tag:blogger.com,1999:blog-376033522024-03-13T21:43:24.558+00:00Martin McKee's blogTales from a travelling public health professorMartin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.comBlogger118125tag:blogger.com,1999:blog-37603352.post-3150004195129223472020-04-17T09:03:00.011+00:002021-08-26T21:26:27.244+00:00COVID 19 - work in progress<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial; font-size: 12pt;">Like many of us in
public health, I've been rather busy with COVID-19. I thought it might be
useful to bring together what I've been involved in in one place:<o:p></o:p></span></div>
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<span style="font-family: arial;"><br /></span></div>
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<b><span style="font-family: arial; font-size: 12pt;">Papers and letters in scientific
journals:</span></b><br />
<b><span face="" style="font-size: 12pt;"><br /></span></b>
<div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 36pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -36pt;"><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>1)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Lloyd-Sherlock
P, Ebrahim S, Geffen L, McKee M. Bearing the brunt of covid-19: older people in
low and middle income countries. BMJ 2020; 368: m1052</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>2)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Anderson
M, McKee M, Mossialos E. Covid-19 exposes weaknesses in European response to
outbreaks. BMJ 2020;368:m1075</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>3)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Hargreaves
S, Kumar BN, McKee M, Jones L,Veizis A. Europe’s migrant containment policies
threaten the response to covid-19. BMJ 2020; 368: m1213</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>4)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Legido-Quigley
H, Mateos-Garcia JT, Regulez Campos V, Gea-Sanchez M, Muntaner C, McKee M.The
resilience of the Spanish health system against the COVID-19 pandemic.Lancet
Publ Health 2020: doi.org/10.1016/S2468-2667(20)30060-8</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>5)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">McKee
M, Stuckler D. If the world fails to protect the economy, COVID will damage
health not just now but also in the future. Nature Med 2020: DOI:
10.1038/s41591-020-0863-y</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>6)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Murphy
A, Abdi Z, Harirchi I, McKee M, Ahmadnezhad E. Economic sanctions and
Iran’s capacity to respond to COVID-19</a><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">.
Lancet PublHealth 2020: doi.org/10.1016/S2468-2667(20)30083-9</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>7)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Flear
M, de Ruijter A, McKee M. Coronavirus shows how UK must act quickly before
being shut out of Europe’s health protection systems. BMJ 2020; 368:m400</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>8)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Kentikelenis
A, Gabor D, Ortiz I, Stubbs T, McKeeM, Stuckler D. Softening the blow of the
pandemic: will the IMF and WorldBank make things worse? Lancet Global Health
2020: doi.org/10.1016/S2214-109X(20)30135-2</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>9)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Boccia
S, Ricciardi W, McKee M, Cascini F. How the Italian NHS is fighting against the
COVID-19 emergency. Frontiers Public Health 2020: doi: 10.3389/fpubh.2020.00167</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>10)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">McKee
M. A European roadmap out of theCOVID-19 pandemic. BMJ 2020; 369: m1556</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>11)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Douglas
M,Katikireddi SV, Taulbut M, McKee M, McCartney G. How can we protect against
the wider health impacts of the COVID-19 pandemic response? Social distancing
maycause significant adverse effects on health inequalities. BMJ 2020; 369:
m1557</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>12)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Forman
R, Atun R, McKee M, Mossialos E. 12 Lessons Learned from the Management of the
Coronavirus Pandemic. Health Policy 2020;
https://doi.org/10.1016/j.healthpol.2020.05.008</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>13)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Anderson
M, McKee M, Mossialos E. Developing a sustainable exit strategy for
COVID-19: health, economic and public policy implications. J Roy Soc
Med 2020; 113(5): 176–178</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>14)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Sassano
M, McKee M, Ricciardi W, BocciaS. Transmission of infections at large sports gatherings:
a surprising gap inour knowledge Frontiers Public Health 2020; 7: 277</a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>15)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Patel P, Hiam L, Sowemimo A, Devakumar D, McKee M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Ethnicity
and COVID-19</a>. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">BMJ
2020; 369: m2282 </a><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>16)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><span style="color: blue;"><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Clark
A, Jit M, Warren-Gash C, Guthrie B, WangHHX, Mercer SW, Sanderson C, McKee M,
Troeger C, Ong KI, Checchi F,Perel P, Joseph S, Gibbs HP, Banerjee A, Eggo RM,
CMMID COVID-19 working group. Global, regional, and national estimates of
the population at increased risk of severe COVID-19 due to underlying health conditions
in 2020: a modelling study. Lancet Global Health</a> </span>2020; 8: E1003-E1017<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>17)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Oh J, Kavanagh MM, Gottschalk K, Subramanian SV, Shibuya K, Hirschhorn
LR, Alonso C, Torres I, Awoonor-Williams K, Minh HV, Bawah AA, Tran H, Kachur
SP, Sáenz R, Barrios OA, Kwon S, Nam EW, Choi JW, Lee J-K, McKee M, Gostin
LO. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Announcement
of launching the JGHS Commission on COVID-19 Response</a>. J Global Health
Science 2020; 2: e20<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>18)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Roberts CM, Levi M, McKee M, Schilling R, Lim WS, Grocott M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">COVID-19:
a complex multi-system disease</a> Br J Anaesthesia 2020:
DOI:https://doi.org/10.1016/j.bja.2020.06.013<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>19)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Han E, Chiou ST, McKee M, Legido-Quigley H. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">The
resilience of Taiwan's health system to address the COVID-19 pandemic</a>.
EClinicalMedicine. 2020 Jun 27:100437. <o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>20)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Toffolutti V, McKee M, Stuckler D. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Is
theCOVID-19 pandemic turning into a European food crisis?</a> Eur J Publ
Health 2020; doi:10.1093/eurpub/ckaa101<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>21)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->McKee M, Gugushvili A, Koltai J, Stuckler D. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Are
Populist Leaders Creating the Conditions for the Spread of COVID?</a> Int
J Health Pol Management 2021;
10: 511-515.<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>22)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><span style="background: white; color: #333333;">Rajan S, Cylus J, McKee M. </span><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">What
do countries need to do to implement effective ‘find, test, trace, isolate,
support’ systems?</a><span style="background: white; color: #333333;"> J Roy Soc Med 2020; 113: 245-50</span><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>23)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><span style="background: white; color: #333333;">McKee M. England’s <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">PPE
procurement failures must never happen again</a>. BMJ 2020: 370: m2858</span><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>24)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Shanks S, Van Schalkwyk MCI, McKee M.<span style="color: #212121;"> <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Covid-19
exposes the UK’s broken foodsystem</a>. BMJ 2020; 370: m3085</span><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>25)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><span style="background: white;">Gugushvili A, Koltai J, Stuckler D, McKee M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Votes,
populism, and pandemics.</a> Int J Publ Health 2020:
https://doi.org/10.1007/s00038-020-01450-y</span><o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>26)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->McKee M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Learning
from success: how hasHungary responded to the COVID pandemic?</a> GeroScience
2020: https://doi.org/10.1007/s11357-020-00240-x<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>27)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--><span style="background: white;">Vanoni M, McKee M, Bonell C, Semenza J,
Stuckler D. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Using
volunteered geographic information to assess mobility in the COVID-19 pandemic
context</a>: cross-city time series analysis of 41 cities in 22 countries from
March 2nd to 26th 2020. Globalization Health </span>2020 Sep 23;16(1):85.<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>28)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Han E, Tan MMJ, Turk E, Sridhar D, Leung GM, Shibuya K, Asgari N, Oh J,
García-Basteiro AL, Hanefeld J, Cook AR, Hsu LY, Teo YY, Heymann D, Clark H,
McKee M, Legido-Quigley H. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Lessons
learnt from easingCOVID-19 restrictions: an analysis of countries in Asia
Pacific and Europe.</a> Lancet 2020: 396: 1525-1534 <o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>29)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Agius RM, Robertson JFR, Kendrick D, Sewell HF, Stewart M, McKee
M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Covid-19
in the workplace</a>. BMJ 2020; 370: m3577<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>30)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Crozier A, Rajan S, McKee M. <a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Fixing
England’s COVID-19 response: learning from international experience</a>. J Roy
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Medical School, 2021. pp 310-40<o:p></o:p></span></span></p><p class="Pa23" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>61)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Sagan
A, Thomas S, McKee M, Karanikolos M, Azzopardi-Muscat N, de la Mata I,
Figueras J. COVID-9 and health systems resilience: lessons going forwards.
Eurohealth 2020; 26(2): 20-24<o:p></o:p></span></span></p><p class="Pa23" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>62)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Rajan,
S, Cylus J, McKee M. Successful find-test-trace-isolate-support systems:
how to win at snakes and ladders. Eurohealth 2020; 26(2): 34-39.<o:p></o:p></span></span></p><p class="Pa23" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>63)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Karanikolos
M, McKee M. How comparable is covid-19 mortality across countries?
Eurohealth 2020; 26(2): 45-50.<o:p></o:p></span></span></p><p class="Pa23" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>64)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->McKee M. O Międzynarodowych Doświadczeniach COVID-19
[International experience with COVID-19]. Menedizir Zdrowia 2020; 9-19: 24-28 <o:p></o:p></span></span></p><p class="MsoListNumber" style="margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span lang="EN-CA">65)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-CA">McKee M</span><span lang="EN-CA">. Achieving zero covid is not easy, but the alternative is far worse. BMJ
2020;371:m3859<o:p></o:p></span></span></span></p><p class="MsoListNumber" style="margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><a name="_Hlk57374068"><!--[if !supportLists]--><span lang="EN-CA">66)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]-->Alwan,
NA, Burgess RA, Ashworth S, Beale R, Bhadelia N, Bogaert D, Dowd J, Eckerle I,
Goldman LR, Greenhalgh T, Gurdasani D, Hamdy A, Hanage WP, Hodcroft EB, Hyde Z,
Kellam P, Kelly-Irving M, Krammer F, Lipsitch M, McNally A, McKee M,
Nouri A, Pimenta D, Priesemann V, Rutter H, Silver J, Sridhar D, Swanton C,
Walensky RP, Yamey G, Ziauddeen H. Scientific consensus on the COVID-19
pandemic: we need to act now. The Lancet, 2020. 396(10260): p. e71-e72.</a><span lang="EN-CA"><o:p></o:p></span></span></p><p class="MsoListNumber" style="margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span lang="EN-CA">67)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-CA">Gurdasani D, Bear L,
Bogaert D, Burgess RA, Busse R, Cacciola R, Charpak Y, Colbourn T, Drury J,
Friston K, Gallo V, Goldman LR, Greenhalgh T, Hyde Z, Kuppalli K, Majumder MS,
Martin-Moreno JM, McKee M, Michie S, Mossialos E, Nouri A, Pagel C, Pimenta D,
Popescu S, Priesemann V, Rasmussen AL, Reicher S, Ricciardi W, Rice K, Silver
J, Smith TC, Wenham C, West R, Yamey G, Yates C, Ziauddeen H. The UK needs a
sustainable strategy for COVID-19. Lancet. 2020 Nov 9:S0140-6736(20)32350-3.
doi: 10.1016/S0140-6736(20)32350-3.<o:p></o:p></span></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>68)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Gurdasani
D, Alwan NA, Greenhalgh T, Hyde Z, Johnson L, McKee M, Michie S, Prather KA,
Rasmussen SD, Reicher S, Roderick P, Ziauddeen H. School
reopening without robust COVID-19 mitigation risks accelerating the pandemic.
