How to find money to save the NHS

This morning was the launch of the Resolution Foundation report, Healthy finances? Options for funding an NHS spending increase – a response to the rumoured government “birthday present” for the NHS as it turns 70 on 5 July 2018.

The audience included party advisers (I spotted a Whatsapp group chat for a party’s comms team), people from various think-tanks, academics (including an Emeritus Professor from Imperial who had a lot to say), and a representative from at least one (non-militant, at least in the room) campaigning group.

The line up:

  • Sarah Wollaston MP, Chair of the Health Select Committee and medic who worked as a GP up until 2010. (Given her generally sensible views, I keep having to remind myself that she’s a Tory).
  • Jon Ashworth MP, Shadow Secretary of State for Health, who has a long history as a Labour professional, including as Special Adviser in the Treasury for Gordon Brown.
  • Ben Page, Chief Executive of Ipsos MORI and fellow of the Academy of Social Sciences.
  • Matt Whittaker, Deputy Director at the Resolution Foundation, who previously worked for the House of Commons Library where he provided stats and economics advice.

The event was chaired by Torsten Bell, Director of the Resolution Foundation, former adviser to Ed Miliband (and, incidentally, architect of the Ed Stone).

Interlude: What is the Resolution Foundation?

The launch was set at Resolution HQ in a bright, wide room, with cosy luxurious seats which wouldn’t be out of place in an up-market indie cinema, so I was curious who they are and how it’s all funded.

Resolution Foundation’s website describes it as “a non-partisan and award-winning think-tank that works to improve the living standards of those in Britain on low to middle incomes.” In their most recent annual report, they defined “low to middle” as those in income deciles 2 to 5, whom they say are overlooked in policy debates. Their focus is on working households.

They receive most of their funding via donations from Resolution Trust, founded by Clive Cowdery with a £50m donation, “believed to be one of the largest endowments for public policy research made in the UK”.

Cowdery made his wealth from “sponsoring insurance vehicles” (an FT article says more) and is also founder of financial services investment firm called (again) Resolution.

Resolution Trust backs Prospect Magazine and, intriguingly, WorkerTech, which seems to be about encouraging alternatives to trade unions for the precarious world of Uberified work. (Here are slides from its launch.)

What did they say on health funding?

All agreed that the NHS needs more funding, so the question is how much more funding and where the money is coming from. The issue was framed as a tug-of-war between Treasury and Jeremy Hunt (with Hunt wanting more money, in case not clear – it’s not always obvious), constrained by a complex parliament and a wish to keep voters happy.

Matt Whitaker took us through some headlines from the Resolution report, emphasising that it was a prediction of what the government was likely to announce rather than what it should do. (Though it sounded very much like advice.)

Borrowing was seen as likely necessary, so long as the total was below 2% of the projected GDP in 2020-21 (to meet a Tory fiscal target). But borrowing alone would not suffice, so some sort of tax raise is almost certainly on the cards – the problem is how to keep keep Tory voters and donors on side, whilst getting it through parliament.

One possibility is increasing National Insurance contributions (or NICs, pronounced “nicks”), which Gordon Brown did when he was chancellor. This is a progressive tax for workers; however, increased NICs was seen by the report authors as “unfair from a generational perspective” since older people who rely more on healthcare don’t pay national insurance (this generational perspective might need some analysis). A solution proposed was to extend NICs to include those above state pension age who are still working.

Increasing income tax could be another way to get the money. LibDems and SNP might support this, and Scotland recently introduced a change to its tax bands meaning some pay more and others pay less tax. Labour, the authors argue, would likely oppose increases for anyone earning under £80k and some Tory MPs might oppose too.

Another approach suggested was to adjust thresholds for (i) when income tax is payable and (ii) the higher rate of payment. Threshold changes were Tory manifesto promises, but the authors suggest a fiddle (p. 24):

“An alternative approach would be to lift the Income Tax thresholds to those pledged in the manifesto in 2020-21, but to freeze both them and the NICs thresholds in the final two years of the parliament. This would of course cost money in 2020-21, but by 2022-23 it would raise £3.7 billion relative to the default of uprating in line with inflation every year.”

