Majorities in poor areas will always vote for the party that gives most handouts.. Payment for breast feeding is not well directed..

Payments for breast feeding could give money to the rich minority…. While we tax the poor who smoke, and die younger.. All education, and health care is divisive in some way. But the politicians role is to devise systems to equalise opportunities as much as possible. Even before breast feeding, the opportunity is potentially “lost” if a mother smokes, and bottle feeding compounds this loss. The next “loss” is lack of nursery placements, lack of meaningful grandparents, divorced parents, and then mitching from school, experimenting with drugs and smoking themselves. Finally underachievement in school meaning less rewarding and productive work, poorer housing, less money and a cycle of deprivation. Where else in this cycle should we “pay” to make a change? Payment not to smoke could result in purchase of more alcohol or drugs. The perverse outcomes of giving handouts to those unable to manage them have been well recorded.. Payments might work for selected groups, like those who have never had a smear (less than 10%), but in Wales, 80% do not breast feed, and when a handout goes to a majority we are on a slippery slope… And how would you confirm compliance? Will breast pumps count? Weighing a baby after feeding? In addition, majorities in poor areas will always vote for the party that gives most handouts.. 

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Chris Smyth reports in the Times 12th December: Health experts say mothers should be paid to breastfeed

Mothers should receive cash incentives as a reward for breastfeeding, experts said last night after a trial found that handing out shopping vouchers improved rates by about 20 per cent.

Public health workers said that a wider use of incentives could improve Britain’s rates, which are among the worst in the world with just 1 per cent of babies breastfed exclusively at six months.

They said that the vouchers made breastfeeding “more normal” in areas where women were embarrassed about it and argued that payments could help to kick-start a wider cultural change.

However, other doctors and midwives said that Morrisons and Asda supermarket vouchers were not the right solution.

Breastfeeding is known to protect babies from infection and has been linked to a lower long-term risk of conditions such as obesity, diabetes and heart disease.

Three quarters of mothers start breastfeeding but this tails off quickly, with fewer than half continuing when their babies are eight weeks old. The figures are worse in poorer areas, with fewer than a quarter of babies starting off breastfed in some places.

To counter this, a trial incentive scheme was set up in areas of Derbyshire and South Yorkshire with low breastfeeding rates.

Women were offered up to £200 in vouchers for supermarkets and the Love2Shop site, which could be redeemed at places ranging from Alton Towers and Champneys spas to New Look, Matalan and Pizza Express.

Over a year 32 per cent of the 5,000 women offered normal care were breastfeeding at eight weeks, compared with 38 per cent of the 5,000 that were offered vouchers.

Clare Relton, who led the study at the University of Sheffield, said she was delighted with the results. “Mothers reported that they felt rewarded for breastfeeding,” she said.

By the end of the trial the gap between the two groups had risen to nine percentage points, with 41 per cent of those offered vouchers breastfeeding, according to data published in the journal JAMA Pediatrics.

Shirley Cramer, of the Royal Society for Public Health, said that payments “could be just the nudge that some mothers need”.

However, Gill Walton, chief executive of the Royal College of Midwives, said: “The motive for breastfeeding cannot be rooted by offering financial reward. It has to be something that a mother wants to do in the interest of the health and wellbeing of her baby.”

The trial relied on women reporting whether they were still breastfeeding and researchers acknowledged that they could not be sure people were not lying to claim the vouchers. Andrew Whitelaw, of the University of Bristol, said that because of this the study was “not a justification for a general policy of economically rewarding mothers who report breastfeeding”.

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Chris Smyth December 8th in The Times: British more likely to die of lung disease



Despite the idea that there might and should be a plan, NHSreality is certain there is only a “void”.

Dennis Campbell in the Guardian reports 11th December 2017: Labour demands Commons vote on ‘secret’ plan for NHS – Party says ministers are trying to push through changes that could lead to greater privatisation and rationing of care

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Labour is demanding that MPs be allowed to debate and vote on “secret” plans for the NHS that they claim could lead to greater rationing of care and privatisation of health services.

The party says ministers are trying to push through the creation of “accountable care organisations” (ACOs) without proper parliamentary scrutiny.