Lancet 2021: https://doi.org/10.1016/
S0140-6736(21)00622-X <o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>69)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Bozorgmehr
K, Jahn R, Stuckler D, McKee M. Free licensing of vaccines to end the COVID-19
crisis. Lancet 2021: /doi.org/10.1016/S0140-6736(21)00467-0<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>70)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Lloyd-Sherlock
P, Kandiyil N M, McKee M, Perianayagam A, Venkatapuram S, Pathare S et
al. Pandemic lessons from India: inappropriate prioritisation for vaccination
BMJ 2021; 373 : n1464<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>71)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Gurdasani
D, Drury J, Greenhalgh T, Griffin S, Haque Z, Hyde Z, Katzourakis A, McKee M,
Michie S, Pagel C, Reicher S, Roberts A, West R, Yates C, Ziauddeen H. Mass
infection is not an option: we must do more to protect our young. Lancet 2021; S0140-6736(21)01589-0.<o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span>72)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]-->Hargreaves
S, Hayward SE, Noori T, McKee M, Kumar B. COVID-19: counting migrants
in. Lancet. 2021; 398: 211-212. <o:p></o:p></span></span></p><p class="MsoListParagraph" style="line-height: normal; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-indent: 0cm;">
</p><p class="MsoListNumber" style="margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: 0cm;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span>73)<span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span><!--[endif]--></span><span>Priesemann
V, Balling R, Bauer S, Beutels P, Valdez AC, Cuschieri S, Czypionka T, Dumpis
U, Glaab E, Grill E, Hotulainen P, Iftekhar EN, Krutzinna J, Lionis C, Machado
H, Martins C, McKee M, Pavlakis GN, Perc M, Petelos E, Pickersgill M,
Prainsack B, Rocklöv J, Schernhammer E, Szczurek E, Tsiodras S, Van Gucht S,
Willeit P. Towards a European strategy to address the COVID-19 pandemic. The
Lancet 2021: doi.org/10.1016/S0140-6736(21)01808-0</span></span></span></p></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 36pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -36pt;"><p class="MsoListNumber" style="margin-bottom: 3pt; mso-list: l0 level1 lfo1;"><span face=""Calibri",sans-serif" style="mso-ascii-theme-font: minor-latin; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="color: #5b616b; font-family: arial;"><o:p></o:p></span></span></p></div></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><div class="MsoListNumber"><div class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt; mso-outline-level: 2;"><div class="MsoListNumber"><p class="MsoListNumber"><span style="font-family: arial;"><o:p></o:p></span></p>
<div style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; margin: 0cm 0cm 6pt;"><b style="background-color: transparent;"><span style="font-family: arial;">Papers in press</span></b></div><div style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; margin: 0cm 0cm 6pt;"><span style="background-color: transparent;"><span style="font-family: arial;"><p class="MsoListNumber">van
Schalkwyk M, McKee M. Research into policy: lessons from the COVID-19
pandemic. Eur J Publ Health<span style="background-color: transparent;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></p><p class="MsoListNumber"><span style="background: transparent;">Oroszi B, Juhász A, Nagy C, Horváth JK, McKee M, Ádány R.</span><span style="background-color: transparent;"> The unequal burden of COVID-19 in
Hungary: a geographical and socioeconomic analysis of the second wave of the
pandemic. BMJ Global Health</span></p><p class="MsoListNumber">Monti M, Torbia A, Mossialos E, McKee M. A new strategy for
Health and Sustainable Development: domestic policies, pan-European
cooperation, and global governance after the pandemic. Lancet<o:p></o:p></p><p class="MsoListNumber">Jit M,
Ananthakrishnan A, McKee M, Wouters O, Beutels P, Teerawattananon Y. Multi-country
collaboration in responding to global infectious disease threats: lessons for
Europe from the COVID-19 pandemic. Lancet Reg Health Europe</p></span></span></div><div style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; margin: 0cm 0cm 6pt;"><b style="background-color: transparent;"><span style="font-family: arial;">Resources:</span></b></div></div></div></div></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="background: white; color: #333333;">Ramon
Martinez, Shah Ebrahim, Lucas Sempe and Martin McKee. Potential impact of
COVID-19 on human mortality tool. This allows you to apply the age specific
mortality seen in Italy or China to age distributions worldwide<br />
<a href="https://www.bmj.com/content/368/bmj.m1052/rapid-responses">Link to
description</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="background: white; color: #333333;"><a href="https://public.tableau.com/views/COVID-19mortalitycalculator/COVID-19mortalitycalc?:display_count=y&:showVizHome=no">Link
to model</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face=""><br />
</span><span face="" style="color: blue;"><a href="https://www.covid19healthsystem.org/mainpage.aspx">European Observatory
COVID Health System Response Monitor</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Our monitor is
bringing together structured reports on how countries across Europe are
responding to the COVID-19 pandemic. You can select themes and countries to
generate your own pdf. We are also adding thematic analyses, for example on
testing practices across countries.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><br />
I am a member of the <a href="https://www.independentsage.org/">Independent
SAGE</a>, convened by Sir David King. Our first <a href="http://www.independentsage.org/wp-content/uploads/2020/05/The-Independent-SAGE-Report.pdf">report</a> was
published on 12th May 2020 <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Our second report, on
reopening of schools, is <a href="http://www.independentsage.org/government-failing-to-follow-own-school-advice-review-by-independent-sage/">here</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Our third report on
FTTIS is <a href="https://www.independentsage.org/wp-content/uploads/2020/06/IndependentSAGE-report-4.pdf">here</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">Other</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif"><a href="https://www.blogger.com/blog/post/edit/37603352/315000419512922347">Lloyd-Sherlock
PG, Kalache A, McKee M, Derbyshire J, GeffenL, Casas FG. WHO must prioritise
the needs of older people in its response tothe covid-19 pandemic. BMJ. 2020
Mar 23;368:m1164. doi: 10.1136/bmj.m1164.</a></span><span></span><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="background: white; color: blue;"><a href="https://blogs.bmj.com/bmj/2020/03/30/martin-mckee-words-have-consequences-and-especially-during-a-pandemic-politicians-must-avoid-saying-things-that-stir-up-hatred-of-others/">Martin
McKee: Words have consequences, especially during a pandemic. BMJ Opinion</a></span><span></span><o:p></o:p></span></p><p class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="color: #333333;">Michael
Roberts<i>, </i>Marcel Levi<i>, </i>Richard Schilling<i>, </i>Wei
Shen Lim<i>, </i>Michael PW Grocott<i>, </i>Martin McKee. <a href="https://blogs.bmj.com/bmj/2020/05/01/covid-19-a-complex-multisystem-clinical-syndrome/">Covid-19:
a complex multisystem clinical syndrome</a>. BMJ Opinion </span><span></span><span><o:p></o:p></span></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif">Martin McKee. <a href="https://blogs.bmj.com/bmj/2020/05/06/martin-mckee-the-questions-we-need-to-answer-before-easing-lockdown/">The
questions we need to answer before easing lockdown</a>. BMJ Opinion</span><span></span><o:p></o:p></span></p><p class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="color: #333333;">Raymond
Agius, John Robertson<i>, </i>Marcia Stewart<i>, </i>Denise Kendrick<i>, </i>Herb
Sewell<i>, </i>Martin McKee</span><b><span face="Arial, sans-serif"> </span></b><span face=""Arial",sans-serif" style="color: #333333;"><a href="https://blogs.bmj.com/bmj/2020/05/12/covid-19-rigorous-investigation-of-healthcare-workers-deaths-is-indispensable/">Covid-19:
Rigorous investigation of healthcare workers’ deaths is indispensable</a>. BMJ
Opinion </span><span></span><span><o:p></o:p></span></span></p><p class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="color: #333333;">Martin
McKee. <a href="https://blogs.bmj.com/bmj/2020/05/26/martin-mckee-trust-is-essential-in-a-pandemic-but-the-british-prime-minister-is-squandering-it/?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage">Trust
is essential in a pandemic, but the British prime minister is squandering it.
BMJ Opinion</a></span><span></span><span><o:p></o:p></span></span></p><p class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face="Arial, sans-serif">Selina Rajan Martin McKee. </span><span face=""Arial",sans-serif" style="color: #404248;"><a href="https://ltccovid.org/2020/06/09/learning-from-the-impacts-of-covid-19-on-care-homes-in-england-a-pilot-survey/">Learning
From the Impacts of COVID-19 on Care Homes in England: A Pilot Survey</a>
LTC COVID responses</span><span></span><span><o:p></o:p></span></span></p><p class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="color: #333333;">Vishal
Arora, Martin McKee. <a href="https://blogs.bmj.com/bmj/2020/07/02/covid-19-has-decimated-independent-u-s-primary-care-practices-how-should-policymakers-and-payers-respond/">Covid-19
has decimated independent US primary care practices—how should policymakers and
payers respond?</a> BMJ Opinion</span><span><o:p></o:p></span></span></p><h2 style="background: white; box-sizing: inherit; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial; font-size: small; font-weight: normal;">Martin McKee: <a href="https://blogs.bmj.com/bmj/2020/07/07/martin-mckee-the-uks-response-to-covid-19-does-not-inspire-confidence-in-its-ability-to-protect-health-as-we-drift-into-a-no-deal-brexit/">The
UK’s response to covid-19 does not inspire confidence in its ability to protect
health as we drift into a No Deal Brexit</a>. BMJ Opinion<o:p></o:p></span></h2><h2 style="background: white; box-sizing: inherit; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial; font-size: small; font-weight: normal;">Martin McKee: <a href="https://blogs.bmj.com/bmj/2020/09/10/martin-mckee-will-boris-johnsons-moonshot-become-lost-in-space/">Will
Boris Johnson’s “Moonshot” become lost in space?</a> BMJ Opinion<o:p></o:p></span></h2><h2 style="background: white; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial; font-size: small; font-weight: normal;">Martin McKee, Iveta Nagyova: <a href="https://blogs.bmj.com/bmj/2020/12/07/could-slovakias-mass-testing-programme-work-in-england/">Could
Slovakia's mass testing programme work in England?</a> BMJ Opinion<o:p></o:p></span></h2><h2 style="background: white; box-sizing: inherit; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial; font-size: small; font-weight: normal;">Martin McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">“NHS”
Test and Trace under fire—a system flawed by design</a>. BMJ Opinion<o:p></o:p></span></h2><h2 style="background: white; margin-bottom: 6.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 6pt;"><span style="font-family: arial; font-size: small;"><span face=""Arial",sans-serif" style="color: #333333; font-weight: normal;">Martin McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">How
can we hold political leaders accountable for failures in pandemics?</a>. BMJ
Opinion</span><span face=""Arial",sans-serif" style="color: #333333; font-weight: normal;"><o:p></o:p></span></span></h2><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial;">Martin
McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">The
UK’s PPE procurement scandal reminds us why we need ways to hold ministers to
account</a>. BMJ Opinion <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial;">Martin
McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">Covid-19
vaccine wars: developing the AstraZeneca vaccine was a triumph, but then things
went wrong</a>. BMJ Opinion <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial;">Martin
McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">What
did we learn from Dominic Cummings’ evidence to MPs on the covid crisis?</a>
BMJ Opinion <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span face=""Arial",sans-serif" style="color: #333333; font-family: arial;">Martin
McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">What
Dominic Cummings said next—the case for an urgent inquiry into England’s
pandemic response gets stronger and stronger</a> BMJ Opinion <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<o:p><span style="font-family: arial;">
<o:p>
<o:p>
<o:p>
<o:p>
<o:p>
<o:p>
</o:p></o:p></o:p></o:p></o:p></o:p></span></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><span face=""Arial",sans-serif" style="color: #333333;">Martin
McKee: <a href="https://blogs.bmj.com/bmj/2020/12/11/martin-mckee-nhs-test-and-trace-under-fire-a-system-flawed-by-design/">Martin
McKee on “Spike: The virus versus the people”</a>. BMJ Opinion</span><span><o:p></o:p></span></span></p></div><div class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;"><div class="MsoNormal" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; line-height: normal; margin-bottom: 6pt;"><span style="color: #333333; font-family: arial;"><div><br /></div></span></div>
</div>
</div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">Media (selected)</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<b><span style="font-family: arial;">Interviews:<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Washington Post <a href="https://www.washingtonpost.com/gdpr-consent/?next_url=https%3a%2f%2fwww.washingtonpost.com%2fworld%2feurope%2fas-coronavirus-surges-a-frantic-europe-scrambles-for-hospital-beds-ventilators-supplies%2f2020%2f03%2f22%2f75adc79e-695d-11ea-b199-3a9799c54512_story.html">23rd
March</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">BBC Radio
Ulster: <a href="https://www.bbc.co.uk/programmes/p087hwht">24th March</a> , <a href="https://www.bbc.co.uk/programmes/p088ftqk">2nd April</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Daily Telegraph <a href="https://www.telegraph.co.uk/global-health/science-and-disease/everyone-wants-coronavirus-data-should-treat-numbers-caution/">6th
March</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">BBC Radio 4 The World
Tonight <a href="https://www.bbc.co.uk/sounds/play/m000h8h7">13th April</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">RTE <a href="https://www.rte.ie/news/coronavirus/2020/0413/1130077-lockdown-exit-austria-and-denmark-take-first-steps/">13th
April</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="">Sky News </span><span face="" style="color: blue;"><a href="https://twitter.com/LSHTM/status/1250375500322803712?s=20">15th April</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://twitter.com/BBCNewsnight/status/1250909147794677760?s=20">BBC
Newsnight 16th April</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="">Toronto Globe and
Mail <a href="https://www.theglobeandmail.com/world/article-italian-doctors-fatalities-reach-tragic-levels-as-they-fight-covid-1/">3rd
April</a>; </span><span face="" style="color: blue;"><a href="https://protect-eu.mimecast.com/s/kTOsCyXjgivq9LFZ3apa?domain=theglobeandmail.com">20th
April</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">Sydney Morning
Herald <a href="https://www.smh.com.au/world/europe/biggest-failure-in-a-generation-where-did-britain-go-wrong-20200428-p54o2d.html">4th
May</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="background: white; color: #141414; letter-spacing: -0.75pt;"><a href="https://www.mirror.co.uk/news/uk-news/your-coronavirus-lockdown-questions-answered-21880150">Your
coronavirus lockdown questions answered - including when schools may reopen.