Another promising source of funding would come from reversing George Osborne’s 2016 pledge to cut corporation tax by 2020. This tax uncut could provide £5.2 billion in 2020-21 and £5.7 billion by 2022-23. Other political parties would likely support the move and the authors argue (p. 27):

“The Chancellor might also feel emboldened to act given the way in which the estimated costings of the move from 19 per cent to 17 per cent have shifted since George Osborne first announced it.”

Remarkably little was said about Brexit. Will it torpedo all the projections and render the suggestions (sorry, predictions?) unimplementable? The exception was Sarah Wollaston, who noted that she never believed the infamous £350m bus claim; she expressed reasonable worries about the effects Brexit would have.

What might more money mean for mental health?

Although the focus was very much top-level – where’s the money? – speakers did say a little about how it should be spent. For instance, Jon Ashworth quoted numbers on additional doctors and nurses required (it’s thousands), citing a report from IFS – also cited by Sarah Wollaston.

Reassuringly, mental healthcare was mentioned a few times as being important and in need of improvement (though note the history of “warm words”). Ben Page cited public support for increased spending, with mental health being second on the list in an April Ipsos MORI survey of priorities, after Accident and Emergency. Jon Ashworth mentioned improving support for addictions, in particular.

Sarah Wollaston cited the Health and Social Care Committee’s report into integrated care, published yesterday, which discusses detailed contractual changes needed to improve how, e.g., mental healthcare integrates with other services, including discussion of accountable care organisations (ACOs). (Perusing this report just now highlights how difficult it is to have public debates on these issues – it’s technical stuff.)

The coming weeks as we approach July 5th would be a good time to campaign for key specifics on how much money mental healthcare should receive and what it should be spent on. If the NHS received £20 billion more in 2022-23, how much should go to mental health and where?

Vote Labour… but…

I am writing to tender my resignation from the Labour Party and to inform you that I have cancelled my direct debit.

I will continue to vote Labour and support many of its policies and its much-needed shift Left. However, I am opposed to Labour’s approach to Brexit – and I have been patient. I have gradually but now completely lost faith in the leadership.

  1. The Brexit ballot was only advisory – even Farage accepts that.
  2. Leave misused official statistics to lie about £350/week for the NHS.
  3. Leave.eu broke electoral law.
  4. All convincing estimates point to Brexit being a disaster for the economy.
  5. There’s a high risk the Northern Ireland peace process will be harmed too.

Corbyn was too quick to call for triggering article 50. Since then Labour’s approach to Brexit has been confused, putting it mildly.

There is enough evidence now to consider the “will of the people” to be uninformed at best and deliberately manipulated through lies and cheating at worst. Brexit could and should be stopped.

I initially joined Labour in 2010. After a brief spell away, rejoined to vote for Corbyn in 2015. I voted again for Corbyn in 2016. For what it’s worth, I wrote a non-resignation letter nearly two years ago in support of Corbyn. I was hopeful for the party and supported Corbyn despite numerous criticisms.

It’s great to see the membership grow and surely Corbyn deserves praise for enabling this. I’m just not convinced that the Corbyn, McDonnell, and Abbott leadership are electable, and mainstream media bias – though partly responsible – is only a partial explanation.

The problems are too many to enumerate. Salient and illustrative examples include Corbyn refusing to condemn the IRA for its bombing campaign which killed civilians; sharing a platform with SWP members despite being asked and promising not to (given the “Comrade Delta” affair); appearing on a platform alongside a CPGB flag fluttering merrily in the wind; employing a former Sinn Féin staffer. The last straw for me was Corbyn publicly expressing sadness that Ken Livingstone resigned – after all the harm Livingstone has caused recently to Labour.

