In 2001 Portugal abolished all criminal penalties for personal possession of drugs, from cannabis to heroin, in an attempt to reduce the number of drug related deaths and the spread of HIV/AIDS. After several years there was tentative discussion about the success of Portugal’s scheme (see for example the Economist’s article of August 2009) and although I don’t intend to add to the debate about the decriminalisation of drug use here, I do hope to discuss one particular element of Portugal’s policy that I find laudable.

Rather than sending drug users to serve jail time, Portugal decided instead to focus efforts and funding on prevention and cure. Campaigns were set up to advertise, for example, the dangers of sharing needles and initiatives were encouraged that offered help to those drug users wishing to wean themselves off the habit. Prioritising treatment over punishment is perhaps a principle that should be adopted more widely in the world of legalised, yet harmful, substances. In Britain there is already some evidence that this is being done with reference to smokers: for example, surgeons treating smokers for smoking-related diseases are strongly encouraging their patients to join the NHS “smokefree” initiative that helps people to quit. Eventually it is possible that calls might even be made for NHS treatment to be refused to smokers who do not sign up to such initiatives, thus using a mixture of carrot and stick to encourage healthier habits. Naturally this raises the question of where to draw the line but there seems to be no reason why the same principles couldn’t be applied in other areas, for example to long term alcohol abusers.

It is clear that the UK and many other countries are moving steadily towards making life more difficult for smokers in particular. Smoking bans in indoor public places are now in place in several countries including China – home to 1/3 of the world’s smokers, and Russia intends to bring in a law to the same effect from 2015. New York has even taken steps to ban smoking outside in public places. In the UK meanwhile it will now be illegal to sell cigarettes from vending machines and there are questions about whether or not smoking should be banned in cars where children are present. Even political leaders, from Obama to Nick Clegg are being encouraged to give up (although whether smoking was simply another convenient stick with which to beat Nick Clegg is open to debate.) These legal changes are welcome in that they do much to protect non-smokers from the effects of passive smoking. However I hope I am not alone in saying that, particularly in a country that is fortunate enough to have a National Health Service, there should be a greater focus on helping current smokers to quit and giving them as many incentives to do so as possible. Only then can we really be sure of doing as much as possible to protect, for example, the children of smokers, who are twice as likely to take up the habit as the children of non-smokers. A radical overhaul in the NHS treatment of smokers alongside increased funding for the Quit campaigns might, in this way, be a step in the right direction to achieve that mixture of incentive and aid.

Last night thousands of viewers watched as “Spanish Flu” swept through Downton Abbey, taking the life of one of its residents. With no antibiotics, the effects of the 1918-1920 flu epidemic were devastating as approximately 25-30% of the world population was infected and 40 million people, mostly between the ages of 20 and 40, were killed.  Although channelled through the medium of ITV drama, it is nevertheless important to take note of this deadly episode as we reach an important milestone in the history of humankind.

On the 31st October 2011, Danica Camacho’s birth in the Philippines was chosen by UN demographers to officially mark the point at which the world population reached 7 billion.  In some quarters the figure of 7 billion has prompted renewed interest in the Malthusian argument for positive population control. See, for example, an article published in The Scotsman in which Professor Wilmut controversially argues that to prevent continuing exponential population growth, we need to start impressing upon younger generations their social responsibility to limit the number of children they have.  Arguments like this for positive population control might be flawed because they tend to only have a narrow application in comparably wealthier and developed nations but, nevertheless, Malthus and others like him are right to seek ways to avoid the alternative: namely negative population control (large-scale death through overpopulation either due to lack of resources or contagious disease).

With increasingly densely populated areas the potential for wiping out large sections of society through the rapid spread of disease are extremely worrying. The effects that poor sanitation, cramped conditions and exponentially rising birth rates can have on the spread of disease are well known: the initiative to eradicate polio for example is faltering in Pakistan and parts of Africa where the disease seems to be spreading faster than children can be vaccinated.  However, the scares over bird flu and swine flu, coupled with a worrying increase in resistance to antibiotics  and very few new antibiotic families to combat this, show that it is not just the “developing” world that may increasingly struggle with disease control. It is clear therefore  that national governments and international organisations need to work together in order to make sure that a growing population does not necessarily mean higher incidents of infectious diseases that end in large loss of life.

The best solutions for tackling this problem remain to be seen but could for example involve internationally agreed emergency measures which shut down global travel quickly and effectively.  Alternatively initiatives to spread a country’s population more evenly through its territory might be required by ensuring that investment goes into several centres of development rather than just one or two. Either way it is crucial that NGOs, governments, medical communities and international organisations offer suggestions for tackling a security issue that won’t always obey the boundaries of nation states, and could be the source of several national and international emergencies if not carefully addressed.