Daily Mirror 17th April</a></span><span face=""> <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.dn.se/nyheter/vetenskap/darfor-kan-en-ekonomisk-kris-skada-folkhalsan-mer-an-det-nya-coronaviruset/">Därför
kan en ekonomisk kris skada folkhälsan mer än det nya coronaviruset</a>.
[Therefore, an economic crisis can harm public health more than the new corona
virus] Dagens Nyhater 20<sup>th</sup> April<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.bloomberg.com/news/features/2020-04-24/coronavirus-uk-how-boris-johnson-s-government-let-virus-get-away">The
Week Coronavirus got away from Boris Johnson’s Government.</a> Bloomberg
24<sup>th</sup> April<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.ft.com/content/f9850a8d-7323-4de5-93ed-9ecda7f6de1c">How
central and eastern Europe contained coronavirus</a>. Financial Times 30th
April<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt; vertical-align: baseline;">
<span style="font-family: arial;">T<a href="https://www.rp.pl/Koronawirus-SARS-CoV-2/305039958-Tragiczny-blad-Zachodu-w-walce-z-koronawirusem.html">ragiczny
błąd Zachodu w walce z koronawirusem</a> Rzeczpospolita [In Polish: A
tragic mistake by the West in the fight against coronavirus] 4<sup>th</sup> May<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.tvanouvelles.ca/2020/05/07/le-royaume-uni-souffre-davoir-retarde-considerablement-le-confinement">Le
Royaume-Uni souffre d'avoir «retardé considérablement» le confinement</a>. TVA
Nouvelles<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="background: rgb(245, 248, 250); color: #14171a;"><a href="https://www.bloomberg.com/news/articles/2020-05-15/why-daily-virus-numbers-mean-little-in-post-lockdown-stakes">Why
daily virus numbers mean little in post-lockdown stakes. Bloomberg business
15th May</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: rgb(249, 249, 249); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.youtube.com/watch?time_continue=2&v=Z6Sska630Tc&feature=emb_logo">UK
eases restrictions: Some people now back at work.</a> Al Jazeera English
16th May<o:p></o:p></span></div>
<div class="MsoNormal" style="background: rgb(249, 249, 249); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.bbc.co.uk/iplayer/episode/m000jcsw/panorama-coronavirus-crisis-europes-migrant-camps">Coronavirus
Crisis: Europe's Migrant Camps</a> BBC Panorama 18<sup>th</sup> May<o:p></o:p></span></div>
<div class="MsoNormal" style="background: rgb(249, 249, 249); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.politico.eu/article/coronavirus-schools-europe-policy-conundrum/">The
dangers of going back to school after coronavirus</a>. Politico 21<sup>st</sup> May<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt; mso-outline-level: 1; vertical-align: baseline;">
<span style="font-family: arial;"><span face="" style="color: #333333;"><a href="https://www.telegraph.co.uk/global-health/science-and-disease/one-three-think-government-has-done-bad-job-managing-coronavirus/">Just
one in three think government has done a good job managing coronavirus
pandemic. Daily Telegraph 4th June</a><o:p></o:p></span><br />
</span><h1 class="a-header__title" style="font-weight: 300; letter-spacing: 0.3px; line-height: 6.25rem; margin: 15px 0px; padding: 0px;">
<div class="MsoNormal" style="line-height: normal; margin: 11.25pt 0cm; mso-outline-level: 1;">
<span style="font-family: arial; font-size: small;"><span face="" style="letter-spacing: 0.25pt;"><a href="https://www.wired.co.uk/article/contact-tracing-app-isle-of-wight-trial">What’s
really happening with the NHS Covid-19 app trial</a>. Wired, 16<sup>th</sup>
June</span><span style="letter-spacing: 0.25pt;"><o:p></o:p></span><br />
<span face="" style="letter-spacing: 0.25pt;"></span></span></div>
</h1>
<h1 class="content__headline js-score" style="color: #121212; font-variant-ligatures: common-ligatures; line-height: 48px; margin: 0px; padding-bottom: 0.375rem; padding-top: 0.1875rem;">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; mso-outline-level: 1;">
<span style="font-family: arial; font-size: small;"><span face="" style="font-weight: normal;"><a href="https://www.theguardian.com/world/ng-interactive/2020/jun/25/revealed-data-shows-10-countries-risking-coronavirus-second-wave-as-lockdown-relaxed">Revealed:
data shows 10 countries risking coronavirus second wave as lockdown relaxed</a>
Guardian 25<sup>th</sup> June</span><b><span><o:p></o:p></span></b><br />
<span face="" style="font-weight: normal;"><br /></span>
<span face="" style="font-weight: normal;"><span style="font-variant-ligatures: common-ligatures;"><a href="https://www.theguardian.com/world/2020/jun/30/rising-coronavirus-infections-in-pockets-of-uk-raise-fears-of-further-local-lockdowns">Rising coronavirus infections in pockets of UK raise fears of further local lockdowns</a> </span>Guardian 1st July</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; mso-outline-level: 1;"><span style="font-family: arial; font-size: small;"><a href="https://www.theguardian.com/commentisfree/2020/jul/20/coronavirus-vaccine-anti-vaxxers-britain" style="background-color: #fef9f5; font-weight: normal;">A coronavirus vaccine would be a triumph, but the worst human impulses threaten its success</a><span style="background-color: #fef9f5; color: black; font-weight: normal;">. Guardian 21st July</span></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; mso-outline-level: 1;"><span style="background-color: #fef9f5; color: black; font-family: arial; font-size: small; font-weight: normal;"><a href="https://www.independentsage.org/martin-mckee-interviewed-on-cnn/">CNN</a> 26th September</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; mso-outline-level: 1;"><b style="background-color: transparent;"><span style="font-family: arial; font-size: small;">Op eds</span></b></div></h1></div>
<div class="MsoNormal" style="background: rgb(254, 249, 245); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="color: #121212;"><a href="https://www.theguardian.com/world/2020/mar/14/why-brexit-will-delay-uk-getting-vaccine-and-cost-more">Brexit
threatens UK’s ability to respond to a future pandemic Guardian 14th March</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: rgb(254, 249, 245); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="color: blue;"><a href="https://www.theguardian.com/world/commentisfree/2020/apr/16/coronavirus-30000-americans-trump-blame-who?CMP=share_btn_tw">Coronavirus
has killed 30,000 Americans, and all Trump can do is blame the WHO. Guardian
16th April</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: rgb(254, 249, 245); line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://www.theguardian.com/commentisfree/2020/apr/23/europe-is-easing-coronavirus-lockdowns-the-uks-failures-have-never-been-so-stark">When
Europe eases its coronavirus lockdowns, will the UK watch and learn?</a> Guardian
23rd April<o:p></o:p></span></div><div class="MsoNormal" style="background: rgb(254, 249, 245); line-height: normal; margin-bottom: 6pt;"><span style="font-family: arial;"><p class="MsoNormal"><a href="https://www.independent.co.uk/voices/lockdowns-coronavirus-regulations-contact-tracing-b1775435.html">Continual boom and bust lockdowns are not the way to managethe virus</a>. Independent 17th December<o:p></o:p></p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">Discussions/ podcasts</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="">BBC World Service The
Real Story. Discussion with Zeke Emanuel, Ben Cowling, Emma Frans and me. </span><span face="" style="color: blue;"><a href="https://www.bbc.co.uk/programmes/w3cszcmq">17th April</a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="">The public health
response to COVID19. </span><span face="" style="color: blue;"><a href="https://soundcloud.com/bmjpodcasts/the-public-health-response-to-covid-19?utm_source=feedburner-bmj.com+download&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fpodcasts+%28The+BMJ+podcast%29">BMJ
podcast </a></span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;">BBC Radio 4 <a href="https://www.bbc.co.uk/sounds/play/m000hgjf">The Briefing Room</a>. 23<sup>rd</sup> April <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">BMJ podcasts</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="http://feeds.bmj.com/~r/bmj/podcasts/~3/i8MvGinxMlQ/the-public-health-response-to-covid-19">The
public health response to covid - 19</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="https://soundcloud.com/bmjpodcasts/public-health-vs-the-economy?utm_source=feedburner-bmj.com+download&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fpodcasts+%28The+BMJ+podcast%29">Public
health vs the economy</a>. <a href="https://soundcloud.com/bmjpodcasts/public-health-vs-the-economy?utm_source=feedburner-bmj.com+download&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fpodcasts+%28The+BMJ+podcast%29">BMJ
podcast</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><a href="http://feeds.bmj.com/~r/bmj/podcasts/~3/E1TqOW-41yE/public-health-response-to-covid-19-data-integrity-and-the-importance-of-international-comparison">Public
health response to covid-19 - data integrity and the importance of
international comparison</a><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">Blogs</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><span face="" style="background: white; color: #222222;"><a href="https://www.futurelearn.com/info/blog/what-is-the-wider-impact-of-coronavirus-on-society">What
is the wider impact of coronavirus on society?</a> FutureLearn</span><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face=""><br /></span></b>
<b><span face="">Webinars:</span></b><span face=""><o:p></o:p></span></span></div>
<div class="MsoNormal" style="background: white; line-height: normal; margin-bottom: 6pt;">
<div style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; margin: 0cm 0cm 6pt;">
<span style="font-family: arial;"><span face="">Physicians
for Human Rights: Discussion chaired by Jennifer Leaning with me and Ashish
Jha. <a href="https://www.youtube.com/watch?v=0lTXMUNCFYI#action=share">Reopening:
Balancing Public Health, Safety, Human Rights and the Economy</a></span><o:p></o:p></span></div>
<div style="margin: 0cm 0cm 6pt;">
<span style="font-family: arial;"><span face="">Royal Society of
Medicine: <a href="https://www.rsm.ac.uk/events/rsm-studios/2019-20/pen73/">COVID-19
Series: Can the UK learn from Europe and, if so, what? - Episode 14</a><span style="background: rgb(249, 249, 249);"><br />
<a href="https://www.youtube.com/watch?v=olJeSuNrQJI">Even more of your
questions answered: Episode 18</a></span></span><o:p></o:p></span></div>
<div style="margin: 0cm 0cm 6pt;">
<span style="font-family: arial;"><span face="">Chatham House: </span><span face="" style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial; color: #31353d;"><a href="https://www.chathamhouse.org/file/role-eu-coordinating-responses-global-health-crises">The
Role of the EU in Coordinating Responses to Global Health Crises</a></span><o:p></o:p></span></div>
<span style="font-family: arial;"><o:p></o:p>
<o:p></o:p>
<br />
</span><div style="margin: 0cm 0cm 6pt;">
<span style="font-family: arial;"><span face="">American Hospital
Association. <a href="https://hospitalsinfocus.podbean.com/e/public-health-expert-martin-mckee-compares-the-europe-and-us-response-to-covid-19/">The
Europe and US Response to COVID-19</a>. July 13, 2020 </span><o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span style="font-family: arial;"><b><span face="">Letters to newspapers</span></b><span face=""><o:p></o:p></span></span></div>
<span style="font-family: arial;"><br />
</span><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt;">
<span face=""><span style="font-family: arial;">Letter to Financial
Times critiquing Oxford study</span><o:p style="font-size: 12pt;"></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzrulFOuwY0GyBxEqH-UMxZUawE55l1gg2BI5p5nBWkmHoqXuVJ_xl73hp1EJ2UVfEIqM7ukhVA7Wm9w4WqKgaDUKUQUnkSQe163i0d8TZ36-Ek06TnDsbvgy_shZwM0xeZRlNmg/s1600/FT1.tif" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="853" data-original-width="1233" height="441" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzrulFOuwY0GyBxEqH-UMxZUawE55l1gg2BI5p5nBWkmHoqXuVJ_xl73hp1EJ2UVfEIqM7ukhVA7Wm9w4WqKgaDUKUQUnkSQe163i0d8TZ36-Ek06TnDsbvgy_shZwM0xeZRlNmg/s640/FT1.tif" width="640" /></a></div>
<span face=""><br /></span>
<span face=""><br /></span><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span face=""><br /></span></div><div><span style="font-family: arial; font-size: x-small;">Letter to Financial Times calling for a public inquiry:</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKvj45atFDGdNua32W9m6vH66aNVi71P6dYV6hSUA3dFoe7uC8RF7NPU7XSdF5pcSjaoBqsZXqkdUKtBaeYAr0ZiyhWKrF9l9OBwjT9pyy5KgqUnYGX-bNVQiOMwQ3szx0JvWVuA/s1600/FT.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: arial;"><img border="0" data-original-height="296" data-original-width="438" height="432" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKvj45atFDGdNua32W9m6vH66aNVi71P6dYV6hSUA3dFoe7uC8RF7NPU7XSdF5pcSjaoBqsZXqkdUKtBaeYAr0ZiyhWKrF9l9OBwjT9pyy5KgqUnYGX-bNVQiOMwQ3szx0JvWVuA/s640/FT.jpg" width="640" /></span></a></div>
