Julia Manning: Notes on a scandal – how the Staffordshire public rose up to seek for justice

Julia Manning is Chief Executive of 2020Health. Follow Julia on Twitter.

In September 2007, Mrs Bella Bailey was admitted to Mid-Staffordshire NHS Hospital Trust. She was ill, but not dying. After the first few days her family were so shocked at her treatment and the neglect of other in-patients they started a 24 hour vigil by Mrs Bailey’s bedside. Despite this constant watch, after eight weeks Mrs Bailey had a fall in the hospital and was given a massive overdose of blood thinner by mistake. She died on November 8^th 2007. Julie Bailey, her daughter, was sure that what she had witnessed were not isolated incidents. Julie wrote to the local press, asking whether other families had had similar experiences.

Over 40 people contacted her straight away and out of their shared experiences they formed a campaign group called ‘Cure the NHS’. After their second meeting, Julie wrote a six page letter to the (then) Healthcare Commission (HCC) (since replaced by the Care Quality Commission, CQC) outlining her mother’s experience, detailing other occurrences of neglect and a list of 66 examples of poor care that she and the other families had experienced. The HCC launched their investigation in May 2008 having realised that the hospital had unusually high death rates. The first result of this investigation was to demand better staffing in A&E, but this didn’t happen until October 2008. The HCC published their full report in March 2009, just days after mid-Staffs Hospital Chief Executive had been suspended and Chairman had resigned. Alan Johnson, the then Health Secretary apologised and launched two separate investigations. At his visit to the hospital days later he claimed that Mid-Staffordshire Hospital experiences were an ‘isolated case’.

Later that same month the Patients Association joined Cure the NHS to launch an online petition calling for a public inquiry into what went wrong at the hospital, backed by local MPs David Kidney and Bill Cash and later supported by David Cameron.  The two investigations quickly reported back and showed that although things were improving, there were still issues around staffing and ability to use equipment. By then the HC had become the CQC and the latter announced they would visit the hospital every three months to check on progress.

Julia Manning: Politicians must start being honest about the NHS and social care. Neither are fit for purpose.

Julia Manning is Chief Executive of 2020Health.

In the ‘Emperor’s new clothes’, everyone from the Emperor to his ministers to the townsfolk, not wanting to appear stupid, go along with the pretence that the Emperor’s new suit is fabulous. It takes a child to blurt out the truth that there is nothing there, but even then the Emperor keeps up the charade.

The question for the NHS in 2013 is whether our leaders will continue their collective denial that the NHS and Local Authorities cannot cope with current demand? The 1948 NHS emerged into a very different country to that of 2013. TB, diphtheria, scarlet fever, pneumonia and syphilis were the big challenges. No one bothered the doctor unless they really had to. There were few drugs to offer (salicylates for rheumatic fever, digoxin for heart disease, sulphonamides and penicillin) and giving bed rest was a major function of hospitals. There were more beds for the mentally ill than all other general hospital beds put together, and a fundamental part of the NHS Act gave the government executive control of all hospitals to allow effective planning.

The original aims of the NHS were to be a comprehensive service, available to all, free at the time of need and administered by centrally appointed, not elected, bodies. It was a transformational approach that pooled risk and dramatically reduced health inequalities. Over time, the comprehensive promise of the NHS has meant that its remit has expanded exponentially as new treatments have been developed (with new medicines and approaches keeping millions of people out of hospitals). Despite this the NHS has remained pretty inclusive but some controversial rationing has developed, based either on age, behaviour (e.g. requirement to stop smoking before surgery) or ‘low therapeutic value’ of a treatment. Charges were brought in after three years for some items such as eye glasses, dentistry and prescriptions and over time certain medicines have become unavailable on prescription, and many hospitals have become self-governing Trusts. The original NHS budget was about 3% of GDP; today it is about 9%.

Julia Manning: More can — and should — be done about unplanned pregnancy

Julia Manning is Chief Executive of 2020Health.

On the eve of the most famous unplanned pregnancy of all time (unplanned by the parents, at any rate), 2020health has supported the Cross-Party Inquiry into Unplanned Pregnancy. Unintentional conception still happens – to knowledgeable doctors, to articulate teenagers, to wives of Prime Ministers – not the usual stereotypes.

