightened, have a black eye, or are heavily pregnant. Abortion consultations are not as simple as phoning your GP for advice on your reflux. They are intimate and challenging discussions, with life-changing physical and psychological ramifications.

Savanta ComRes polling of the general public reveals a high number of serious concerns. We are so often told to simply ‘trust women’ when it comes to liberalising abortion laws. Why then should we ignore the 92% of women who agreed that a woman seeking an abortion should always be seen in person by a qualified doctor?

‘At-home’ abortions were a hasty, temporary measure, introduced at a time when it was feared women should not attend an abortion clinic. This should not be a permanent solution. When making the difficult decision to pursue an abortion, we must be sure that women get a face-to-face consultation. Let us give women the space, the safety and the specialist assessment they deserve. I therefore implore the Government to bring this temporary policy to an end with immediate effect.

Andrew Gimson’s Commons sketch: Johnson’s former adviser gives us politics as a disaster movie

26 May

“We’re heading for total and utter catastrophe,” Dominic Cummings, the Prime Minister’s chief adviser, told his colleagues on the evening of Thursday 12th March 2020.

Or as Helen MacNamara, the Deputy Cabinet Secretary, put it when she burst into the meeting he was holding with two of his scientific advisers: “I think we are absolutely fucked.”

This is politics as a disaster movie. In his evidence today to MPs, Cummings made Downing Street sound like the control room of a space ship which is hurtling towards oblivion while most of the senior people on board go on convincing themselves, thanks to the operation of almost irresistible groupthink, that no course correction is required.

The captain, Boris Johnson, is “about one thousand times too obsessed with the media to do his job”, and has only become Prime Minister because the other candidate, Jeremy Corbyn, was even worse.

“A choice between two people like that,” Cummings said, “is obviously a system that’s gone extremely badly wrong.”

And as MacNamara has just announced: “There is no plan.”

Cummings proceeds to “press the panic button”, but will it be too late? For a long time it seems that it will be. Today’s dialogue, though often riveting, will have to be cut before this picture makes its way to a big screen near you.

The Department of Health pretended it had prepared for the pandemic, but instead collapsed under the strain, unable even to obtain sufficient supplies of Personal Protective Equipment.

By Cummings’ account, Matt Hancock, the Health Secretary, lied that “everything is fine on PPE,” and then lied again, blaming the shortages of PPE on Rishi Sunak, the Chancellor of the Exchequer, and Simon Stevens, the Chief Executive of the NHS.

How would he rate Hancock’s performance, Rosie Cooper (Lab, West Lancashire) wondered, somewhat superfluously.

Cummings: “I think the Secretary of State for Health should have been fired for at least 15 or 20 things.”

And Cummings did what he could to get this message across: “I said repeatedly to the Prime Minister he should be fired. So did the Cabinet Secretary. So did many other people.”

Meanwhile a small number of brilliant people wrestled to regain control of the stricken space ship. Cummings wishes he had been quicker to understand how bad things were: “If I’d acted earlier lots of people might still be alive.”

At the start of this long session, and several times during it, he said how sorry he was for his own mistakes.

But he also described the rescue mission which he and a few others mounted, once they realised “all the claims about brilliant preparations…were basically completely hollow.”

The behavioural scientists who advised the Government insisted the British public would not accept a lockdown, which is one reason why that essential measure was not introduced sooner.

Unfortunately, Cummings pointed out, “in the field of behavioural science there are a lot of charlatans”.

That is no doubt true, but as Edmund Burke once wrote, “The temper of the people amongst whom he presides ought…to be the first study of a statesman.”

It is the responsibility of ministers to judge what the people of this country will accept: whether in this instance we would accept being prisoners in our own homes, forbidden even to go to the pub, let alone to watch the races at Cheltenham or the football at Anfield.

A big call, but the buck stops with Johnson, not with his advisers, no matter how gifted they may be, and Cummings is clearly very gifted.

Spoiler alert. At the end of the movie, the space ship is saved, though only after an horrifically high number of those on board have died.

We have taken heavy casualties and had one hell of a fright, but as the credits roll, and the feel-good music plays, we are not, perhaps, quite as censorious as Cummings, played as usual by Dominic Cumberbatch, is about the manifold deficiencies of those who were supposed to be running the show.

Tracey Follows: Vaccine passports just the start of a digital identity revolution. Here’s what you need to know.

19 Mar

Tracey Follows is a Futurist and CEO of Futuremade.