Given the targets Corbyn’s critics choose, these are clearly misguided decisions, and harm the chances of a democratic socialist government taking power from the Tories.

As I said I will vote Labour and encourage others to do so, to try to get the Tories out so there’s a chance the welfare state can be restored with sanctions and other conditionality stopped; to undo marketisation of the NHS; improve mental health care; and for a range of other important issues. I continue to be an active trade unionist in higher education. But I don’t feel I can be a member of Labour under the current leadership and with its current approach to Brexit.

 

Samaritans

Today Samaritans announced that Esther McVey has left its advisory board.

This is great news, thanks to hard work by groups like Disabled People Against Cuts, Recovery in the Bin, and Black Triangle — groups led by disabled people, mental health service users and survivors. Their investigations revealed McVey’s membership on the board.

These groups should be confident Samaritans is on their side and should be more involved in informing policy.

This episode reveals a need for a review of advisory board membership. Samaritans must win back the trust of disabled people and others who have been harmed by disability (re)assessment policies, “sanctioning”, and cuts to welfare payments.

Additionally, there should be an urgent review of Samaritans’ communications policy. It is not acceptable for the same message to be copied and pasted to multiple people who are concerned about serious conflicts of interest which harm Samaritans’ reputation, potentially affecting donations and most worryingly putting people off calling.

Mental healthcare funding: Letter to Jeremy Corbyn 22 September 2017

Dear Jeremy,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

  1. Who is responsible for decisions made in relation to mental health care budgets?
  2. How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under sec tion 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

  1. The effectiveness of mental healthcare treatments and support, e.g., in comparison to physical health care;
  2. The costs of the various treatments; and
  3. The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Thanks,

Andy

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html

[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html

[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647

[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf

The social model of disability as a case study of social ontology

Ontology is the study of what kinds of entities there are in the world and how they relate to each other. As Effingham (2013, p.1) explains, “You will not find ontologists rummaging around your wardrobe” cataloguing everything they find. Rather, the idea is to conceptualise more broadly the kinds of things there are, including material and abstract “things” like numbers and colours. Social ontology concentrates on entities relevant to social theorising at various levels of explanation from the sub-personal (including unconscious processes like those controlling finger tips on keyboards) to people, their interactions, institutions and beyond.

Debates in social ontology, such as on ontological individualism or emergentism, can be abstract and their relevance hard to grasp. There has even been a case to “rid social sciences of ontology altogether – of all philosophized metaphysics of how the social world is” (Kivinen and Piiroinen, 2007, p.99). This short post tries to make it clearer why it’s important to think about ontology, using an example from disability activism.

In 1975, the Union of the Physically Impaired Against Segregation, a group of disability activists, published a series of fundamental principles which challenged the ontology of disability:

“In our view, it is society which disables physically impaired people. Disability is something imposed on top of our impairments, by the way we are unnecessarily isolated and excluded from full participation in society. Disabled people are therefore an oppressed group in society. […] For us as disabled people it is absolutely vital that we get this question of the cause of disability quite straight, because on the answer depends the crucial matter of where we direct our main energies in the struggle for change. We shall clearly get nowhere if our efforts are chiefly directed not at the cause of our oppression, but instead at one of the symptoms.”

Here a distinction is made between impairment and disability. From this perspective, it doesn’t make sense to say that someone “has a disability”; individual people can have impairments, but it is society which determines whether someone is disabled. Note how the conceptualisation is used to unite people behind one social struggle.

This guide from the activist group Disabled People Against Cuts explains how social barriers cause disability:

“… we live in a society that’s designed by, built for, and used by non disabled people. Because of poor historic attitudes to disabled people […] disabled people were effectively locked away in hospitals, sanatoriums, in care homes or other kinds of institution.

“And that meant that we were excluded from the development of the way our society works, the way our buildings are designed, transport systems, education systems, machines and appliances, leisure activities and the world of work anything really that you care to think about was designed at a time when disabled people weren’t included in the process.