Newsnight’s Allegra Stratton yesterday covered the nub of the problem – and it is most definitely a problem – which is why, in a country where contraception is free and the pressures on the NHS unsustainable, the number of abortions is still rising. We felt this review was an eminently sensible way to look at just what more can be done.

There were many striking findings that I hope will influence policy makers, two in particular I want to mention here. The first was just how much young people, especially teenage girls, want relationship education. Not sex education. Relationship education. In a society where teenage sexual activity is considered normal, where adults no longer protect children from pornography, where not enough parents give their teens emotional support, where airbrushed images leave children desperately insecure that they are not ‘normal’, young people – especially girls - are feeling confused, defenceless, anxious and exploited.

Julia Manning: Pills and power: why access to contraception isn’t enough

Julia Manning is Chief Executive of 2020Health. 

On Wednesday, a huge international summit hosted by Melinda Gates and DfiD will take place with the focus on access to contraception. I went to Kenya 2 weeks ago, funded by the Gates Foundation, to look at women's health. Whilst I support this call for access, if we don't address the culture in which teenage girls live in these developing nations we are giving them pills without power. This is the message of the feature below.

Winnie was 13 and had been through the “Healthy Choices” programme supported by the US based Centre for Disease Control satellite that is based in Kisumu County, Kenya. The programme covered the usual health and lifestyle issues with a strong emphasis on teaching girls in their final year of primary school how to resist pressure to have sex, and how ‘bad company’ should be avoided. Winnie said there had been a lot of emphasis on bad company, which is sound stuff, but much harder to put into practice when your relations are the ‘bad company’, or you live without the street lighting that helps you spot it approaching or in a society that still has so many sex-based customs. The global call for access to contraception that will be made on Wednesday is valiant, but it will be an empty promise of power if we don't change the culture.

I was in Kenya 2 weeks ago on a visit with the International Reporting Project, an organisation housed by Johns Hopkins University with this trip funded by the Bill and Melinda Gates Foundation to specifically look at women’s health. The Gate’s Foundation has decided that universal access to free contraception is now a key goal. The Kisumu based CDC team had brought us to this school in Kibuye as part of a two-day whistle-stop tour into which they had packed rural home visits, a hospital tour and patient interviews as well as the primary school call.

Julia Manning: A mixed bag of a Queen's Speech

Julia Manning is Chief Executive of 2020Health.

The vision of 2020health is to create a healthy society. Our response to the Queen’s Speech is to test its measures with our six criteria.  Are they likely to -

• Improve health and mental health outcomes?

• Stimulate personal and private investment in health and social care or opportunities for job creation? Is this good for our economic health?

• Promote information and education to encourage good choices?

• Help older people?

• Reduce inequity, encourage caring and enable strong families?

• Help other countries? Have they worked in other countries?

Economic and personal health go hand-in-hand. You cannot have a healthy society without a healthy economy, and overall we are concerned that this speech lacked the radical ideas necessary to create both jobs and well-being.

Julia Manning: Adopting elements of the American healthcare system is essential for the NHS to save hundreds of millions of pounds

Julia Manning is Chief Executive of 2020Health.

The Veteran’s Health Association (VHA) is a major part of the Department of Veterans Affairs in the USA, which delivers federal benefits and patient care to veterans of the armed forces.  Its mission is “to keep patients healthy”, and to that end, it employs 225,000 staff in 153 hospitals and a number of other centres, delivering healthcare services to about 23 million veterans. In 2010, the VHA’s annual budget for medical care was £30 billion. In 2004, a RAND corporation study noted that the VHA was superior when compared to other American healthcare systems in 294 measures of quality. It is a shining example of universal coverage that has been able to deliver high quality healthcare and value for money. On these figures, if they were running the NHS, the cost to the Exchequer would be just £81bn, a reduction of 26% on current spending.