This week MPs gathered, in a socially-distanced fashion, to debate the merits or otherwise of vaccination certificates. Steve Baker MP took to quoting The Prisoner in his attempt to dissuade his audience from even thinking about instituting a programme of certification designed to identify who and who has not received a vaccination against Covid-19.

As one after another contributor rose to make their point, the focus was very much on how the decisions that were going to be made today would turn out to have much more serious and long-term consequences in the future.

But this is to view the issue through the wrong end of the telescope. In order to better understand the benefits and drawbacks of such a verification system, we have to look at the future and work backwards to make the right decisions today. Looking at least ten years ahead, we can envision a world in which many countries, many citizens and also many consumers use some kind of digital identity system. Here’s why.

In 2015 the United Nations committed itself to achieving seventeen sustainable development goals by 2030. The sixteenth of those goals relates to justice and, more specifically, clause 16.9 commits nations to “provide legal identity for all“. This is an important goal and we should remember that over one billion people in the world have no official form of identification to prove who they are, and therefore cannot access essential health and financial services that most of us take for granted in every day life.

At the same time, more and more of those everyday services in modern life, are delivered digitally. Nations are acting like technology companies as they digitise public services, and technology companies are acting like nation states owning newspaper media, offering schools to disadvantaged children and increasingly operating in the field of telehealth. Someday soon, nearly all of our essential services will be digitised and therefore our access to them will require a digital authentication of some kind.

But we should not jump to the conclusion that a digital identity would necessarily be state-controlled. Plenty of countries do run centralised systems, linked to biometric data like a fingerprint, in the case of India; or an eighteen-digit code that combines everything from birth data to local authority data, in the case of China. The UK government has not in the past suggested any kind of centralised model for identity. In fact it has gone out of its way to operate what is known as a federated model.

This federation consists of trusted “identity assurance services” such as your bank, the tax office or the postal service who altogether provide a package of assurances, which gives citizens a sense of privacy and control. However it is a very complex system which needs updating and in 2020 the UK government announced it would be creating a Digital Identity Strategy Board to bring together numerous government departments from the Home Office to the Department of Health and Social Care, to avoid any one department developing a digital identity system in a silo of its own.

What is often forgotten is that there is a further model which is already taking place among a new generation and technology enthusiasts at large. More and more people are downloading identity apps onto their smartphones so they can manage their digital identity themselves. In Jersey, for example, more than half of 18-25 year olds have already downloaded the Yoti app which they can use to prove their age at retail or hospitality establishments and festivals.

The way these apps work is that the user can release whatever identifying attribute they wish to share without jeopardising all of their other personal information. In the past when an eighteen-year old wanted to prove they were of drinking age they might have shown a driving licence which states not only their age but birth date and full address too. A decentralised digital identity app such as Yoti, or Evernym or many others, will only release the identifying information that is relevant to the situation at the time.

Many of these companies are now working hard to deliver Coronavirus credentials, the digital proofs of vaccination. These are the gateway drug to a more complex digital wallet that one day will be full of credentials for university qualifications, travel passports and visas, business cards or work badges, and of course your NHS number and many health records besides.

The truth is that all nations are becoming digital nations, and their digital citizens will require access to digital services. Decentralised, downloadable apps will ensure the user always has control of their digital credentials in a digital wallet, and ultimately has sovereignty of their digital identity too.

After all, no-one seems to worry about the surveillance that an autonomous vehicle will bestow on each of us. These cars will be ordered online, arrive at our doorstep, they’ll know what time that was, who we picked up on the way and what time we arrived at our destination. Likewise, not many people seem concerned about the surveillance of the self in Amazon’s new cashier-less store in Ealing that uses “just walk out” technology consisting of QR codes, sensors and cameras.

The fact is there are many ways we are already monitored on the street, at work and in our homes. Our digital identity is already out there it’s just not evenly distributed. Some people are not waiting for their governments to give them a digital identity, they have already taken control and created one of their own.

The Future of You: Can Your Identity Survive 21st Century Technology by Tracey Follows is published by Elliott & Thompson, available from now.

Ben Howlett: Hancock must seize this opportunity for health and social care reform

19 Feb

Before becoming MD of Public Policy Projects, Ben was Member of Parliament for Bath from 2015 to 2017 and Chair of the first Parliamentary Group for Rare, Genetic and Undiagnosed Conditions. He also Chaired the Stroke Group and supported the personalised medicines and data analytics groups. Prior to entering Parliament Ben worked alongside the NHS in management consultancy.

The recent announcement of a White Paper to formally integrate health and social care is ten years overdue. Given the widespread support the proposals have received from all corners of the healthcare sector, it is clear that no one has any appetite to repeat the same arguments that sucked the life out of a room with the infamous Health and Social Care Act of 2012.