“And that means that all these things don’t work in a way that enables us to use them.

“And the upshot of all that is that in hundreds of different ways, some big, some seemingly small, its difficult for us to take a full part in all kinds of activities that non-disabled people take for granted.

“So we believe that its not our impairments that disable us, it is the social barriers that disable us. Our own impairments we can adapt and/or use aids to overcome, but social barriers are out of our control.”

Whether someone with a particular impairment becomes disabled is also affected by scientific and technological advances. For instance, many people who have a visual impairment wear glasses or contact lenses and wouldn’t consider themselves disabled (see Slorach 2016, p. 37).

A related example is illustrated in this piece on the difference between deaf and Deaf identity:

“To be ‘deaf’ (small d) is to fit into the medical definition of deafness as something to be cured and eradicated. Being deaf means you have a hearing loss, but you choose or don’t feel able to function within the Deaf Community. […] Deaf – with a capital “D” (and occasionally with capital E, A and F too) – is used to refer to people who are culturally Deaf. These people actively use British Sign Language; they see themselves as being culturally Deaf and part of the Deaf community. […] I consider myself to be culturally Deaf; this is my Deaf Identity. […] I don’t see it as a disability – there is nothing I feel I cannot do – rather, I see it as an important aspect of my character that makes and shapes me.”

These conceptualisations of impairment and disability, social barriers, adjustments, aids, deaf and Deaf identity, concern ontology. The debates on these topics occur naturally in social struggles and discussions of social policy, whether or not explicitly articulated as being about ontology. They also have clear implication for how social research is carried out and understood.

References

Effingham, N. (2013). An introduction to ontology. Cambridge: Polity Press.

Kivinen, O., & Piiroinen, T. (2007). Sociologizing Metaphysics and Mind: A Pragmatist Point of View on the Methodology of the Social Science. Human Studies, 30, 97–114.

Slorach, R. (2016). A very capitalist condition: a history and politics of disability. London: Bookmarks Publications.

Disease vs. drug-centred model of psychiatric medication

“The disease-centred model suggests that psychiatric drugs work because they reverse, or partially reverse, the disease or abnormality that gives rise to the symptoms of a particular psychiatric disorder. Thus ‘antipsychotics’ are thought to help to counteract the biological abnormalities that produce the symptoms of psychosis or schizophrenia… the ‘drug-centred’ model suggests that far from correcting an abnormal state, as the disease model suggests, psychiatric drugs induce an abnormal or altered state. Psychiatric drugs are psychoactive substances, like alcohol and heroin… The drug-centred model suggests that the psychoactive effects produced by some drugs can be useful therapeutically in some situations. They don’t do this in the way the disease-centred model suggests by normalising brain function. They do it by creating an abnormal or altered brain state that suppresses or replaces the manifestations of mental and behavioural problems.” 

Blog post by Joanna Moncreiff

Critical realism in 100 words

A summary of an introduction by Margaret Archer and colleagues:

Critical realism is a mess, but there are four themes in the literature. The first is ontological realism: there is some sort of reality out there existing independently of people’s minds. The second is epistemic relativism: our knowledge of reality is conditional on particular contexts, e.g., standpoints, theories, communities, conflicts of interest. The third is judgmental rationality: it is possible to decide whether one theory is better than another at explaining some phenomenon. The fourth is ethical naturalism: although “is” does not imply “ought”, the two are not independent; empirical research can help us determine what values we should hold.

Letter to MP: Mental health funding

Dear Tulip Siddiq,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

(i) Who is responsible for decisions made in relation to mental health care budgets?
(ii) How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under section 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

(i) The effectiveness of mental healthcare treatments and support, in comparison to physical health care;
(ii) The costs of the various treatments; and
(iii) The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Yours sincerely,

Dr Andy Fugard

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html
[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html
[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647
[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf

Mental health services should not be paid by outcomes

The UK government promised a “drive towards an equal response to mental and physical health” in England as part of a five-year plan. Two years later and there is little sign that any progress has been made. Calls to improve mental health services peaked this month when 20 years’ worth of former health secretaries wrote an open letter criticising the government for “warm words” but no action.