In any such reallocation, beneficiaries are likely to conclude that the new version is fairer, whereas anyone losing out will prefer the old version. The Yorkshire Evening Post quotes Maureen Idle of Leeds Hospital Alert as saying “If the money has been given in the first place then there’s clearly an acknowledgement that it’s needed.”

The precise change causing the fuss is a reduction in the “Health Inequalities Weight” from 15 per cent to 10 per cent. Labour North online have made a full table available, although I couldn’t find Tower Hamlets in it when I looked this morning.  It shows  11 PCTs, all in the North of England, due to receive a smaller allocation than if the weight used by the last Labour government were continued. The remaining PCTs in the table receive an increase. This reduction in weight to two-thirds of its previous value means that however much areas decry the reduction in the reallocation, twice as much is still being taken from the “wealthier” areas to fund the “poorer”.  The reports are only talking about one aspect of the overall funding. By reducing the health inequalities share from 15 per cent to 10 per cent, the share devoted to everything else rises from 85 per cent to 90 per cent. By concentrating on a single aspect, some PCTs can be persuaded that their overall allocations have been cut when they are in fact rising. Most overall changes are considerably smaller than any change to a single aspect, since “pace of change policy” is designed to keep any overall change within constraints.

In this case, much of the problem lies in the over-complexity of the funding formula. The justification is on the basis of need rather than ability to pay. Reallocation, a 10 per cent weighting to redress health inequalities, is not because areas are poorer but because they are supposedly less healthy. The difference is important. The National Health Service is there to treat people freely at the point of delivery. Short of recourse to private medicine, there is no option for the wealthier to contribute more to their own treatment. Differences in per-person funding may be justified on grounds of need but not on grounds of income.

This note is too short for a comprehensive analysis of how the formula operates. An interested reader may refer to the Department of Health description and a spreadsheet setting out the calculations. The particular part of the formula currently at issue concerns Disability-Free Life Expectancy (DFLE). That part of the funding is based on estimates of the years less than seventy that people may expect to live without disability. Seventy was an apparently arbitrary choice. Had it been 69, 75, 80 or 100, the allocations would have been different again. ACRA, the committee that devised this version of the formula, felt that the pre-2008 version

“did not adequately address the objective of contributing to the reduction in avoidable health inequalities.” (Resource Allocation: Weighted Capitation Formula, page 10.)

Rather than address the oddities and over-complications in their existing formula, they added this extra component.  Already the formula considered income deprivation, standardized mortality ratios, limiting long-term illness rates, which might be thought to relate closely to DFLE, but these cannot have produced the desired effect. A detailed delve into the calculation spreadsheet will also reveal rates of low-birth-weight, proportions with no qualifications, numbers of armed forces, prisoners and asylum seekers, house prices, ethnic minority proportions, fertility rates and diabetes prevalence. The result is not an allocation that people can tell to be right but only one that they cannot tell to be wrong.

Professor Mervyn Stone, a previous Civitas author on this very subject, advocates a survey of health needs rather than dependence on a plethora of variables that are assumed to be good for predicting them.  The current system has been designed to include political levers, of which adjusting the “health inequalities weight” is an example. If we do not want political influence on the funding, the answers are to simplify the formula to the point where anyone can understand it and include only directly relevant information, such as population and measurable health need. To anyone worried that their allocation is being diverted somewhere richer, I offer the consolations that the smoothing arrangements will prevent the cut reaching them, they still receive twice as much in diversions from areas with a longer disability-free life expectancy, and what they lose by DFLE they should pick up by mortality ratios or income deprivation. I cannot offer the consolation that they are guaranteed an equitable share of PCT funding. Even if I could define fair, I would not use a formula like this to apply it.

One of the key criticisms outlined was that the reforms follow a long line of centrally-driven initiatives that “move the chairs” in NHS commissionning, without fundamentally altering lines of accountability. GP consortia fundamentally will be statutory bodies placed in a hierarchical framework reporting first and foremost to Whitehall, and not to patients or the public; just as with PCTs.  The difference – and, the Government hopes the key difference that will lead to a step change in the quality of commissioning – is that consortia will be led by clinicians, not managers (or ‘bureaucrats’ as Cameron et al. prefer to badge them).