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<br /></div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com1tag:blogger.com,1999:blog-37603352.post-90451422739666888102018-08-17T06:54:00.001+00:002018-08-17T08:09:25.688+00:00E-cigarettes - more evidence of English exceptionalism<span style="font-family: "arial" , "helvetica" , sans-serif;">The House of Commons Science and Technology Committee has just published a report on e-cigarettes. <span style="font-size: 12pt;">Those involved in tobacco control outside England are amazed at its conclusions although not entirely surprised as the England has long been an international outlier on this issue, far</span></span><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;"> out of step with the rest
of the world. For example, two major reports, from the </span><a href="http://nationalacademies.org/hmd/Reports/2018/public-health-consequences-of-e-cigarettes.aspx" style="font-family: Arial, Helvetica, sans-serif; font-size: 12pt;">US National Academies ofScience</a><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;"> and, only a few days ago, from </span><a href="https://www.csiro.au/en/Research/BF/Areas/Nutrition-and-health/E-cigarettes-report" style="font-family: Arial, Helvetica, sans-serif; font-size: 12pt;">Australia</a><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;">, highlight how much is not
known. The American Heart Association agrees that " the potential
health effects unknown, especially in long-term users" and has made a series of <a href="http://www.heart.org/idc/groups/heart-public/@wcm/@global/documents/downloadable/ucm_485779.pdf">recommendations</a> that are almost the opposite of those in the Commons report. And it's not just in the Anglophone world. leaders of the <a href="https://www.ersnet.org/the-society/news/we-have-not-learned:-ers-leaders-respond-to-bmj-article-on-the-use-of-e-cigarettes-for-smoking-cessation-">European Respiratory Society </a>recently responded to a paper on e-cigarettes in Engl</span><span style="font-family: Arial, Helvetica, sans-serif;">and saying "<span style="background-color: #f9f9f9; color: #333333;">(A) There is little evidence that e-cigarettes are an aid to smoking cessation and much evidence that tobacco manufacturers are advertising e-cigarettes as a bridge to starting nicotine and as a vehicle for long term continuation”; and “(B) no-one, expert or otherwise, can credibly assert that e-cigarettes are safer than tobacco in the long term, given that they contain a whole new tranche of unregulated and unstudied compounds being inhaled into the lung.</span>"</span><br />
<span lang="EN-AU" style="font-size: 12pt;"><span style="font-family: "arial" , "helvetica" , sans-serif;">
It is especially astonishing that the 95% safer figure is used, given that it
has <a href="https://www.bmj.com/content/351/bmj.h4863/rr-1">no credibility</a> internationally. There are serious questions about the
<a href="https://www.bmj.com/content/351/bmj.h4863">funding </a>of the meeting it came from and it is simply impossible to know how
safe a product is when it has only been used widely for a relatively short
time. It took decades to discover the health effects of smoking. </span></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span lang="EN-AU"><span style="font-size: 12pt;">The <a href="http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf?ua=1">World Health Organisation</a> has said explicitly that a precise figure cannot be given, referring to "</span></span>Unsubstantiated or overstated claims of safety and cessation<span style="font-size: 12pt;">".
Also, as reported earlier this week in a st</span></span><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;">udy from <a href="https://www.birmingham.ac.uk/news/latest/2018/08/e-cigarette-vapour-disables-key-immune-cells-in-the-lung.aspx">Birmingham</a>, new evidence is
appearing weekly raising co</span><span style="font-family: "arial" , "helvetica" , sans-serif;">ncerns about safety.</span></div>
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<span lang="EN-AU"><span style="font-family: "arial" , "helvetica" , sans-serif;">
It is equally astonishing to see the claim that they are a proven smoking aid
given the recent publication of a large controlled trial in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa1715757">New England Journal of Medicine</a> concluding that "</span></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; color: #4d4d4d;">Among smokers who received usual care (information and motivational text messages), the addition of free cessation aids or e-cigarettes did not provide a benefit.</span><span style="background-color: white; color: #4d4d4d;"> </span>". Moreover, th<span style="font-size: 12pt;">ere is n</span></span><span style="font-family: "arial" , "helvetica" , sans-serif; font-size: 12pt;">ow lots of evidence
from <a href="https://tobacco.ucsf.edu/our-new-meta-analysis-entire-relevant-literature-shows-e-cigarettes-used-are-associated-less-not-more-quit">observational studies</a> that they reduce quitting.</span></div>
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<span lang="EN-AU"><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 12pt;">
The suggestion to increase n</span>icotine is especially worrying given that
organisations such as ASH have argued that the UK is safe from the rapid
increase in use of Juuls by schoolchildren seen in the USA because of the lower
levels permitted here. The report simply dismisses concerns such as that by the </span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">former chair of the American Academy of Pediatrics Tobacco Consortium, who has said “<a href="https://www.newyorker.com/magazine/2018/05/14/the-promise-of-vaping-and-the-rise-of-juul">Juul is already a massive public-health disaster".</a> But then, the report ignores the considerable evidence that these products are a <a href="https://ses.library.usyd.edu.au/bitstream/2123/17579/2/Etter%20response.pdf">gateway to smoking</a>.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Fortunately, other countries are not following England's direction, despite massive pressure from a very well funded <a href="https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(17)32561-8">Big Tobacco operation</a>. Instead, they are waiting for the results on our giant experiment on our people.</span></div>
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Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-41464646667046424272017-11-17T08:38:00.001+00:002017-11-17T08:38:45.201+00:00The EHIC post Brexit: The devil is in the detailThe House of Lords Home Affairs Committee has a sub-committee on the EU. It is an extremely impressive group, chaired by a former head of the diplomatic service, and with a former chief executive of the NHS among its numbers. I was asked to give evidence on the prospects for retaining the European Health Insurance Card post Brexit. What other arrangements does the EU have with third countries? Are there arrangements from before we joined the EU that we could revive?<br />
This involved a lot of homework - for example, dredging through the National Archives to find ancient treaties. That was a fascinating exercise. Several were with countries that no longer exist, such as Czechoslovakia (although in that case it seems that <a href="http://www.euronews.com/2017/10/25/brexit-boss-refers-to-czechoslovakia-in-boast-about-european-intelligence">David Davis is unaware</a> that it split in two in 1993), Yugoslavia, and the USSR. The wording revealed how far we have come. Many of the treaties talked of how, if a national of one country was residing in another, <b>he</b> would be entitled to something, as would <b>his wife</b>. Clearly, the possibility of a woman ever working abroad was unimaginable to them.<br />
I've written a blog about what I discovered on the <a href="http://blogs.bmj.com/bmj/2017/11/16/martin-mckee-the-devil-is-in-the-detail-why-retaining-the-european-health-insurance-card-may-be-an-impossible-dream/">BMJ website</a>. But to cut a long story short, it is clear that, once again, UK ministers are living in cloud cuckoo land. Their remarks reveal a profound ignorance of even the most basic aspects of how the EU works. I cannot see any prospect of retaining the EHIC given the UK government's red lines.<br />
No wonder our European neighbours are now <a href="https://www.theguardian.com/politics/2017/nov/16/brexit-netherlands-told-to-prepare-for-a-no-deal-chaos-scenario">planning for the worst</a>. Until now, they persisted in the belief that the UK government could not be so stupid. But now they realise that it is. And it is both tragic and embarrassing.Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-239924739623487762017-11-01T13:57:00.000+00:002017-11-01T13:57:05.035+00:00A running commentaryThe Brexit negotiations continue - I deliberately do not use the word progress. It is now abundantly clear that the UK is totally unprepared. The Cabinet is hopelessly divided. Weekly, politicians make statements revealing their deep ignorance of how the EU works. The general view is that if they wait long enough, someone else will find a solution.<br />
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The Prime Minister has said that she won't provide a running commentary. She seems strangely shy about sharing the news about what she seems to think will be an amazing success, refusing to publish her government's assessments of the impact of Brexit. This may not matter - even the ministers in the department that is meant to be negotiating Brexit <a href="http://www.independent.co.uk/news/uk/politics/david-davis-theresa-may-brexit-reports-not-read-secret-detail-uk-economy-impact-leave-eu-a8022946.html">haven't read them</a> - and can't even confirm they actually exist. Still, if she isn't willing to, I thought I could help with some observations from time to time. So as well as the blogs mentioned in previous posts here, I've added a few more. I hope you find them interesting.<br />
<span style="background-color: white; color: #333333; font-family: interfaceregular, "Helvetica Neue", Arial, sans-serif; font-size: 1.5rem;"><br /></span>
<span style="background-color: white; color: #333333;"><span style="font-family: Times, Times New Roman, serif;">BMJ blogs:</span></span><br />
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<span style="font-family: Times, Times New Roman, serif;"><a href="http://blogs.bmj.com/bmj/2017/05/03/martin-mckee-the-infamous-brexit-dinner-party-health-was-a-major-issue-but-only-for-the-eu/">The infamous Brexit dinner party—health was a major issue, but only for the EU</a></span></div>
<div style="background-color: white; box-sizing: inherit; clear: both; color: #333333; font-weight: normal; line-height: 1.2; margin: 0px 0px 3px;">
<a href="http://blogs.bmj.com/bmj/2017/06/12/martin-mckee-creating-chaos-and-confusion-from-strength-and-stability-the-general-election-2017/" style="font-family: Times, "Times New Roman", serif;">Creating chaos and confusion from strength and stability—the general election 2017</a></div>
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<a href="http://blogs.bmj.com/bmj/2017/06/20/martin-mckee-the-brexit-negotiations-have-started-but-are-they-going-anywhere/" style="background-color: white; font-family: Times, "Times New Roman", serif;">The Brexit negotiations have started, but are they going anywhere?</a></div>
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UK in a changing Europe:</div>
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<a href="http://ukandeu.ac.uk/brexit-should-come-with-a-massive-health-warning-ideally-painted-on-the-side-of-a-bus/" style="background-color: white; font-family: Times, "Times New Roman", serif;">Brexit should come with a massive health warning, ideally painted on the side of a bus</a></div>
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Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-48657807171242439342017-04-04T22:40:00.002+00:002017-11-15T16:23:06.271+00:00The sound of ideology smashing into the wall of reality is echoing around WhitehallThe UK government has issued its latest Brexit White Paper. Well, some of it is white. Five of the 44 pages are completely blank. Another 5 only have blue rectangles. One wonders how much time was spent in deciding what shade of blue was used. It must have been light relief from the much more difficult task of thinking of words to include. Yet it does say something. It seems to recognise that Brexit will be much more difficult than the Leavers thought, and many will be very disappointed. But it also shows that the UK government still has very little clue if how to proceed.<br />
My take on it can be seen in my latest BMJ blog, which you can read <a href="http://blogs.bmj.com/bmj/2017/04/03/martin-mckee-article-50-has-been-triggered-now-what/">here</a>.Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-8749730037572818132017-03-30T01:59:00.000+00:002017-03-30T01:59:30.401+00:00So Theresa May has triggered Article 50. It didn't go down well. First, she called for talks on the UK's exit from the EU to proceed in parallel with those on a free trade deal. Clearly she hadn't been listening to what everyone else had been saying for months. It isn't going to happen, as <a href="https://www.theguardian.com/politics/2017/mar/29/angela-merkel-rejects-one-of-theresa-mays-key-brexit-demands">Angela Merkel</a> (and many others) quickly pointed out. Then she issued a veiled threat - be nice to us or we will stop co-operating on security. At a time when all European countries face a severe threat, this is not good timing. And her obvious disregard for the interests of Scotland, Wales, Northern Ireland and Gibraltar greatly increases the likelihood that, in 10 years time, it will be England alone outside the EU.<br />