2020health today launches its latest report: ‘Telehealth: What can the NHS learn from experience at the US Veterans Health Administration’. As debates still rage about Obamacare, and with the US traditionally held up for derision as having a "no credit card, no healthcare" system, the VHA has transformed, spending the last ten to fifteen years implementing Care Coordination with Home Telehealth as an integral element to improve veterans' healthcare, providing “the right care in the right place at the right time.”  The initial purpose of the programme was the vigorous control of chronic conditions and post-traumatic stress disorder (PTSD), but it has now been expanded to primary prevention of the above conditions, with for example, obesity management programmes.

Julia Manning: The elderly need love, not rights

Julia Manning is Chief Executive of 2020Health.

Shoddy, pitiful care for the elderly and failing care homes are back in the papers today, being flagged up by a team of Telegraph journos (Emily Gosden, Tim Ross, Martin Beckford and Richard Alleyne). It's understandable that the challenges that this neglect and inadequate care raises are put in terms of 'human rights'. However, listening to the coverage this morning I found myself wondering about whether we have the correct narrative.

It seems to me that if we immediately put the case in terms of 'rights' then we lose the essence of what is going wrong. And the best way I can think of to describe this essence is love. Because an absence or opposite of love is not hate, but indifference. And indifference is at the heart of the problem we now face. Too many of us think that caring for the elderly is someone else's job. Whether it's been a sub-conscious abdication of personal responsibility to the Social Services, a weak-willed acceptance of State-dependency or deliberate elder neglect the causes, or even the causes of the causes, need urgent exposure.

Julia Manning: The Prime Minister’s changes to the Health Bill - at a glance

Julia Manning is Chief Executive of 2020Health.

Past	Present	Comment
Commissioning would be GP led in ‘GP Commissioning Consortia’.	Name change - Commissioning will be undertaken by ‘Clinical Commissioning Consortia’.	We welcome this change in terminology – the commissioning term should have been more inclusive.
GPs could decide who would be on their Commissioning board.	Loss of freedom and primary care focus - They have been told to include a hospital doctor and nurse.	This is a backwards step. A major point of the Bill was to put the planning and buying of services into the hands of frontline, community staff who could relocate services from the local hospital when indicated. This will hamper moving care into the community.
No formal care pathway planning design.	Formalising pathway design - Introduction of clinical ‘Senates’ where clinical staff can come together to plan integrated care.	We welcome this and had called for a formal structure to allow planning of care pathways – this is where hospital staff should be included.
All GPs had to have their consortia ready by 2013 and PCTs would disappear.	No deadline - Local commissioning will only proceed when the GPs are ready. Much more like fund-holding situation.	PCTs have already been downsized and aggregated. Looks like they – and the overarching ‘clusters’ that have been formed, might be with us for some time. This is a very confused picture. However conscripts never did make good volunteers.
Any Willing Provider – more competition welcomed and the regulator Monitor having a duty to promote it.	Competition remains - Any Qualified Provider (name change had already occurred) will remain but not promoted and Monitor will ensure competition is there to ensure quality rises. No ‘volume’ contracts will be given and re-emphasis on only ‘best’ providers being in the field.	There were some positive words about the contribution of the independent sector. They will have to contribute to the costs of NHS training. It will be harder for new entries with no guaranteed income. ‘Best’ providers will have more consequences for NHS than independent sector.
Monitor as an economic regulator	Monitor will also now have a duty to ensure integration.	We think Monitor’s position is becoming confused. We think it should merge with CQC and they should oversee finance and quality together. Integration relies largely on clinical freedom and payment mechanisms.
Reducing Management	Now we have DH + National Commissioning Board + Public Health England + Commissioning Consortia + PCTs + Clusters + SHAs + Senates	Liberating the NHS from bureaucracy has gone out of the window.
Health and Wellbeing Boards	Here to stay	An important part of joining up health and social care.
(18 week waiting time Target & A&E target)	The Bill rhetoric was outcomes not Targets. Outcomes now in addition to not instead of these Targets.	It’s political suicide to get rid of waiting times targets so this is a positive step with the added value of focus on outcomes.
Ring-fenced spending	The spending will increase & by prioritising public health demand will be contained.	With a 50% increase in over 65’s in the next 20 years, nothing is going to stop rising demand. We have to allow more co-payments on top of a universal, basic NHS service.

Julia Manning: The right policies on clinical research can power economic growth

Julia Manning is Chief Executive of 2020Health.