Jonathan Ashworth, the shadow health secretary, has written to Andrea Leadsom, the leader of the House of Commons, urging her not to let “the biggest change to our NHS in a decade” go ahead without MPs’ involvement.

NHS England’s chief executive, Simon Stevens, and the government see ACOs as central to far-reaching modernisation plans that they hope will improve patient care, reduce pressure on hospitals and help the NHS stick to its budget.

ACOs involve NHS hospital, mental health, ambulance and community services trusts working much more closely with local councils, using new organisational structures, to improve the health of the population of a wide area. The first ACOs are due to become operational in April in eight areas of England and cover almost 7 million people.

Labour has seized on the fact that the Department of Health plans to amend 10 separate sets of parliamentary regulations that relate to the NHS in order to pave the way legally for the eight ACOs.

In his letter, Ashworth demands that Leadsom grant a debate on the plans before the amended regulations acquire legal force in February.

“Accountable care organisations are potentially the biggest change which will be made to our NHS for a decade. Yet the government have been reluctant to put details of the new arrangements into the public domain. It’s essential that the decision around whether to introduce ACOs into the NHS is taken in public, with a full debate and vote in parliament,” he writes.

A number of “big, unanswered questons” about ACOs remain, despite their imminent arrival in the NHS, he adds. They include how the new organisations will be accountable to the public, what the role of private sector health firms will be and how they will affect NHS staff.

Ashworth also says “the unacceptable secrecy in which these ACOs have been conceived and are being pushed forward is totally contrary to the NHS’s duty to be open, transparent and accountable in its decision-making. The manner in which the government are approaching ACOs, as with sustainability and transformation plans before them, fails that test.”

Stevens’s determination to introduce ACOs has aroused suspicion because they are based on how healthcare is organised in the United States. They came in there in the wake of Obamacare as an attempt to integrate providers of different sorts of healthcare in order to keep patients healthier and avoid them spending time in hospital unnecessarily.

A Commons early day motion (EDM) on ACOs also being tabled by Labour on Thursday, signed by its leader, Jeremy Corbyn, and other frontbenchers, notes that “concerns have been raised that ACOs will encourage and facilitate further private sector involvement in the NHS”.

In his letter Ashworth adds: “There is widespread suspicion that the government are forcing these new changes through in order to fit NHS services to the shrinking budgets imposed from Whitehall.” The EDM also notes “concerns that ACOs could be used as a vehicle for greater rationing”.

The King’s Fund, an influential health thinktank, denied that ACOs would open up NHS services to privatisation. “This is not about privatisation; it is about integration,” said Prof Chris Ham, its chief executive.

“There is a groundswell of support among local health and care leaders for the principle of looking beyond individual services and focusing instead on whatever will have the biggest impact in enabling people to live long, healthy and fulfilling lives,” added Ham.

However, he added: “ACOs will not in themselves address the desperate underfunding of the NHS and may divert more money into processes of reorganisation. Current procurement and competition regulations create the potential for ACOs to be opened up to global private providers within a fixed-term contract and with significant implications for patient services and staff.”

The Department of Health refused to say if MPs would be able to debate ACOs. “It is right that local NHS leaders and clinicians have the autonomy to decide the best solutions to improve care for the patients they know best – but significant local changes must always be subject to public consultation and due legal process.

“It is important to note that ACOs have nothing to do with funding – the NHS will always remain free at the point of use,” a spokesman said.

The Canadians shame us with their plans for end of life care..

The Assisted Dying bill was rejected by Parliament and by the profession. The BMA conference is full of older members as the younger ones are working, but if their opinions were canvassed, the UK would introduce similar legislation to Canada. The Canadians are shaming us and more in touch with their young people. Just as with Brexit, where the oldies votes have outweighed those of the young, assisted dying will not become UK law – for some time yet.

Trish Audette Longo reports in the Canadian National Observer 11th December:  Canadian Parliament makes plans for end of life care.

Canada has moved one step closer to creating new national guidelines for palliative care following the Senate’s passage of a private member’s bill this week.

The legislation was adopted more than a year after it was first introduced in the House of Commons by Sarnia-Lambton Conservative MP Marilyn Gladu in 2016.

“This is the best gift at Christmas time that Canadians could receive,” Gladu told National Observer Friday.