Maybe we could be more reassured if we felt that the UK government had some plan for how to proceed. Sadly, as I noted in a recent blog for the <a href="http://blogs.bmj.com/bmj/2017/03/16/martin-mckee-a-plan-for-brexit-some-hope/">BMJ</a>, it is now all too apparent that it doesn't. Indeed, listening to the news today simply confirmed my suspicion. Those who support Brexit simply don't understand the EU and our relationship with it, something that has taken 40 years to develop and, by all accounts, will take 40 years to disentangle ourselves from.<br />
Can the notification of Article 50 be revoked. Certainly our European partners <a href="https://www.theguardian.com/politics/2017/mar/29/first-eu-response-to-article-50-takes-tough-line-on-transitional-deal">think so</a>. And for this we should be very grateful because, sometime in the next few years, the UK will hit the wall we call reality. And we may be very grateful for an escape from this insanity. <br />
<br />Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-36657940411224899332017-02-04T21:07:00.001+00:002017-02-04T21:07:12.418+00:00Brexit White Paper - or should it be Blank PaperI've written a new blog on the Brexit White Paper on the BMJ website. You can read it <a href="http://blogs.bmj.com/bmj/2017/02/02/martin-mckee-the-brexit-white-paper-making-britain-great-again/">here</a>. As you will see, I was quite amazed that any government would have the audacity to produce such an appalling document and pass it off as a something as serious as a government White Paper. It adds almost nothing to Theresa May's Lancaster House speech, contains factual errors, and includes no serious analysis of the challenges ahead. It has all the realism of a 5 year old writing to Santa Claus.<br />
Others have noted how, by reading the metadata on the HTML version, one can see that it was only finished at 4 am in the morning it was published. One feels that it may only have been started the evening before.<br />
Those wanting to read more (and after reading the White Paper, anyone with even a passing interest in Brexit is likely to want much more) should also look at Steve Peer's excellent analysis <a href="http://eulawanalysis.blogspot.co.uk/2017/02/as-bad-as-it-gets-white-paper-on-brexit.html">here</a>. There is also a great thread by on <a href="https://twitter.com/WomaninHavana/status/827216646783848449">twitter</a> by Schona Jolly, another perceptive observer of these things.<br />
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<br />Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-34562728179311818262016-09-13T08:47:00.000+00:002016-09-13T08:47:08.393+00:00Brexit 2 months onIt gets worse. Once, when a UK cabinet minister spoke on his brief at the despatch box in the House of Commons it was assumed that it was government policy. No more. Of course, the blame doesn't lie entirely with the Secretary of State for Exiting the EU. The problem is that there is no government policy. Or indeed, no prospect of developing one.<br />
It must now be clear to everyone that:<br />
a) the UK government lacks the capacity to actually leave the EU (unless it wants to just walk away in the desperate hope that something will turn up, which it won't)<br />
b) the arguments advanced by the Leave campaign were blatant lies<br />
c) there is no easy way out - Theresa May can't even call an election and lose it, leaving someone else to clean up the mess as the lamentable state of the Labour Party means that she would win<br />
I've written a few new blogs that try to set out some of the issues. They are pretty depressing. But they may inject a degree of reality to a debate characterised by political demonstrations of optimism that make one wonder if the speakers inhabit the same world as the rest of us.<br />
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<a href="http://blogs.bmj.com/bmj/2016/09/08/martin-mckee-brexit-the-confusion-continues/">Brexit - the confusion continues</a>. BMJ 8th September 2016<br />
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<a href="http://blogs.lshtm.ac.uk/hppdebated/2016/09/07/brexit-means-brexit/">"Brexit means Brexit"</a> Health Policy & Planning, 7th September 2016Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-66925301465704259482016-07-03T13:06:00.001+00:002016-07-03T13:06:55.841+00:00The EU referendum and beyondSo now we have a result. And it is not good. A brave politician has been murdered. We have had months of blatant lies by those supporting the Leave campaign. We have had a massive upsurge in racist attacks. We now know that some politicians were willing to bring our country to the brink of disaster in pursuit of their own personal agendas. The two main political parties are rudderless. Research collaborations are already being damaged. Citizens from other EU countries are terrified.<br />
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We show no evidence of learning the lessons of history, whether they are from the 1930s in Europe or from the last time a UK government launched a major initiative without a plan, as we will hear in the Chilcot Report in a few days. <br />
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Those who supported Leave are revealing massive optimism bias. They make Voltaire's <a href="https://en.wikipedia.org/wiki/Candide">Dr Pangloss </a>look like a pessimist. They think we can negotiate trade deals rapidly, despite our lack of negotiators. They show no sign of appreciating the crisis we face. Yet there is no excuse - they just need to look at the <a href="https://www.theguardian.com/world/2016/jul/03/eu-swiss-single-market-access-no-free-movement-citizens">Swiss situation</a>. But of course, they think they will be different. This is verging on teh delusional.<br />
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None have a clue what to do. The unwillingness of those who have at least some insight to trigger Article 50, which would start the clock ticking, is revealing. See <a href="https://twitter.com/DavidAllenGreen?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor">David Allen Green</a> (aka Jack of Kent) for the best analysis. <br />
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The only reassuring thing is that some day, they will realise the complexity of what they seek and that it is likely to paralyse the parliamentary process for years. But the damage done by then will be enormous. <br />
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I've written a few blogs on the fallout from the EU referendum are on the BMJ site:<br />
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24th June 2016: <a href="http://blogs.bmj.com/bmj/2016/06/24/martin-mckee-on-the-eu-referendum-we-have-no-idea-what-will-come-next-but-it-wont-be-good/">We have no idea what will come next, but it won’t be good</a><br />
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27th June 2016: <a href="http://blogs.bmj.com/bmj/2016/06/27/martin-mckee-brexit-and-health-the-confusion-grows/">Brexit and health—the confusion grows</a><br />
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30th June 2016: <a href="http://blogs.bmj.com/bmj/2016/06/30/martin-mckee-fair-and-balanced-science-in-a-post-fact-society/">Fair and balanced? Science in a post fact society</a><br />
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Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-92106760285359555612013-05-02T03:17:00.000+00:002013-05-04T22:28:59.864+00:00Why are people losing faith in conventional politics?<br />
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">People in many countries are losing faith in politics as
usual. Some are returning to the politics of an earlier age, voting for
neo-fascist parties such as Golden Dawn in Greece and Jobbik in Hungary. Elsewhere,
those calling for transparency and direct democracy, whereby those elected should
represent the people rather than powerful vested interests, are achieving
success. The most newsworthy example was in Italy, where a party led by a
professional comedian emerged as the largest single party in the 2013 general election
although elsewhere, the Pirate Party, which originated in Sweden, is seeing
electoral success in a growing number of countries, with Iceland only the most
recent. In the England, the UK Independence Party is now in third place in
opinion polls, despite revelations from e-mails exchanged by its senior
officers that it is so desperate to have semi-coherent policies on a range of
topics that <a href="http://www.guardian.co.uk/politics/2013/apr/27/ukip-local-elections-emails">it
is considering buying them</a> from sympathetic think-tanks. </span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">History, especially that of Europe in the first half of the
twentieth century, reminds us that a failure by politicians to manage an
economic crisis can lead to a rejection of conventional political parties so,
to some extent, what is happening now should not be a surprise. But history
also reminds us that the importance of these developments should not be
underestimated. No matter how justified it may seem to describe parties such as
UKIP as being composed of “loonies and fruitcakes”, this rather misses the
reason why a disillusioned electorate has lost faith in conventional politics. </span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">Two recent health-related events typify this view. The wave
of revulsion that followed the shooting of 20 children and six staff in Sandy
Hook Elementary School, in Connecticut, seemed to many people to be a game
changer. The National Rifle Association attracted ridicule when it suggested
that the best way to prevent more deaths in school shootings was to arm
teachers. Opinion polls shows overwhelming support for tighter gun control
measures, with 92% supporting the closure of loopholes that enable those buying
firearms at gun shows to avoid background checks. Yet, when even such a modest
measure such as this reached the Senate, it was defeated. 43 of the 46 senators
voting against it had <a href="http://www.nj.com/times-opinion/index.ssf/2013/04/editorial_the_list_of_46_senat.html">received
campaign donations</a> from the National Rifle Association. They found every
excuse possible, no matter how incredible, to justify their failure to act against
products responsible for the murders of over 8,000 Americans every year. Having striven relentlessly to prevent any
research that might challenge their position being undertaken, they ignored or
dismissed what did exist, such as that showing a <a href="http://www.nytimes.com/2013/04/03/us/report-links-high-rates-of-gun-violence-to-weak-laws.html">clear
link</a> between the laxity of state-level gun control laws and shootings.
Bizarrely, a few days later, many of the same senators, who had rejected what
they saw as intrusive surveillance by the federal government, rushed to condemn
the FBI for failing to identify the Boston bombers before they acted. </span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">About the same time, the upper chamber of the UK parliament
was debating another health-related matter, the regulations requiring NHS
services to be opened to competition. Ministers had offered copious
reassurances that the Act, from which the regulations flowed, meant something
other than what it plainly said. When the regulations confirmed its true meaning
they claimed it was a mistake and, after scattering a few words such as
integration almost at random, claimed to have fixed it. Legal opinion, not
refuted by the government’s response that sidestepped the key issues, confirmed
that the <a href="http://nhsrationing.org/2013/03/22/what-is-wrong-with-the-governments-nhs-procurement-regulations/">revised
version was effectively unchanged</a>. A major campaign was launched to ensure
that peers were aware of this and the concerns of by health professionals
and their representatives, some of whom seemed finally to have woken up to the
threat being posed. Yet as in the US Senate, the government dismissed the
evidence. A subsequent detailed <a href="http://t.co/quJP3GrtXi">legal analysis</a>
suggests that the speech by the minister introducing the regulations was
incorrect in almost every respect. Despite overwhelming opposition by those who
had studies the provisions, the government was successful, leaving those
responsible for managing the NHS struggling to reconcile the regulations with
ministers’ stated intentions. Quite why so many peers supported this obviously
flawed legislation remains unclear but, as with the US Senate, a growing number
of people are asking questions about the <a href="http://socialinvestigations.blogspot.com/2012/02/nhs-privatisation-compilation-of.html">financial
links</a> between the private healthcare industry and some of the most eloquent
supporters of the Act and the subsequent regulations. </span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;"> Politicians are meant
to represent the views of the people, not powerful vested interests.