Following the Prime Minister’s Downing Street Business Summit yesterday it can’t be a complete coincidence that Sir Michael Rawlins (Chairman of NICE and Senior Fellow of the Academy of Medical Sciences) review of the regulation and governance of UK clinical research was published today.  Scientific research is central to economic growth in the UK. Although it fits in neatly with the Conservative’s pre-election plans to have a bonfire of regulation, it was actually instigated by Andy Burnham when he was at the Department of Health in March 2010.  It was a response to the fact that the UK global share of clinical trials had fallen from 6% in 2002 to 2% in 2007 (and is now lower still) and successive reports had detailed just how much regulation was strangling the setting up of clinical trials. My report on Emerging Technologies published in October last year included a one page chart on page 80 on just how many hurdles researchers have to jump before they can conduct a clinical trial in the UK.

In 2007, the UK pharmaceutical industry alone invested £4.2 billion in R&D, employed 73,000 people and was ranked first for its contribution to the UK’s trade surplus (£4.3Bn). At a time when we are battling the trend for research going East it is vital that we ensure scientific research can flourish here, and having universal NHS provision should make this much easier, as recognised by Sir David Cooksey’s report of 2006.

However streamlining governance is only one part of the equation. There are two other key factors. One is that in order to conduct a medicine trial in the UK we have to already be using the best ‘gold standard’ medicine to compare the new agent against it. For a whole variety of reasons we have fallen behind in the uptake of new medicines in the UK, meaning that when wanting to test a new drug for an improved response, we literally don’t have enough or sometimes any patients on the existing ‘gold standard’ medicines with whom to compare.

Julia Manning: My ten hopes for this afternoon's Health White Paper

Julia Manning is Chief Executive of 2020health.org, a web-based, centre-right think tank for Health and Social Care which uniquely focuses on bottom-up policy development by front line professionals.

Maybe I wasn’t watching, but I can’t remember this much speculation, hype and opinion-mongering around a health white paper as there has been around Andrew Lansley’s first article expected today. So feverish has it been that it wouldn’t be surprising that a new condition – repetitive speculation syndrome – arises. There are two key reasons for this excitement. One is the subject – putting GPs in charge of commissioning up to £80bn worth of NHS services – and the other the context – an NHS that is tasked with finding £20bn of operational savings over the next 4 years in order to meet anticipated demand.

Considering practice-based commissioning (PbC) was pronounced dead last year by many of its creators, in true Doctor Who style, ‘regeneration’ is ensuing but the next death – in the form of the failure of a universal GP commissioning strategy - is already a source of conjecture in some quarters.

This is somewhat premature, possibly immature. Do we really think things should stay as they are?! Primary Care Trusts (PCTs) reluctant to test new pathways that could benefit patients; ‘Payment by Results’ (PbR) meaning power remaining with the big Hospital Trusts and GPs only gaining bureaucracy not control to improve patient care? And how can we predict a crash before we know how the track is going to be laid?  We won’t have long before the White Paper reveals its particulars, but there are certain details that we believe are vital for success. Mapping the ground over which the tracks should and should not be laid and the essential signalling that should be incorporated, I came up with ten essentials.

1. Say what you mean
And the first has to be ditching the word ‘commissioning’ – or at least agree precisely on what we mean GPs should do. “Practice-based”: yes, simple, and in the interests of continuity should be retained. ‘Commissioning’ – well – what are we talking about? Buying, selling, planning, strategy, monitoring, evaluating, performance management, specialism appraisals, data collection, reconfiguration, IT systems? The successful PbC models we have seen have been where practices have analysed a service or pathway, designed and implemented something more focused and efficient. In other words they have planned and procured successfully. Patients have benefitted and money has been saved. This is precisely what clinical leaders are excited about, but they do not have the capacity to undertake nor should be burdened with all the other roles simply because they can’t do it all and should focus on what they do best – improving care for their patients.

Julia Manning and Pav Kahlon: People should know the real value of their NHS-funded medication

Julia Manning is Chief Executive of 2020health.org, a web-based, centre-right think tank for Health and Social Care which uniquely focuses on bottom-up policy development by front line professionals. Pav Kahlon is a researcher at 2020health.org.