The bill, “An Act providing for the development of a framework on palliative care in Canada,” is expected to receive royal assent, or come into force, on Tuesday, Dec. 12. Gladu explained that the legislation incorporated recommendations made by an all-party committee report on palliative and end-of-life care.

The legislation requires the government to come up with a palliative care framework.

In an e-mail Friday, Thierry Bélair, a spokesman for Health Minister Ginette Petitpas Taylor, told National Observer: “The framework is expected to define palliative care, the training needs of, and other supports for, health care providers and other caregivers, as well as (find) ways to facilitate consistent access to palliative care in Canada.”

A final framework is also expected to “promote research” and “evaluate whether to re-establish a secretariat on palliative care and end-of-life care.”

Bélair noted health care falls primarily under provincial and territorial government jurisdiction, and the federal government is committed to working with them to improve palliative care access. “In addition, our government continues to support pan-Canadian initiatives that enhance quality palliative and end-of-life care, as well as a range of programs and services, such as family caregiver benefits and resources.”

Gladu said the federal health minister would need to meet with the provinces over the next half-year to develop a “plan to get consistent access to palliative care for all Canadians.”

“We have to define the services that the federal government is going to cover in palliative care, the levels of training for the different service providers and caregivers, the data collection,” Gladu said, adding the framework should be established within a year and the federal government would be making transfer payments for defined palliative care services.

End-of-life care can include acute, hospice, home, and crisis care, as well as counselling. Options are particularly difficult to access in rural, remote and northern areas, however, the Ontario MP noted.

Life would be better if we faced up to death…. important conversations are put off until too late

Suicide clinics a preserve of middle class A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

A Dignified Death

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

About time too – Doctors ponder ending ban on assisted dying

Why the Assisted Dying Bill should become law in England and Wales

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The Patients’ Association and the Charities should challenge, and define what is happening in the courts… Crawley: NHS “not rationing” hospital treatments and operations.

Denial in the Shires. Of course the Health Boards / Trusts / Commissioners cannot admit to the “R” word. They are “prioritising”, “restricting”, “reducing”, “limiting”, and “excluding”, different services for different people in different post-codes in different years. So no citizen can find out what, consistently, will NOT be available in his or her area of the country. Ask a retired consultant or GP or Nurse, or Physio in an exit interview whether Rationing is happening and they will almost all say yes. But there are no exit interviews… If policy does not conform with delivery, we have a collusion of denial. This is why the health service staff are disengaged. We need honesty in use of the English language before we can progress, so NHSreality calls for the Patients Association and the Charities together to challenge and define  what is happening in the courts… They may find GP commissioners, infuriated at the current “rules of the game“, help them in their case, and want to change them.

Joshua Powling reports for the Crawley Observer Friday 8th December: NHS “not rationing” hospital treatments and operations. 

Hospital operations and treatments for West Sussex patients are not being rationed, according to health chiefs.

Government reforms put clinical commissioning groups (CCGs), which are led by GPs, in charge of planning and buying healthcare from 2013, but all three organisations covering West Sussex are in special measures in part due to financial deficits.

The three CCGs are part of a new regional NHS initiative called clinically effective commissioning, which looks to standardise policies for when patients should undergo certain treatments and procedures.

According to a recent West Sussex Health and Social Care Committee (HASC) report, the aim of the project is to make sure commissioning decisions across the region are consistent, reflect best clinical practice, and represent the most sensible use of resources.

But last Friday James Walsh, vice-chairman of the HASC, asked: “What exactly is being proposed? Is this some form of rationing or delaying treatment?”

He explained that rather than dealing with statistics, they were talking about patients who had problems, many of which interfere with their daily lives.

Geraldine Hoban, accountable officer for the Horsham & Mid Sussex CCG and the Crawley CCG, explained the changes were bringing in more consistent thresholds for treatment.

She said: “We are not doing this for arbitrary reasons or to save money. This is based on up to date clinical evidence.”

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She added: “This is about people having procedures which we do not believe adds the clinical value they need.“It’s not rationing, it’s about adhering to the clinical evidence.”She went on to outline the ‘significant financial challenge’ facing the healthcare system in West Sussex, and how these changes were taking place before ‘we starting making some difficult decisions about difficult services’. They also found that previously some procedures had no formal policy, while in others such as orthopaedics activity the area was a significant outlier.