However, before we get too excited, we should remind ourselves of some of the exhaustive debates surrounding the provision of health and social care in this country. In a country where the NHS is the closest thing to a national religion, this Government needs to be cautious about any “reforms”.

Andrew Lansley’s reforms were well intentioned: give more power to frontline clinicians to make the decisions themselves. How could this go wrong?

What ended up as the dog’s breakfast that we now call the Health and Social Care Act 2012 is not where his vision started. Most of us know that the Government is genuinely passionate about the formal integration of health and care – who isn’t?

But, and this is a big but, if this means that Ministers are now going to be responsible for 4000 people on waiting lists… and if this means that the relatively poor cancer outcomes of the pre-pandemic era are now the responsibility of Ministers rather than the NHS…I hope you can see where this is going. There may not only be charges of politicisation of our sacred NHS, but patients might start directly blaming Ministers rather than “the system”.

The White Paper is clear that these decisions should be led by local communities, with local government formally integrated into the decision-making process. This is good news: local accountability for locally-provided services.

However, what happens to national, more specialist services? We have not yet heard what will happen to NHS England when Sir Simon Stevens stands down. Is this the point where almost universal warmth towards these reforms begins to break down?

For those of you with the crystal ball, give it a rub to see what happens to the operations run out of Skipton House, the Canterbury Cathedral of the NHS. Will some of those policy making powers find their way to Victoria Street, the new home of the Department of Health and Social Care? Lansley’s reforms were designed to give the NHS more independence and if the reforms go the way some of us predict, then Sir Simon may be elevated to a status not seen since Thomas Becket.

The right time?

While the Opposition is asking whether this is the right time to “reform the NHS”, they flagrantly fail to recognise that these are reforms are intended to bring health and care together. For those of us who can remember a time before the pandemic, statutory health and care integration has been discussed at length.

Remember when Jeremy Hunt, as Secretary of State, decided to change the name from an Accountable Care System to an Integrated Care System? The Kings Fund, Nuffield Health, Public Policy Projects, The Health Foundation etc. have called on a formal system of integration for many years. Integrated Care Systems (ICSs) have been around for several years with varying degrees of success. There are those of us who have been calling on the Government to create a standardised system in law for a while.

However, parliamentary arithmetic to offer up new legislation has not existed until now. A significant proportion of the system already exists, so the Government should consider this a “tidying up exercise” to bring consistency and equity to the provision of joined-up health and care, as opposed to a proposal for something new and untested. In short, this is a very good opportunity to incorporate some of the lessons from the pandemic whilst we all await the formal public inquiry.

What is missing?

Digitisation. This is extremely surprising given the Secretary of State’s “Duracell Bunny” status as a cheerleader for digitisation. Matt Hancock was on the airwaves as soon as the White Paper landed, expressing his desire to reduce bureaucracy. I counted at least seven times on BBC Breakfast he made the point, yet he barely mentioned innovation.

For those of us who know just how passionate Hancock is about the subject, this seems like a missed opportunity. Public Policy Projects will be publishing our first State of the Nation report of 2021 on digitisation and medical technologies next week where we will hear from the Minister for Innovation, who is helpfully responsible for digitisation.

At one of our events last year, Hancock said that his proudest achievement as Secretary of State was the digitisation of health and care. The pandemic has seen rapid transformation of digital healthcare provision. When it was once a long wait in a GP waiting room, you can now download an app such as Babylon or Livi (other providers are available) and see a clinician within minutes. Does anyone want to see us go back to the dark ages where we have to book time off work to visit a doctor?

The forthcoming reforms must embrace digitisation to truly make this a 21st century system of universal healthcare provision. I have little doubt that the Secretary of State would receive extremely positive support from patients and clinicians alike if he were to make this his statutory legacy.

Building a country fit for heroes

The pandemic has been a disaster for the health of our population. With over 115,000 dead, tens of thousands left with the long-term challenges of Covid recovery, mutant virus strains and some of the longest waiting lists in a generation, this is going to be an extremely difficult time for any Government as they try to reset the agenda. The Secretary of State has shown tremendous leadership during this pandemic and I have no doubt that he will be able to set a vision for the long term, with integration being his legacy.

The country needs some optimism and, if we can be sure of one thing, it is that Hancock is definitely optimistic. He must focus on what is important and focus in on boosting the health of the nation, and not let ulterior motives impact upon his vision. As numerous former Secretaries of State have said to me over the years, beware the law of unintended consequences.