Last week's conference on the Post-Bureaucratic Age (PBA) highlighted the growing need for transparency as a key to reform - in an age where speed of access and choice have revolutionised the services we receive, and attitudes regarding what is normal, what is an essential and what we are rightfully entitled to have inevitably changed.

People expect more and have increasingly become more aggressive in their attitudes towards entitlement. Whether it’s electricity, food or medicine, as a nation we are demanding more of the commodities around us. What once were considered luxuries, greater access has turned into the basics in life and we’ve forgotten the price that has to be paid even for these. Gratitude has lost its cachet and familiarity has led to huge wastage. Yet the evidence is there from the high street that the more conscious people are of how much they are paying for ‘an item’ then the less likely it is to be wasted.

Evidence from other sectors
The mere knowledge that electricity consumption levels were being monitored in houses alongside unit prices was found to highly effective in inducing positive behavioural change by The Centre for Sustainable Energy. The experience of viewing numbers change on the energy display when an electrical appliance was switched on was described as being far more powerful than an educational experience of discussing domestic energy saving measures in a focus group. The idea of transparency and awareness continues to achieve success with other commodities. A report by the Environment Agency suggests that in order to reduce water consumption and help lower UK carbon emissions, households need to invest in water meters. Those who did were made more conscious of how much they were using and in affect typically used at least10% less water than those without the device. 

Julia Manning: The NHS has our money. We all deserve better treatment.

Julia is Director of 2020health.org, a web-based, centre-right Think Tank for Health and Social Care and uniquely focuses on bottom-up policy development by front line professionals.  She also blogs at CentreRight.com.

‘The promise of happiness has created an epidemic of depression’ says Tobias Jones in the first chapter of his brilliant book ‘Utopian Dreams’. It’s not a book about health but his statement could equally apply to feelings about the NHS today. We have been promised so much, firstly by Frank, then Alan M and John, Patsy and now Alan J. We have spent unparalleled sums. Yet we have an NHS that is falling in productivity. We have a crisis in inner-city nursing that means the most vulnerable newborns are getting no attention. And innovative new drugs that save sight or give a few more years of life to those who already know they won’t reach three score years let  alone the extra ten, are denied or delayed leaving anguish and anger instead of hope or healing.

It was to this last betrayal that 2020health turned it’s attention in our latest report, ‘Our health, our money, our say’, available on our website. Now I want to make clear from the outset that I am a realist. No health service in the world can meet the demands of its population; there is an infinite illness burden and finite therapeutic resources. However we believe that Labour’s consultation on ‘top-ups’ is premature as it is partly based on a false premise, which is that there isn’t enough money to pay for new drugs. The consultation doesn’t question the status of non-NHS drugs but asks for opinion on whether to allow them alongside NHS care.

Julia Manning: Vaccinating for the greater good

Julia Manning, Director of 2020health.org, says that discrediting new vaccines such as the MMR risks the lives of more than those who don't take them.

Last week, 2020health.org held a seminar on the crucial role that modern vaccines have to play in the delivery of Public Health in the UK. We heard a story from a Consultant Paediatrician working in South East London about two children who had previously received kidney transplants at the age of two. They had had their first MMR jab but not the booster which is contra-indicated following organ transplants. The children came into contact with the measles virus and caught the disease. Both of them suffered permanent brain damage.

This week, the General Medical Council hearing begins into serious professional misconduct by Dr Andrew Wakefield and two other doctors who published their damaging theory of a link between the MMR vaccination jab and autism in 1998. One of the accusations is that Dr Wakefield did not declare to his hospital Ethics Committee that he was getting money from the Legal Aid Board for advising the parents of autistic children who wanted to pursue compensation in the courts. Only 3 years before in 1995, the uptake rate of the vaccine had reached 95%, the target rate to achieve ‘herd immunity’. This is where the immunity of a sufficient number of individuals in a population is such that infection of one individual will not result in an epidemic. Every parent who declines the MMR jab increases the risk not only to their child of serious disease, but also the risk to many others. It is precisely this herd immunity that is vital to protect people who are immunocompromised, which includes all organ transplant recipients.