David Price

NHS capital expenditure and the private finance initiative-expansion or contraction?

This is the first of four articles on Britains public-private partnership in health carennBefore 1948, building the hospital and community health service was primarily a local government responsibility and new investment depended on local authorities ability to meet the cost of borrowing. The “depressed areas,” which had the worst health status, were inevitably disadvantaged. Investment patterns during the interwar years contributed to the inequitable distribution of the infrastructure, which was, according the official historian of the NHS, a “ramshackle and largely bankrupt edifice.”1 The 1946 act led to the nationalisation of the inherited hospital infrastructure and the centralisation of the responsibility for financing its improvement within the ministry of health. NHS hospital building was to be financed by central government grants and funded out of general taxation and national insurance contributions.nnThe NHS initially made little impact on its inherited infrastructure problems because public sector investment in the postwar years was concentrated on education and housing. Aneurin Bevan, among others, suggested that spending controls could be evaded if hospital boards were allowed to borrow from the market, as they had before the war. But with funding now ultimately paid for out of general taxation, no rationale could be found for allowing boards to borrow at interest rates that would necessarily be higher than those incurred by central government (J Mohan, personal communication). Not until the mid-1950s did a gradual release of funding allow new hospital building in some areas that had a legacy of prewar planning inequities. Even so, the scale of investment fell a long way short of “complete replacement.”2nnThe principle of major hospital investment was finally adopted in the 1962 hospital plan. The plan was the first attempt to modernise the hospital infrastructure as a whole. But it remains unfulfilled, with only a third …

No evidence that patient choice in the NHS saves lives

The Health and Social Care Bill 2011 has been framed to abolish direct parliamentary control and public accountability for the National Health Service (NHS) in England. In the face of enormous public opposition to the Bill, the UK Government stood down the legislative process between April and June, 2011. Prime Minister David Cameron used the temporary pause to advance the case for the Bill and argued “Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.” The study to which Cameron referred was a working paper by Zack Cooper and colleagues. However, contrary to Cooper and colleagues’ claims, their study did not show a causal inverse relation between patient choice and death rates. A statistical association is not the same as causation. As set out by Bradford Hill in his seminal paper, certain factors must be considered when determining whether a statistical association is likely to be causal: ”experiment” or study design, plausibility of intervention and outcomes, strength, consistency, specifi city, coherence, temporality, and quality of data. Cooper and colleagues’ study does not meet scientifi c standards. In the absence of evidence proving that competition improves health, Cooper and colleagues’ work should not be cited as scientifi c evidence in support of choice, competition, or the current market-oriented Health and Social Care Bill 2011. A revised version of the study, published in The Economic Journal, clarifi ed points of detail, but Cooper large comparative studies, one reporting data from two academic institutions and one from a multicentre community-based cohort, both noted—after many adjustments for case-mix and disease risk—substantially improved outcomes after surgery compared with radiation. The community-based analysis also recorded, as did Warde and colleagues, better out comes after either surgery or radiation than after androgen deprivation monotherapy. In both studies, diff erences between treatments were small for men with low-risk disease, and increased progressively as risk rose. Warde and colleagues have provided the strongest evidence to date that androgen deprivation therapy alone for men with high-risk prostate cancer is not adequate. These patients require an aggressive, multimodal approach incorporating prostate-directed local therapy. However, the crucial question—whether the optimum initial strategy should include radiation combined with androgen deprivation therapy, or surgery followed by selective radiation on the basis of pathological fi ndings and early biochemical outcomes— is still open. The defi nitive answer will only come through trials of men with high-risk disease randomly assigned to receive surgery or radiation as an initial treatment.

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of healthcare provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law. Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision. Clauses 1 and 12 of the Bill will dismantle key sections of the 1946 founding legislation of the NHS by repealing the unifying duty from which all other legislative powers and functions flow. This unifying duty is currently laid down in Sections 1 and 3 of the National Health Service Act 2006. It requires the Government to promote a comprehensive health service by providing or securing the provision throughout England of a list of specified NHS services and hospital accommodation in ways that meet all reasonable requirements. Accordingly, since 1948, most NHS hospital and community-based provision has its own facilities and NHS staff. The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area. Experiments with internal and external markets since 1990 have taken place within this overarching geographical framework. The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced. Powers currently exercised by the Secretary of State for Health will be transferred to each CCG, which, in contrast to PCTs, will act in place of, and not on behalf of, the minister. The NHS Commissioning Board will exercise its functions at a distance from the Secretary of State and have oversight of CCGs. These changes will repeal the minister’s core duty to provide or secure provision of specified health services. Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services.

Private finance initiatives during NHS austerity

Allyson Pollock, David Price, and Moritz Liebe believe that ring fencing of private finance initiative payments prioritises investor returns over patient care and call for tighter monitoring and renegotiation

Pancreatic exocrine insufficiency in HIV‐positive patients

We describe the management of a cohort of eight HIV‐positive patients on antiretroviral medication with evidence of pancreatic insufficiency consisting of chronic diarrhoea and a low faecal elastase measurement.

The final frontier: The UK’s new coalition government turns the English National Health Service over to the global health care market

Abstract The authors describe the incremental approach to the marketisation of the English National Health Service (NHS) since the introduction of an ‘internal market’ in 1990 until the 2010 White Paper, ‘Equity and Excellence: Liberating the NHS’, and the subsequent Health and Social Care Bill published in January 2011. The introduction of a competitive market for a universal, tax-financed health system requires fundamental changes in regulation in order that market bureaucracy can be substituted for direct management. The components of reform are insufficiently captured by the framework of hierarchies and networks in new public management theories of decentralisation.

Occult hepatitis B virus coinfection in HIV-positive African migrants to the UK: a point prevalence study.

Occult (surface antigen‐negative/DNA‐positive) hepatitis B virus (HBV) infection is common in areas of the world where HBV is endemic. The main objectives of this study were to determine the prevalence of occult HBV infection in HIV‐infected African migrants to the UK and to determine factors associated with occult coinfection.

HIV-associated fatigue in the era of highly active antiretroviral therapy: novel biological mechanisms?

The aim of the study was to determine the prevalence and risk factors for HIV‐associated fatigue in the era of highly active antiretroviral therapy (HAART).

Developing Independence: The experience of the Lawnmowers Theatre Company

This paper describes an action research project in which the Lawnmowers Theatre Company (a company of performers with learning disabilities) mounted drama clubs and a series of night clubs for people with learning disabilities. The objective of the project was to demonstrate that initiatives involving what might loosely be called drama offer important opportunities for adult education and that night clubs for people with learning disabilities can be effective in providing new opportunities for social contact and also recognition for disability arts. All of these factors, it is argued, are important if people with learning disabilities are to be taken seriously as capable, interesting individuals with something useful to say. The project found high levels of participation and a range of skills acquisition.

Life threatening infections labelled swine flu

Algorithms for remote diagnosis and issue of antiviral drugs are indispensable during a pandemic.1 Their application through the National Pandemic Flu Service to both high and low prevalence areas is, however, controversial, and the lack of specificity in the use of the algorithm has been highlighted by Payne et al and at November’s …