Other revisions were required were policies did not improve outcomes or patient experience. So far the clinically effective commissioning programme is split into three tranches. The first two have been reviewed by all the CCGs and updated where necessary in line with National Institute for Health and Care Excellence guidance.

Changing the rules of the game


UK government accelerates plans to ration and privatise National Health Service

Whilst being true on the face of it, the article below applies only to England. There is no “National Health Service” and without political recognition of the hidden rationing which happens by post-code lottery, how can we expect politicians to be honest about the need for overt rationing? The political classes, mostly covered by PMI (Private Medical Insurance), and with London’s excellence options, and choice, will ALWAYS ask for more evidence that the Regional Health Services are failing..

Ajanta Silva in the World Socialist Website December 2017 reports: 

UK government accelerates plans to ration and privatise National Health Service

A board meeting of NHS England (NHSE) held at the end of November made clear that a further erosion of services, missing waiting time targets and rationing of vital care across the country is inevitable over the coming years.

This followed Conservative Chancellor Philip Hammond’s autumn budget, which rejected granting an above-inflation funding increase to the NHS that would allow it to manage rising demand for services and to settle a funding crisis created by years of underfunding.

Hammond allocated a derisory rise of £2.8 billon for the NHS over the next three years, under conditions in which the combined deficit of NHS trusts alone stood at £770 million last financial year.

Before the budget, NHSE chief executive Simon Stevens stated that £4 billion extra funding was necessary to maintain the services next year. This sum had been recognized by several health think tanks. Nonetheless, the government will give only £1.6 billion of the allocated £2.8 billion this year, with a meagre £350 million to get through the massive additional pressures brought on by the winter.

A recent report by Oxford and Cambridge Universities and the University of London (UCL)—which revealed the link between savage cuts to the NHS and Social Care provision and tens of thousands of “excess” deaths over the period of austerity—recommends far more funding is required just to stand still. To close the mortality gap, the report concludes that the NHS budget needs to be increased by £6.3 billion each year to 2021.

While the demand for health care is growing rapidly year on year, government increases under current plans amount to 1.1 percent—far below the inflation rate—until 2021. The last seven years have seen the lowest ever funding increase in the history of the NHS. Government is also demanding £26 billion in “efficiency savings” by 2021 from the NHS which is “at the breaking point” according to many clinicians and experts.

Moreover, companies involved in Private Finance Initiatives (PFIs), suck life-blood out of the NHS. Over the last six years they have made a record £831 million pre-tax profit which otherwise would have been spent on patient care.

NHSE board papers declared, “Our current forecast is that—without offsetting reductions in other areas of care—NHS constitution waiting-time standards, in the round, will not be fully funded and met next year.”

This means the target of 92 percent of elective surgeries like hip, knee and cataract to be performed within 18 weeks and the Accident and Emergency (A&E) target of 95 percent patients to be assessed and treated within four hours will go from bad to worse from next year. Currently, only 90 percent of patients are assessed and treated in A&Es within four hours and one in 10 patients wait more than 18 weeks to have their elective operations done. This year Stevens watered down elective surgery targets saying that he was allowing the hospitals to “concentrate on more urgent priorities.”

Health Secretary Jeremy Hunt, who is leading the decimation and privatisation of the NHS, tries to appear as the champion defender of it. However, even as Hunt goes on record that waiting time targets should be upheld, he approves the pitiful budget allocation for the NHS.

The difference of tone between Stevens of NHSE and Hunt is not a case of them being at loggerheads as is generally portrayed. Stevens was appointed as NHS England chief by the Tories not with the intention of improving it but to dismantle and privatize it and to introduce a US-style insurance-based health care system.

Millions of working class patients will have to wait longer to be seen and be treated in Accident and Emergency (A&E) departments, wait longer to have GP appointments, wait months for elective surgery or go without treatment as rationing has become the order of the day. The aim of depriving vital care for patients is to force them to seek treatment in the already thriving private sector promoted by Labour and Conservative-led governments over the last three decades.