Unfortunately, at times, they seem to echo the suggestion by <a href="http://en.wikiquote.org/wiki/Bertolt_Brecht">Bertolt Brecht</a> when he
observed that, as the East German communist party had lost the confidence of
the people, “would it not be simpler if the government simply dissolved the
people and elected another?” Maybe they should reflect on this if they don’t
want to join the Communist Party of the DDR in the dustbin of history. </span></div>
Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com1tag:blogger.com,1999:blog-37603352.post-39452346411225827942012-12-26T19:14:00.000+00:002012-12-26T19:14:00.585+00:00Hinchingbrooke - a (very minor) correction<br />
<div class="MsoNormal" style="margin-bottom: 6pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="background-color: white;">Mr Birrell has, correctly, pointed out that I was mistaken in
saying that the Public Accounts Committee had condemned the franchising arrangements
at Hinchingbrooke Hospital. In fact, the Committee has yet to issue a final
report. I should instead have said that <b><i>members of </i></b><span style="font-size: small;">the Committee had
condemned it. I was thinking, in particular, of the closing comments of one of
their members in their report of evidence taken: </span><i>“I have to say, this should never ever happen again, because it is a
financial disaster for value for money and for taxpayers. </i></span><i>”<o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-bottom: 6pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="background-color: white;">I should also have mentioned the <a href="http://www.nao.org.uk/publications/1213/hinchingbrooke_health_care.aspx">report</a> into the franchising
by the National Audit Office, which was the basis of the Committee’s hearing. Although
measured in its wording, concludes that “<i>The
Authority should work with the Department to undertake a formal lessons learned
process before agreeing any further franchise agreements.”</i> This is on the
basis of a long catalogue of problems, including a lack of clarity about
transfer of risk and what measures of success were being used. One of the
Committee members, used to reading these reports, describes it as <i>“probably the worst report of financial
incompetence in the NHS that we have seen.</i></span><i>”</i> The chair noted that <i>“I haven’t read a Report as bad as this on
the health service. This is probably the worst.”</i><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 6pt;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="background-color: white;">The views of the members suggest a fairly consistent tone of
incredulity, such as <i>“this report is
chock-a-block full of people saying, "Never before anywhere in the NHS has
this level of savings been achieved." McKinsey, who are probably the
consultants who are around the NHS more than anybody, say that they think it is
unachievable. We accept that it is early days. We know from Mr Parsa that they
have not got to where they planned to be when they put the bid in to you. We
know from the document here that they added 25% savings in at the last minute
to give you a viable bid that you could accept. You seriously sit here and
think that that will be achieved? You are seriously doing that?</i></span><i>”<o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-bottom: 6pt;">
<span style="background-color: white;"><span style="font-family: Arial, Helvetica, sans-serif;">Of course, as the evidence presented to the Committee and the
NAO report indicate, there are many serious concerns about the franchising
process, and not just the fact that Circle has a get out clause if it racks up
excessive losses. But then, maybe this is unsurprising, given the description
of the calculation of risk in public-private partnerships as <a href="http://en.wikipedia.org/wiki/Private_finance_initiative">"pseudo-scientific
mumbo-jumbo".</a><o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-bottom: 6pt;">
<span style="background-color: white;"><span style="font-family: Arial, Helvetica, sans-serif;">I do hope that this has put the record straight. The
Committee has not yet reached a considered conclusion on the Hinchingbrooke franchise
but, I would suggest, it is already pretty clear what it is likely to be.</span></span></div>
Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-12562116153616332092012-12-26T11:01:00.001+00:002012-12-26T11:01:43.402+00:00NHS privatisation - we are right to be afraid<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;">Just before Christmas David Cameron’s former
speechwriter, Ian Birrell, wrote in praise of private sector involvement in the
delivery of healthcare (<a href="http://www.guardian.co.uk/commentisfree/2012/dec/20/nhs-privatisation-fears">NHS
privatisation fears? Grow up</a>). It is no secret that many members of the current
government see the NHS, along with the BBC and the Royal Mail, as ripe for
privatisation (or what you and I might describe as untapped opportunities for
profiteering by their friends and supporters in large corporations). Yet Birrell’s
enthusiasm for privatising the NHS overlooks two fundamental characteristics of
private companies. They hate uncertainty (as their advocates tell us again and
again) and they will invest their capital wherever they can be sure of making
the greatest profits. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;">For health care to be attractive to them it is
necessary to distort the delivery of care so much as to make it almost
unrecognisable. As Margaret McCartney has set out in detail in her excellent
book, <a href="http://www.amazon.co.uk/Patient-Paradox-Sexed-Medicine-Health/dp/1780660006">The
Patient Paradox</a>, it must exclude anyone whose condition cannot be put into
a tidy box and costed. Hence, the concern he voices for elderly and disabled
patients seems at odds with the profit imperative to get rid of them, ideally
to the social care sector where their care will be means tested. As we have
shown in a recent <a href="http://ageing.oxfordjournals.org/content/42/1/11.abstract">paper</a>,
this is only part of a multipronged attachment on older people (or as certain
politicians would say, sotto voce, those who have outlived their usefulness). Consequently,
while no-one wants to see older people stuck inappropriately in hospital, we
must consider the motives of those now suggesting that they should never be in
a hospital at all. Recall that, in many cases, it is only possible to know that
someone is entering the final few months of life in retrospect. The exclusion
of old people from the health system will free space needed to screen the
worried well until some harmless anomaly can be found and treated at a
guaranteed profit. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;">Private providers will only contract with the NHS
if the market is <a href="http://www.bmj.com/content/345/bmj.e8082">rigged in their favour</a>, for example by capping their losses as
happened in the deal with Hinchingbrooke Hospital, since condemned by the <a href="http://www.publications.parliament.uk/pa/cm201213/cmselect/cmpubacc/uc789-i/uc78901.htm">Public
Accounts Committee</a>. He invokes Germany as an example of a country where the
private sector is heavily involved in health care delivery but seems unaware of
the very different model of Rhineland capitalism in force there, with trade
unions represented on supervisory boards of firms. The benefits of this
approach over the Anglo-Saxon model we use have been set out at length by <a href="http://www.amazon.co.uk/State-Were-Revised-Britain-Overcome/dp/0099366819">Will
Hutton</a>. The situation in our two countries is entirely different.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;">Birrell’s claim that “competition works in health,
just as it works elsewhere” displays an ignorance of a literature stretching
back fifty years. The theory was set out in 1963 by the Economics Nobel
Laureate <a href="http://www.kaiserhealthnews.org/columns/2010/september/~/media/Files/2010/May%20to%20September/1963Arrow_AER.pdf">Ken
Arrow</a> and the empirical evidence gathered since then. He must surely know
that the research he cites has generated results that are medically implausible
and have been <a href="http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext">heavily
criticised</a>. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.0pt; mso-ascii-font-family: Calibri; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-hansi-font-family: Calibri;">People with complex disorders, cannot be
commodified. The abject failure of the market-based health system in the USA to
improve <a href="http://www.commonwealthfund.org/Publications/In-the-Literature/2012/Aug/Variations-Amenable-Mortality.aspx">health
outcomes</a>, despite spending vast sums of money, should give him pause for
thought. On a whole range of measures, the NHS in the UK <a href="http://www.bmj.com/content/344/bmj.e1079">outperforms those in other
industrialised countries</a>. When someone is proposing something so completely
at odds with the evidence, it is only reasonable to ask why and who will
benefit?</span></span></div>
Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com1tag:blogger.com,1999:blog-37603352.post-21928670241509471142012-08-17T15:59:00.002+00:002012-08-17T15:59:25.866+00:00My perspective on London 2012<span style="font-family: Arial, Helvetica, sans-serif;"><i>This blog originally appeared on the LSHTM site</i></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<br />
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Something quite remarkable has happened to me in the past 10 days. Normally I find televised sport barely more exciting than watching paint dry and I share Dr Samuel Johnson’s view that patriotism is the last refuge of a scoundrel.</div>
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Yet, somehow, I’ve found myself avidly watching sports events that, if I knew they existed (omnium, keirin?) I certainly didn’t understand the rules. Now I’m even beginning to understand what the judges are looking for in gymnastics, beyond not falling off the apparatus. So what has happened?<span id="more-935" style="border: 0px; margin: 0px; padding: 0px; vertical-align: baseline;"></span></div>
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It began even before Danny Boyle’s fantastic opening ceremony. What an amazing surprise! But there was the clue. It was a surprise even though many thousands of people, the performers, the technicians, those present at the rehearsals, knew what was going to happen.</div>
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But they kept it to themselves so that they wouldn’t spoil the surprise for the rest of us. Not because they were threatened with arrest under the many powers that the British government now has to prevent freedom of speech. Rather, because Danny Boyle asked them to.</div>
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And what a surprise! A feat of sheer technical mastery, with the most amazing special effects presented with superb timing. A combination of seriousness (the tribute to the dead in the London bombings the day after London was awarded the Olympics, even if not shown in the version on NBC in the USA) and comedy (combining the queen – not Helen Mirren but the real one – and Mr Bean). But above all, a celebration of Britain, showing where it has come from but also where it is going.</div>
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There was something for everyone, with Chelsea pensioners alongside rap artists. Well, not quite everyone.</div>
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There was Aidan Burley, the Conservative MP who complained on Twitter of “multicultural crap” and a columnist in the Daily Mail who ridiculed the idea that one could find an ethnic minority father living with a white British family in a stable family union. He obviously didn’t know who Jessica Ennis was, but presumably he does now as the story has been removed from the paper’s website.</div>
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But the storm of protest that these comments provoked showed that, at a time when politicians are doing their best to divide us, vilifying migrants (perhaps we need a few more like Mo Farah), older people (like Hiroshi Hoketsu, the 71 year old Japanese equestrian team member who is at his last Olympics as his horse will be too old at Rio), and anyone who is different, the vast majority of the British people realises just how much we benefit from diversity and we will not tolerate those who seek to divide us.</div>
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And of course we have the actual events. For years it has seemed that there has been no association whatsoever between ability and fame in Britain. News stands are lined with “celebrity” magazines telling us the latest exploits of some sad individual plucked off the streets to be exploited by the producers of reality TV, the modern equivalent of the Victorian habit of going to Bedlam to laugh at the lunatics.</div>
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Now they are covered with images of people who really do have talent and, most importantly, have worked to develop it. The commitment that these athletes have made is remarkable. Interviewed after winning Gold in the 10,000 metres, Mo Farah said that running 120 miles a week was hard, and long distance running was lonely. What an understatement!</div>
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Yet, as Malcolm Gladwell wrote in his book Outliers, real success at anything seems to require about 10,000 hours of work. What a difference from today’s celebrities with their 15 minutes of fame.</div>
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Of course, none of this could have happened without the volunteers. People of all ages, smiling and cheerful even in pouring rain, doing everything possible to welcome the world to this great cosmopolitan city. What a contrast to those who sought to exploit the games for profit.</div>
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The reputation of G4S, which so spectacularly failed to provide the security it promised is now in ruins. Coca-Cola and McDonald’s sponsorship of the games has simply attracted attention to the contrast between the health promoting focus of the games and the health damaging effects of their products.</div>
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The involvement of ATOS in the Paralympics, given its treatment of disabled people being assessed for work has appalled those who watched recent television investigations into their practices, is beyond parody.</div>
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But here I am rather more pessimistic. Will anything change? The idea that G4S should receive any money for its lamentable performance is bizarre and, if they do, it begs the question of what was going through the mind of whoever wrote the contract. How can they possibly be allowed to bid for another government contract for many years?</div>
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And now we must look forward to the legacy. These games have surely inspired countless young people to take up sport. Few will become the elite athletes winning medals at future Olympics (although some will). But that is not the point.</div>
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In a country with rapidly increasing rates of childhood obesity, what we need is simply to move us all up a notch on the activity scale. But this means investment. We are forever being told by ministers seeking to cut spending that “it is not simply a matter of money”.</div>
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Maybe not entirely. But Britain’s success (recall the one Gold medal at Atlanta) is very substantially about money. Yet there are now real fears that as soon as the Olympics are over the budget for sport will be slashed.</div>
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This would be a tragedy and the British people must not allow it to happen. What is more important – high quality sports facilities in every school or a nuclear deterrent almost entirely under American control and which no-one can suggest a realistic scenario in which it would ever be used?</div>
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This takes me to my final point. What the Olympics have shown is that government works, whether in its investment in athletes or its stepping in, with the armed forces, when a private corporation fails (yet again).</div>
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If a government funded sports strategy can work so well, why do we seem so determined to avoid a government funded industrial strategy? The reason that politicians were given brains was so that they could learn from experience. Now is the time to break the habit of a lifetime and do so.</div>
Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-873038225493655212012-02-27T19:30:00.000+00:002012-02-27T19:30:11.713+00:00<div class="MsoNormal">Politicians and media pundits from across the political spectrum have been lining up to compare the Health and Social Care Bill to the Poll Tax. The comparisons are obvious. A seemingly simple idea that was scrambled beyond recognition as it was transposed into legislation, that was hugely unpopular, unworkable in practice, and which ended the career of a member of the cabinet and his prime minister. Yet there is a much more recent analogy, Tony Blair’s decision to invade Iraq. The parallels are striking. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Few questioned John Major’s rationale for going to war with Iraq in 1990, given that it had just invaded Kuwait but, a decade later, many people struggled to ascertain quite why we were attacking Iraq, given that the countries most closely linked to the events of September 11<sup>th</sup> were Afghanistan and Saudi Arabia. Similarly, having been promised “no top down reorganisation of the NHS”, many were extremely puzzled when the Prime Minister proposed to do exactly that. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Tony Blair needed to provide evidence to justify his decision, giving the English language the alliterative term “dodgy dossier”. David Cameron had to do the same so he produced statistics that seemed to show the UK underperforming on a wide range of measures, from health outcomes to patient satisfaction and productivity. Yet within days the evidence was discredited. Although deaths from heart attacks had lagged behind France, they were catching up very rapidly and would overtake it with a year or so just by doing more of the same. The public was not clamouring for change; satisfaction with the NHS was at an all time high. And, as a recent Lancet paper showed, the story of declining productivity is a myth.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">But there was other evidence underpinning the government’s case. In 2000 it was secret material that we were unable to see on grounds of national security. Now it is a risk register that must be hidden lest it alarm us.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Of course, Tony Blair could point to the widespread international support he enjoyed. Countries such as Georgia, Macedonia, Latvia and Albania, each contributed a few companies of troops to the overwhelmingly Anglo-American effort, encouraged by some judiciously targeted financial support. Yet the big guns, such as France, were missing this time round. David Cameron can also point to support, from groups such as National Association of Primary Care, which on a good day could also contribute the equivalent of a few companies, although as disillusionment has set in even among these groups, it might be more optimistic to hope for a platoon. In contrast, the Royal College of General Practitioners, comprising the equivalent of four NATO divisions, is displaying open disdain. Almost all of the other Royal Colleges, each of which could contribute at least a few brigades, are equally perplexed, with the few that continued to believe that the government must understand what it is doing, such as the paediatricians and physicians, finally jumping ship, just as Turkey when it realised the folly it risked being sucked in to. Then there are organisations that have discovered, to their bemusement, their names listed among supporters of the Bill (or at least of its highly debated “intentions”) when they are nothing of the sort, just as Costa Rica and the Solomon Islands had to ask to be removed from the list of members of the “coalition of the willing”. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">In 1990, Tony Blair made clear that, once the troops had deployed to Saudi Arabia, there was no going back, regardless of what decisions were made by the UN Security Council, in the same way that events in the first few weeks of the First World War were dictated by the railway timetables. Once started, they could not be stopped. In 2012, even though the Bill has not even been approved by parliament, and indeed if it is, it is unlikely to bear much resemblance to what it looks like now, David Cameron says that it is essential to advance and any delay will cause chaos. Those warning that chaos will instead be the consequence of advance are ignored.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">In 2000 the invading troops were closely pursued by a pack of multi-national corporations, such as Blackwater and Haliburton, salivating at the prospects of the vast profits they were about to make, accompanied by organisations whose ownership and business model was opaque in the extreme. In 2012, the Health and Social Care Bill is being pushed forward by a different set of corporations, such as McKinsey & Co and KPMG, again accompanied by operations such as Circle Health, whose business model in Hinchingbrooke Hospital remains a mystery to outside observers.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Finally, there is the aftermath. Few believe that life under Saddam Hussein was perfect. Yet what came after was far, far worse. What will happen if the Health and Social Care Bill is enacted is a matter of speculation. However, virtually all academic analyses have concluded that what emerges will be more expensive, fragmented, and dysfunctional.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">David Cameron has frequently claimed to be continuing policies on public sector reform begun by Tony Blair. History will judge whether this is the only thing that these two prime ministers have in common. Indeed, there may be a case for booking Sir John Chilcot and his inquiry team to stay on to explain how we failed to learn from experience yet again. </div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com4tag:blogger.com,1999:blog-37603352.post-51195528332415481212012-01-30T14:12:00.001+00:002012-01-30T14:12:21.306+00:00I'm grateful to Lucy Reynolds for additional analysis of the latest YouGov poll on attitudes to the Health and Social Care Bill. The survey was of 1601 NHS staff and was conducted between 17th and 20th January 2012.<br />
<br />
If you take out the don't knows, the figures work out like this:<br />
<div><strong>Of those who expressed an opinion:</strong></div><div><div></div><div><strong>80% expect the new system to be more costly, 89% think it will increase bureaucracy, and 78% think it will be more fragmented. 84% expect quality of care to deteriorate as a result of the passage of the Bill. </strong></div><div></div><div><strong>91% think the reform will introduce too much competition, and 87% expect privatisation of services to increase. 83% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.</strong></div><div></div><div><strong>80% consider that the Health and Social Care Bill should be withdrawn entirely. </strong><strong></strong></div><div></div><div><strong>71% think that Andrew Lansley is failing in his role as Secretary of State. </strong></div><div></div><div><strong>77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available. </strong></div><div></div></div><div> </div><div>Raw data (before correction to remove don't knows):</div><div>72% expect the new system to be more costly, </div><div>83% think it will increase bureaucracy, and </div><div>68% think it will be more fragmented. </div><div>74% expect quality of care to deteriorate as a result of the passage of the Bill. 81% expect privatisation of services to increase. </div><div>Two-thirds of people polled think that the Lansley reform will make the NHS worse (66%) and that the Health and Social Care Bill should be withdrawn entirely (65%). </div><div>84% think it will introduce too much competition. </div><div>78% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.</div><div>71% think that Andrew Lansley is failing in his role as Secretary of State. </div><div>77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available. </div><div></div><div><div>See the detail on: </div><div><div></div><div><a href="http://library.constantcontact.com/download/get/file/1102665899193-831/YouGov+NHS+survey+results.pdf">http://library.constantcontact.com/download/get/file/1102665899193-831/YouGov+NHS+survey+results.pdf</a></div><div></div></div></div> Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-19748315359605542342011-10-07T08:08:00.000+00:002011-10-07T08:08:23.141+00:00<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-margin-top-alt: auto;"><i><span style="font-family: 'Arial Narrow', sans-serif;"></span></i></div><div align="center" class="MsoNormal" style="display: inline !important; line-height: normal; margin-bottom: 0.0001pt; text-align: center;"><i><span class="Apple-style-span" style="font-size: 19px;"><b>Lucy Reynolds and I offer our views on the provisions for competition in provision in the Health and Social Care Bill</b></span></i></div><i><span style="font-family: 'Arial Narrow', sans-serif;"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center;"><span class="Apple-style-span" style="font-size: 19px;"><b><br />
</b></span></div></span></i><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-margin-top-alt: auto;"><i><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Segoe UI"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">“It is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner but their regard to their own self-interest.”<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Adam Smith, 1776<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn1" name="_ednref1" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[1]</span></span><!--[endif]--></span></span></a><o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-margin-top-alt: auto;"><br />
</div><div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 26.05pt; margin-top: 5.0pt;"><i><span style="font-family: "Arial Narrow","sans-serif"; mso-bidi-font-family: "Segoe UI";">“That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg is enough to make one despair of political humanity.”<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto; text-indent: 14.2pt;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">George Bernard Shaw 1913</span><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn2" name="_ednref2" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Segoe UI";"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Segoe UI"; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[2]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><br />
</div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><br />
</div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">EXECUTIVE SUMMARY<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Without basis in any solid evidence, the NHS is about to undergo a market reform which may well be, for all practical purposes, irreversible. It is likely to cost the country much more than the existing system, because of extra bureaucracy, loss of economies of scale and full bargaining power with suppliers, maintenance of redundant capacity, and the need to cover return to capital and the costs of commercial borrowing. It will deliver less, not just because of the diversion of effort into the copious administration of commissioning and contracting, but because the embedded incentives of market-based healthcare will lead to physician-induced demand (unneeded tests and treatment undertaken to increase provider income, which may harm patients subjected to them). More effective regulation will be needed to control the problems to which this system is prone, again elevating costs. Overall, the reforms will reduce the quantity of front-line care which can be provided for each pound of the NHS budget spent.<span> </span>This paper comments specifically on the theoretical weakness of the Cooper and Propper econometric studies which are being used to justify the reform. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">In conclusion, the proposed market-based reform to the NHS will be an expensive step in the wrong direction.<span> </span>It was rushed through the Commons and its content needs to be carefully scrutinised: in addition the policy consequences of adopting a market-based reform should be examined.<br clear="all" style="mso-special-character: line-break; page-break-before: always;" /> <o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">FIGURE 1<o:p></o:p></span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEib0LpY-RNAfOlNXyX3TU1aTBOZopINf_b95DXxgIfzdX9tu8UsANjnZZSoBe_WZgC_rSWBbb9gR4PCWkEjtSH_a6tGUmnaDAC6nWIoBV8pk26rna7hg81RbrHA6arsZ4_T_9Iljw/s1600/fig+1.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEib0LpY-RNAfOlNXyX3TU1aTBOZopINf_b95DXxgIfzdX9tu8UsANjnZZSoBe_WZgC_rSWBbb9gR4PCWkEjtSH_a6tGUmnaDAC6nWIoBV8pk26rna7hg81RbrHA6arsZ4_T_9Iljw/s400/fig+1.jpg" width="400" /></a></div><div class="MsoListParagraph" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;"><br clear="all" style="page-break-before: always;" /> </span> <div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">FIGURE 2<o:p></o:p></span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpFTG180htpKdRgkG2SoVdst00RtvZYrVKHCFhPfStey7mE6QHRyv_41ikV-g4Nqf3KLREnQ8ohgpiKQVpkmiRKuhMc-KsAB6nbZ7uM_XPDnxARhm-NH35N5t8vOo8Kku6UKKwzA/s1600/fig+2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpFTG180htpKdRgkG2SoVdst00RtvZYrVKHCFhPfStey7mE6QHRyv_41ikV-g4Nqf3KLREnQ8ohgpiKQVpkmiRKuhMc-KsAB6nbZ7uM_XPDnxARhm-NH35N5t8vOo8Kku6UKKwzA/s400/fig+2.jpg" width="400" /></a></div><div class="MsoListParagraph" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" /> </span> <div class="MsoNormal"><br />
</div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Introduction<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">This market-based reform (see Figures 1 and 2 above for the financial changes involved) has been presented to the electorate as essential in the interests of cost-saving for the taxpayer. It has been justified on the basis of saving money and improving outcomes, neither of which hold up to more than cursory inspection.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><br />
</div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">The only “evidence” that competition can benefit healthcare performance is at best debatable <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">After a quarter of a century of assertions that competition benefits healthcare<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn3" name="_ednref3" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[3]</span></span><!--[endif]--></span></span></a>, lobbyists finally, in 2010-11, found three UK-based studies which purport to test and prove this theory.<span> </span>They are<sup> </sup>known as the Cooper et al paper<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn4" name="_ednref4" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[4]</span></span><!--[endif]--></span></span></a> and the Propper et al<a href="" name="_Ref305618088"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn5" name="_ednref5" title=""><span><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[5]</span></span><!--[endif]--></span></span></span></a><span></span><sup>,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn6" name="_ednref6" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[6]</span></span><!--[endif]--></span></span></a></sup> studies.<sup> <o:p></o:p></sup></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">As these authors could not measure competition <i>per se</i> they used the density of service provision as a proxy, comparing it with routine health service data on heart attack mortality. These three papers stand against a background of many other studies which do not find a positive association (as noted in a review of the literature in one of them</span><span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">5</span></sup><!--[if gte mso 9]><xml> <w:data>08D0C9EA79F9BACE118C8200AA004BA90B02000000080000000E0000005F005200650066003300300035003600310038003000380038000000</w:data> </xml><![endif]--></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">) and in contrast to the theoretical case for why market-based competition in healthcare would be harmful, as set out by the Nobel Laureate Kenneth Arrow and explained in section 4 below. While the three papers contain elaborate mathematical models corrected for many relevant confounding factors including distance to hospital, they suffer from a basic scientific error, the confusion of association and causation: they document the former and impute the latter. A small but perceptible difference in the outcomes before and after the introduction of small-scale competition mechanisms in the NHS is present, but the authors do not offer any convincing mechanism for how reduction of heart attack mortality might result from higher hospital density (which, as noted, they treat as a proxy for greater market competition between providers). Instead they postulate a general “halo” effect of greater operational efficiency arising from bidding for some types of work in the same hospitals that treat heart attacks, via a more “competitive” culture. Alternative explanations for the outcomes generated from the models they have devised exist, such as under-correction for the time taken for ambulances to drive heart attack patients to the nearest hospital. They also ignore the possibility of “upcoding”, although this exaggeration of the gravity of illness in incoming patients is a well-known consequence of paying hospitals according to the quantity and type of cases they treat<a href="" name="_Ref305615857"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn7" name="_ednref7" title=""><span><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[7]</span></span><!--[endif]--></span></span></span></a><span></span>, a change which is part of the competitive internal market introduced in the NHS. If hospitals are judged on mortality and outcome data there is an incentive to record medical problems as more severe than they are, a practice that is hard to detect even by tracking back to case notes. For this overlooked explanation both motive and mechanism are evident, and so is much precedent</span><span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">7</span></sup><!