But the reality is the central grip over commissioning will be retained, through the NHS Commissioning Board.  Today, the Health Bill confirms this, stating, for example, that:

• The NHS Commissioning Board can sack a GP consortium’s accountable officer, or disband the consortium altogether if it underperforms.
• The board can vary the area a consortium covers, force it to take on additional practices, or remove practices from it.
• The board can strip consortia of any functions it wishes if they underperform.
• The board can top-slice consortia funding to create contingency funds.
• Consortia performance will be assessed annually and published by the NHS Commissioning Board.

This creates significant potential for any local action by consortia to be constrained.

Given that the DH has, also today, announced some 130 performance indicators for PCT clusters/GP consortia in the transition, there is, is there not, a very real possibility that the next three years is spent performing less of a ‘liberation’, more of a reinvention of the wheel?  Sir David Varney, former head of public service transformation for Gordon Brown, documents the big risks involved in the plans, in an essay for Civitas today.

Lansley would be better off pursuing a course of commissioning reform that would, instead, transfer accountability to the patient and taxpayer.

We are among ‘generations of women in crisis’ reveals a women-only mental health charity in receipt of some government funding but ‘desperately needing more’.   A closer look at Platform 51’s latest report, Women Like Me: supporting wellbeing in girls and women, suggests there’s little escaping their criteria for concern if you’ve got two pretty average X-chromosomes and managed to survive the first year or so of puberty.  Congratulations! Your mental health will ‘inevitably affect children and families’, not to mention ‘leave communities and wider society poorer.’  I thought Michel Foucault’s ship of fools had sailed; but, clearly I’ve been laboring under a misapprehension – us girls are all back in the same boat.

The resultant hysteria, fortunately confined to their 24-page report, was inevitable given that ‘mild’ and ‘moderate’ mental health problems, ranging from feeling sad and tearful, to eating disorders, had been merged.  Expanding these measures is much like squeezing into skinny jeans post-pregnancy: unless you’re Claudia Schiffer, it doesn’t yield positive results.  The range, scale and frequency of mental health problems displayed in any one individual are due collective review; but, the problem with clumping mild and moderate classifications together is that you lose sight of the serious amongst the manageable.

Similarly, in a review of women’s mental health problems, age matters.  Platform 51’s research respondents were grouped according to age (12 to 17 years, 18 to 24 years, 25 to 44 years, 45 to 54 years, 55 to 64 year and 65 years +), but this never translated into print.   Denied our development through adolescence, young adulthood and beyond, we are just ‘women’ – listless and directionless.  Taken individually, many mild mental health problems may, in light of age, be considered quite natural.  Support, either professional or personal, may be needed, but it will be within the context of ‘growing up’.  A girl whose self-image is momentarily upset upon the arrival of a couple of teenage pimples in the company of a few attractive school boys might be advised to buy a bottle of Clearasil and stick it out.   Per contra, a woman whose persistent skin problems shattered her self and social confidence may need more sustained and professional support.  In the moment of their anxiety, whether it lasts a week or many years, low self-esteem weighs heavily on both minds; yet, in reality, its management differs vastly and as such should be considered separately.  This is not to suggest mental health problems in adolescence are always fleeting, but rather, stages of development are symptomatic of recurring themes and that against this backdrop, the significance of individual mental health problems will be considered differently.

Raising the profile of good mental health is important, but we shouldn’t undermine female development in the process, nor should it come at the expense of creating new cases.

Despite a few significant contradictions (like n administrative cap on commissioners or including in the ‘liberation’ of foundation trust hospitals new powers for the Secretary of State to demand information from them), there is much to applaud.  By and large, Lansley gets it: that for the NHS to meet its productivity challenge it will need competitive challenge from new providers with new ideas.

And so, the consultation response is explicit about the need to create a competitive ‘social market’ in the NHS, through the principles of any willing provider and impartial commissioning; and through the extension of patient choice.  Recognising, also, the fact that markets in public services, typically, are only as good as the regulatory framework they are placed in, much attention is paid to reforming Monitor, reconfigured as an economic regulator, with the function of supporting continuity of vital services, yes, but also promoting competition.  It will have teeth: including the power to fine providers that indulge in anti-competitive practice, and the power to direct commissioners to open up markets.

There is also a big emphasis on rolling back the ability of the Secretary of State to micromanage, with additional freedoms for foundation trusts (in essence, Monitor’s compliance regime being dropped, with responsibility passed onto FT governors) and the removal of the Secretary of State’s general power of direction over NHS bodies (as well as a ‘duty’ to maximise autonomy).  Finally, recognising the power of published information in driving performance, there is a concerted and long-overdue effort to provide for a comprehensive set of indicators on clinical performance (via the NHS Outcomes Framework and NICE quality standards).