As a result of funding cuts more people will die, with the rollout of new medicines and treatment under threat. NHSE warns that guidelines of the National Institute for Health and Care Excellence (NICE) for allowing new drugs and treatments may not be followed unless “they are accompanied by a clear and agreed affordability and workforce assessment at the time they are drawn up.” Such restrictions can only result in patients being refused new drugs for serious medical problems including heart conditions, diabetes and blindness.

Rationing is proceeding apace and to save a mere £141 million a year from the NHS’s £17.4 billion medicines bill, NHSE has decided to stop prescribing 18 medicines under the banner of taking action to “reduce inappropriate prescribing.” Thirteen treatments described as “ineffective” have already gone, with NHSE instructing doctors to further restrict the funding of medications from a list of 36 common conditions. These include treatments for coughs and colds, painkillers and indigestion pills and remedies for dandruff, athlete’s foot and cold sores.

The criminality of these decisions is clear when the NHSE states that some of these are “products which are clinically effective but due to the nature of the product are deemed a low priority for NHS funding.”

Stevens said that the mental health services, planned investment in primary care including GP surgeries and cancer services would be protected. But all these services are already struggling to deliver care safely as a result of years of slashing funds.

Responding to the budget, Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, expressed her disappointment that no money was allocated to General Practices to cope with winter pressures. She said the Chancellor had “overlooked the increased pressures that GPs and our teams will be under, and the role general practice plays in alleviating pressures on our colleagues in secondary care.”

With people suffering long waits on hospital trolleys for treatment, people dying in corridors, and ambulances queuing to deliver patients to A&E departments, the Red Cross described the NHS as being in a “humanitarian crisis” at the start of the year. The government’s response was to downplay the crisis, and to continue slashing services and accelerate the privatization process.

Dozens of A&E units, community hospital, maternity units, GP surgeries, walk-in centres and mental health units have been closed or earmarked for closure across England under the Sustainability and Transformation Plans (STPs). These plans were produced by Clinical Commissioning Groups (CCGs) created under the 2012 Health and Social Care Act. Their aim is not to deliver “care safely,” “efficiently” and “closer to home” as they proclaim, but to balance books at the expense of patient care, services and the workforce. The STPs allow private health care providers to make severe inroads into publicly run services.

Some of the 44 STPs set up in England are now moving towards forming Accountable Care Organizations (ACOs) or Accountable Care Systems (ACS), widely associated with private health care in the US. ACS/ACO allows clinical commissioners and providers to bypass tendering and competition rules.

While starving funds for hospital trusts, the government is forcing the trusts to earn money from private care to fund public services. This has created a two-tier system in hospitals, which goes against the founding principle of the NHS to provide care depending on the “clinical need not the ability to pay.” People who have insurance or money can jump the queues to have elective surgery while the others are languishing weeks, if not months, in waiting lists.

Third way for Scottish GP contracts?

Margaret McCartney opines in the BMJ (2017;359:j5628) : Third way for Scottish GP contracts? 

The proposed Scottish GP contract is clearly intended to shore up doctors and support primary care, and there’s much in it to like. It effectively underwrites premises so that younger GPs won’t be dissuaded from joining a practice that owns its buildings. It includes a minimum income expectation for 40 hour full time GP equivalents, some 20% of whom in Scotland earn less than the proposed minimum of £80 000. It contains impressive statements on the link between workforce morale and patient experience and says that not all patients need a doctor’s expertise to be treated. And help is promised through pharmacists and physiotherapists stepping in and up, as well as nurses and receptionists being trained to do more. It reads as though GPs, taking on the role of expert medical generalist and team leader, will become quasi-salaried. The critical issue for me is this: health boards, under the new contract, will be responsible for managing the team to which the GP provides clinical leadership. Some of this may make sense, and district nurses and health visitors in my area have long been employed by the health board. But it’s also a recipe for fractured relationships. Morale comes, often, from team support. Make the team a group of temporary, ever moving players, and we lose that sustenance and create administrative mess. A team of regular district nurses whose coffee cups are stored in the tearoom, who know the staff and patients, is a different proposition from a team who can’t offer