There is a consensus that more funding should reach mental health care. But what should be funded and exactly how? From April 2017, payments to adult mental health services must be linked to the quality and outcomes of care provided. National guidance published by NHS England and NHS Improvement claims that doing so will improve care, “ensuring value for money and the best use of limited resources”. But there is worrying evidence that doing so might have little impact and, at worst, actually be harmful to services.

How will payment for performance work?

The money flows are complex. Here is a picture showing key parts of the system.

How funding flows to mental health services.

At the top end is the Treasury, which determines how much money health care receives, alongside all other public services. The Treasury does not directly determine how much money goes to mental health, however – it receives advice from below in the hierarchy so it can calculate a total including all other areas of health.

The money flows on to the Department of Health, NHS England, then Clinical Commissioning Groups which are distributed across the country. They may choose to commission an NHS Foundation Trust. They may also commission a commercial company such as Virgin Care, which recently won a £700m contract.

Payment for performance will be at this final stage between commissioner and provider, and will be agreed locally between them. National guidance on how to implement the approach suggests that the chosen targets should be achievable yet stretching; informed by clinicians and people with experience of mental health problems; avoid creating an adversarial relationship between commissioners and providers; and should be used for the “reinforcement of positive behaviour”.

Oxford Health NHS Foundation Trust is provided as an example in the guidance. A fifth of its income will be linked to performance, which will include ensuring that people “improve their level of functioning”, determined using two measures.

One is the Mental Health Recovery Star, which tracks the progress of people who use mental health services by their ability to manage their mental health and feelings of hopefulness. This measure is completed jointly by people who use mental health services and staff providing care (such as psychiatrists, psychologists or nurses).

The other measure is a checklist rated only by staff which is used to track changes in symptoms such as depression and self-injury. The service has also promised its commissioners that it will ensure people live longer.

Does payment for performance improve services?

A recent systematic review of research found no evidence of impact when payment was linked to health outcomes, such as how long people live – which makes Oxford Health’s choice of outcomes puzzling. There was a small benefit when payment was linked to what services actually did, for example, providing cancer screening or recording whether someone smokes, as this was much easier for services to control than were the consequences of care.

Given national advice to involve people who use mental health services in decisions about outcomes chosen, it is also curious that the recovery star has been chosen. An increasingly influential group who use mental health services, called Recovery in the Bin, singled out the measure as “redundant, unhelpful, and blunt”, and suggested an alternative focusing more on the social causes of mental distress which are often ignored in outcomes.

UnRecovery Star, developed by Recovery in the Bin as an alternative to an outcome measure used in services.
Recovery in the Bin

Putting high-stakes targets on measures tends to mean that the measures stop measuring what they are supposed to measure because people cheat to achieve the targets. The effect is so common that it has a name: Goodhart’s law. For example, ambulance services had a target to get to the patient in eight minutes for life-threatening emergencies. This led to a third of services fiddling their timings towards the target.

There are various subtle ways to cheat outcome measures in mental health, such as by not bothering people who drop out of services with questionnaires to complete. People who drop out are less likely to have benefited from treatment, so excluding their answers from data analyses will improve a service’s apparent outcomes. Given the complexity of people’s experiences and predicaments, reducing them to scores on questionnaires can feel absurd, so it might be easy to justify this kind of gaming if it results in more funding which could improve the care provided. It seems especially easy for measures completed by staff who are under pressure from management to tick the right boxes.

Outcomes measures have an important role to play in understanding and improving the care people receive and should be tracked as part of care, but linking them to payment risks demoralising staff and making the measures meaningless. This seems a dangerous path to take given the state mental health services are in. A better solution might lie further upstream at the Treasury when it decides how much money is available for mental health.The Conversation

This article was originally published on The Conversation. Read the original article.