But then it all becomes a bit of a dog’s breakfast.  One word, commissioning.  All PCTs – the current geographically-based commissioners of care in the NHS, in charge of how the NHS budget is spent in 151 regions of England – are being abolished in 2013, to be replaced by consortia of general practice (of which every general practice in the country must be a member).  Now, there is nothing wrong with the aim of greater clinical involvement in commissioning: it is a key weakness in PCTs.  PCTs, too, have by and large not done a great job (in some cases to put it mildly).

But what is problematic is mandating that all PCTs be abolished across the country, by 2013, in favour of organisations by and large starting from scratch.  If you need an idea of how difficult this will be, and how risky it will be at a time when the NHS finances will be squeezed like no other time in its history, look no further than the Government’s own Operating Framework for the NHS in England 2011/12.  ‘This is a broad and complex agenda… I do not underestimate the scale of what lies ahead’, says Sir David Nicholson, NHS Chief Executive, in the introduction.

The problem, really, is twofold.  One, as the Operating Framework well recognises, there is a very real risk of a loss of financial control in transition – either as attention is diverted to putting in place new structures and systems, or as things fall through gaps in organisational responsibilities.  In order to deal with this, then, ‘a tight grip on finances is required’ (Operating Framework words).  This, in plain English, means a tight central grip on what commissioners are doing, and how they are spending their money.  PCTs are being herded into larger clusters to manage their demise (not good news if you look at the past evidence of PCT mergers on performance).   In reality they will be little more than local enforcers of the DH; as evidenced by the ‘reform’ framework they are to be assessed against.  The new NHS Commissioning Board, supposedly the vehicle for liberating commissioning, is to be headed up by none other than Sir David Nicholson himself: more of an old-skool ‘command and controller’ than a ‘liberator’ in the Lansley mode.  And QIPP – the DH’s programme for efficiency savings –the first thing new GP consortia are to be engaged with during the transition, is earmarked for ‘tighter grip’.   The language of the Operating Framework, at times, could not be more different than the White Paper response.

The second point is that, with such wholesale change, it is very unlikely that you’ll see too much of the new competitive impulse that Lansley has correctly identified as a big route out of the NHS’s productivity dilemma.  Why?  Because this requires strong commissioning, not the entire commissioning system being in flux.  It is no accident that the number of tenders issued by PCTs has dropped off sharply since the publication of the White Paper.  And neither is it enough to simply rely on the potential of expanding patient choice; or, for that matter, introducing competition law.  The latter won’t be properly operational until at least 2013.  And, for the former to be effective, it requires alternative options; i.e. new entrants.  It is naive to expect private and voluntary sector organisations, that need to justify their existence, to jump into a politically uncertain market without any guarantee of income and rely on GPs offering patients an impartial choice.  (This is not to mention potential difficulties with the BMA’s stance on competition, and the impact of GP’s having clear provider interests.)

The biggest concern, however, is this: that once we get to the point where GP consortia are operational, all but the most entrepreneurial and trailblazing will be subsumed in the very same centralised, restrictive and unsupportive structure as currently besets PCTs.  And then the NHS truly will be stuck with regard to driving productivity: waiting lists will have returned and care will be rationed.

Let’s be clear, I’m not taking issue with GPs being involved in, or leading, commissioning organisations, but with the way in which this reform is being advanced.  To start with, as the recent Civitas publication Refusing Treatment showed, there is much that could be done to make the market in the NHS more effective without significant structural change (including many of the measures mentioned in the opening paragraphs of this blog).

More widely, while some (or even many) GP consortia may well do a better job than PCTs, it is highly unlikely that all GP consortia will do a better job than the best PCTs: organisations should be assessed by their worth, rather than political imperative.  It would be, in essence, far better to lead reform on a human scale: allowing the undertaking of the small-scale experiment, the watching of results, the mimicking of what works and the discarding of what doesn’t.

What might this entail for commissioning reform? First, take the shackles off PCTs and assess commissioners by the outcomes they achieve, not processes followed. Second, enable entrepreneurial GPs (such as the 52 GP “pathfinders”) and other organisations to take over PCTs following a rules-based procedure and failure regime, not central mandate. Third, allow commissioning organisations to change organisational form and governance structures, including to mutuals or cooperatives. Fourth, work towards a system where patients could choose who they want to commission their health care, rather than the state deciding it for them.

With such an approach the NHS could build on the best of what currently exists, and focus on what it should be doing: improving quality and driving productivity.