patients continuity of care (and who don’t know what the octogenarian down the road likes—or what she’s usually like). Another big issue with the contract is its reliance on advance care planning to reduce admissions despite large uncertainties about whether this is possible. My fear is that GPs will continue to fill the gaps created around work that others don’t take on—and that we may have little choice in what that work is. It’s striking, and impressive, how well some other professionals have laid out what they can do and what resources they need to do it. I don’t think that GPs, as a group, have ever articulated this well enough. I can see two futures. One is where GPs see the most complex patients, filling in workforce gaps where needed and doing lots of paperwork. The second is where we become salaried and clearly define what it is that we do and what resources we need. As it stands, this would inevitably lead to waiting lists for GP appointments. What about incorporating another way—a rigorous and bottom-up identification and exclusion of the administrative and system waste that GPs don’t need to do? I have little doubt that the will to make a good contract is there. But, as proposed at present, we retain responsibility without necessarily the resources to discharge it. Margaret McCartney is a general practitioner, Glasgow Follow Margaret on Twitter, @mgtmccartney

The potential for ID cards in accessing health, and progressive redistribution

I have been thinking for some time that the benefits of an Identity Card might outweigh the loss of liberty implicit in their use and existence. We never complained about them during the war, and we are at war once again, albeit with a less tangible foe. By adding a tax code, an appropriate and layered co-payment could be charged. Provided waiting lists were equal and universally low ( Planned Overcapacity of Doctors and Nurses ) there would be few complaints. But the whole system would have to improve, and initially those asked to pay most would probably choose private care until standards rise..

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Philip Collins in the Times 30th June 2017 agrees, albeit for different reasons: Why I’ve come round to the idea of ID cards – Fears about illegal immigration which drove many to vote for Brexit would be answered by a national identity scheme

….Identity cards are compulsory in over 100 countries, many of which — Belgium, Germany, Israel, the Netherlands, Poland, Portugal and Spain, for example — are hardly surveillance tyrannies. It is not true either that all government IT projects have been a disaster: the Passport Office itself is a case in point.
On the cost, it is worth bearing in mind a basic rule of policy — that nobody ever mentions cost who is not already opposed to the policy. Many of those objecting to the expense would be opposed if the scheme came free. The real question is whether the benefits are worth it.

In three ways they may be. The first is improving border control. If the government were able to tell the population, plausibly and confidently, that Britain had effective control of its borders then at least some of the concern over immigration would be mitigated. In 1998 Britain stopped counting people out of the country. Men and women were stationed at airports to count the crowds coming in but we had no idea how many had left. Since 2015 the successor to the e-Borders programme has begun to clear up the mess, based on passenger lists supplied by airlines, rail and ferry companies rather than by passport scanning. An identity card that, where relevant, contained a holder’s visa status would make this process a lot easier.

The second issue is illegal working and benefit claims. Fraudulent claims on the basis of identity are rare but it is all but impossible to get people to believe this. The scale of illegal immigration is another problem for which we lack reliable data. It would be a simple matter to make it illegal to employ anyone who did not present a valid identity card. Likewise, an entitlement to benefits or NHS care would be denied to anyone who could not display the relevant document. It is no more onerous or intrusive than showing a utility bill to get a parking permit. The advantage could be considerable if anti-immigration sentiment, based on the fallacy of benefit tourism, were to fall.

The third problem is terrorism. There is no panacea but identity cards might help. Imagine a list of activities defined as potentially risky or in some way anterior to an act of terrorism. All of them could require the provision of an identity card. For the vast majority of people who hired a white van, for example, the imposition would be meagre and the consequences non-existent. The benefit would be that counter-terrorist officers would get valuable information about the activities of the 23,000 people they are trying to keep tabs on.

The British attitude to such ideas is still rather defined by Passport to Pimlico, the Ealing comedy in which Pimlico asserts its claim to independence because Britain has become too restrictive. The country is in a suspicious mood and insecurity is the political currency of the time. Political leadership now is, at least in part, about reassurance and a sense of control.

It is an illusion that leaving the EU will provide control but the illusion will only be revealed by living it out. There are better things we could do and, strange to say, identity cards is one of them. We are crashing out of the EU because of fears that could have been allayed. We are acting like this is still the world of Willcock v Muckle, as we head backwards into the future.

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