--[if gte mso 9]><xml> <w:data>08D0C9EA79F9BACE118C8200AA004BA90B02000000080000000E0000005F005200650066003300300035003600310035003800350037000000</w:data> </xml><![endif]--></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">. Even if there is a true effect, these studies provide no evidence that it was competition that brought it about: it could as easily have been due to other changes taking place at the same time. None of these papers actually provide any evidence that the market competition reform proposed will in any way improve the NHS, and their citation as the best proof available tells its own story.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">Contrary to the government’s line, the new arrangements will be much more expensive than the Beveridge system that they replace<a href="" name="_Ref305605435"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn8" name="_ednref8" title=""><span><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[8]</span></span></span></span></span></a><span></span>. The change will benefit only corporate market entrants, many of them foreign. The main reasons for the extra costs are:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-top-alt: auto; text-indent: -10.35pt;"><!--[if !supportLists]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><!--[endif]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Fragmentation of purchasing among more entities <o:p></o:p></span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">The single purchaser system that the NHS has moved away from in recent years can provide excellent value for money. This is demonstrated by the success of the PHARMAC single purchasing agency in New Zealand</span><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn9" name="_ednref9" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman";"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[9]</span></span></span></span></span></a><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">,</span></sup><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn10" name="_ednref10" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman";"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[10]</span></span></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">, and the contrasting failure of cost control in many parts of the American health care market<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn11" name="_ednref11" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[11]</span></span></span></span></a>. The arrangement we are moving to, with purchasing decentralised into hundreds of consortia, involves multiplication of procurement arrangements, reducing the bargaining power of each purchasing entity, and requiring creation of extra bureaucracy to enable this more costly arrangement.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto; text-indent: -10.35pt;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;"> </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-top-alt: auto; text-indent: -10.35pt;"><!--[if !supportLists]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><!--[endif]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Competition between providers involves redundant capacity and loss of economies of scale<o:p></o:p></span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">Government insistence on trying to run the system through “consumer choice” (a nonsense in this context, as explained in section 4 below) involves the need for redundant capacity; providers will need to charge more for the services they do provide in order to cover the costs of having capacity lying idle in order merely to allow creation of a competitive market.<span> </span>In addition, market competition generally involves spending on marketing. <span> </span>Obviously, unification of provision as in the Beveridge-system NHS allows services to be supplied more cheaply because of economies of scale, avoidance of redundant capacity and no need to spend money on marketing.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-top-alt: auto; text-indent: -10.35pt;"><!--[if !supportLists]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><!--[endif]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Shift to individual billing to facilitate competition between providers multiplies bureaucracy<o:p></o:p></span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">To facilitate competition between providers, the future arrangement in the NHS will be that “the money follows the patient”, in the words of the White Paper. This results in a shift from efficient pooling of cost and risk across the nation toward the use of individual healthcare budgets. The change will require both providers and commissioning groups to maintain administrative capacity to set up and monitor individual billing.<span> </span>Again this requires a multiplication of unnecessary bureaucracy which provides no benefit to patients, while increasing costs to the taxpayer.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-top-alt: auto; text-indent: -10.35pt;"><!--[if !supportLists]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><!--[endif]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">The structural problem of supplier-induced demand results from competition in healthcare <o:p></o:p></span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">Henceforth all hospitals will be required to generate their income from selling services to private patients or to Clinical Commissioning Groups (CCGs: composed of GPs and others). This is to occur through what is known in general as fee-for-service and in the NHS as “payment by results”, although in fact it is activity not results which is rewarded. Except for a few facilities which offer essential services which are otherwise unavailable, they will need to cover their costs from such sales or face insolvency and closure. The government has explicitly rejected calls from the Chief Executive of the NHS to maintain the mechanism for a failing hospital to be taken back into public ownership<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn12" name="_ednref12" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[12]</span></span></span></span></a>. Hospitals will be permitted to retain any profits they make, for reinvestment or payment to their shareholders or partners.<span> </span>This arrangement ensures that hospital staff are keen to provide services, and is represented as encouraging them to maximise efforts to provide patient-friendly service of high medical quality so as to generate repeat custom and patient recommendations.<span> </span>However, it also incentivises clinicians to recommend and provide services that are unnecessary or of marginal medical benefit, and hospital managers to overprice services where this can be arranged. In this era of light-touch regulation<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn13" name="_ednref13" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[13]</span></span></span></span></a>, both of these undesirable options would be much easier and cheaper to arrange than genuine improvements in service provision, and would more reliably boost the bottom line. One corporation that is now offering commissioning services to our CCGs<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn14" name="_ednref14" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[14]</span></span></span></span></a> has previously found it necessary to compensate the US government following allegations of its fraud against the Medicare scheme<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn15" name="_ednref15" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[15]</span></span></span></span></a>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">The setting of a fixed tariff for each procedure is intended to block over-pricing, but experience in countries which use this system shows that the profit-making provider’s response to this form of control is to miscategorise patients’ conditions, so that they are registered as suffering a more severe medical condition than is actually the case, “upcoding” or“DRG-creep”<a href="" name="_Ref305441186"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn16" name="_ednref16" title=""><span><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[16]</span></span></span></span></span></a><span></span>.<span> </span>A patient miscategorised in this way could be treated more aggressively than is appropriate to their condition, so might for instance undergo unneeded surgery or suffer side-effects from treatment with stronger medication than appropriate. The patient may thus be harmed in order to generate money for the provider.<span> </span></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">The planned new system will be vulnerable to this sort of malpractice because the rationalisation for this market based reform (welfare economics and its offshoot public choice theory<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn17" name="_ednref17" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[17]</span></span></span></span></a>) relies on a consumer versus supplier model which does not fit healthcare.<span> </span>In this model, providers wishing to sell more services at higher prices to generate more profits oppose customers trying to acquire the services they need in adequate quantities at lower prices, and the two come to a mutually agreeable arrangement. This model relies on a number of assumptions including one which is rarely met in the case of medical services, as explained in 1963 by the economics Nobel Laureate Kenneth Arrow<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn18" name="_ednref18" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[18]</span></span></span></span></a>, the possession by both buyers and sellers of complete information about the nature and quality of the services to be supplied.<span> </span>Such symmetry of information allows a balance of power between buyer and seller to facilitate a fair negotiation process between these two principals in the transaction.<span> </span>However, this is evidently not the situation where medical services are concerned. Few patients are medically qualified, and they visit doctors in order to ask what is wrong with them and how it may be treated. That is, the patient relies on the clinician to provide advice as their agent.<span> </span>When the clinician is also allowed or required to act as a seller of services, the two roles of agent for the patient and principal in the transaction can come into direct conflict, resulting in an increase in demand (through an upward shift of the demand curve in economist’s jargon) induced by the physician’s inclination to increase income by maximising services provided<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn19" name="_ednref19" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[19]</span></span></span></span></a>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">Where the survival of the service and the owners’ requirements for financial returns put pressure on clinicians to increase the money they bring in by selling more services to patients, the stage is set for systematic exploitation of patients’ ignorance through unneeded billable tests and investigations, diagnosis of minor problems as severe, unnecessary treatment, and over-aggressive treatment<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn20" name="_ednref20" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[20]</span></span></span></span></a>.<span> </span>The ability of a patient-consumer to assess the quality of medical services received is for many types of treatment limited to such peripheral issues as waiting time, comfort of waiting rooms and wards, and friendliness of staff, while the clinician-seller is able to exploit their inability to detect profit-led over-treatment, possibly at the cost of subjecting the patient to the side-effects and risks of unnecessary procedures.<span> </span>In the future NHS, the proposed use of “fee for service” payment arrangements for clinical services adds a dimension of moral hazard, incentivising this form of abuse. Where exploitation does not ensue, it is because the professional ethics of the medical profession constrain it.<span> </span>But unnecessarily creating such a temptation is surely unwise.<span> </span></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">The more market-driven the health care system the more it is prone to this problem:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 26.05pt; mso-layout-grid-align: none; mso-margin-top-alt: auto; text-autospace: none;"><i><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Comparing two societies of similar economic and cultural status, in 1993 doctors in the US performed hysterectomies two and a half times as often as doctors in Sweden, and caesarean sections twice as often. And doctors in the US performed 4.4 times more coronary bypasses than doctors in Canada.<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 26.05pt; mso-layout-grid-align: none; mso-margin-top-alt: auto; text-autospace: none;"><i><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Another revealing comparison can be made between certain professions and everyone else. The American Medical Association conducted a study of medical intervention in cases of stage II prostate hypertrophy. They asked urologists what they would do if it were their own case. Just 40.5% of urologists asked said they would opt to have a transurethral prostate resection, yet for the population as a whole the rate of transurethral resections actually carried out in cases of stage II prostate hypertrophy was 80%.<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn21" name="_ednref21" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[21]</span></b></span><!--[endif]--></span></span></a><o:p></o:p></span></i></div><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">The Economist calculated that the market-driven, corporate-dominated US health care system in 2009 generated between $250 and $325 billion of charges for unnecessary care; this comprised 10-12% of US healthcare spending that year<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn22" name="_ednref22" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[22]</span></span><!--[endif]--></span></span></a>. <o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-top-alt: auto; text-indent: -10.35pt;"><!--[if !supportLists]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><!--[endif]--><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">The proposed means of controlling the extra cost of supplier-induced demand involves a second layer of profit-taking and incentivises denial of needed care<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">It is well-known by health economists that fee-for-service medical provision causes inflation of medical spending<a href="" name="_Ref305615637"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn23" name="_ednref23" title=""><span><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[23]</span></span><!--[endif]--></span></span></span></a><span></span>.<span> </span>This is the reason why the US medical system provides such poor value, consuming 18% of GDP (compared to our 8%) and yet leaving a high proportion of the population without access to decent medical care (according to the Commonwealth Fund report comparing seven developed world health systems<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn24" name="_ednref24" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[24]</span></span><!--[endif]--></span></span></a>). Because medical providers in the USA are too politically powerful for the government to be able to introduce the universal coverage the population<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn25" name="_ednref25" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[25]</span></span><!--[endif]--></span></span></a> and the President<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn26" name="_ednref26" title=""><span class="MsoEndnoteReference"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[26]</span></span><!--[endif]--></span></span></a> would prefer, other means have had to be found to try to contain soaring medical costs. A mechanism, “managed care”, was devised to oppose the incentive for providers to over-treat with another which uses the profit incentive to motivate limitation of the amount of care provided.<span> </span>This is the arrangement which the Health and Social Care Act would move us to, with commissioning at GP level used to restrain overcharging by hospitals through gate-keeping of referrals. <b><o:p></o:p></b></span></div><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">In this model, managed care is undertaken by health maintenance organisations (HMOs) which invite members of the public to pay an annual insurance premium in order to access treatment for any new illness that befalls them (in our new system this premium will initially be fully replaced by an allowance from the NHS budget, which will for now also cover treatment for pre-existing conditions).<span> </span>The HMOs employ doctors who diagnose and recommend referral to hospitals as appropriate (as our GPs do).<span> </span>The HMOs keep any difference between the total of the premiums they receive and the care they pay for (as our CCGs will).<span> </span>This creates a financial incentive for the HMO (or CCG) to reduce total referral cost.<span> </span>Proponents emphasise that this deters referrals undertaken more to keep the patient happy than for any medical benefit, and that it creates a financial incentive for referring doctors to control the amounts charged by referral services. Both are good goals if provision is under fee-for-service arrangements, which encourages excessive charges, as explained above.<span> </span>Medically qualified HMO employees are more knowledgeable customers than are patients, and can better control supplier-induced demand, also clearly beneficial.<span> </span>Unfortunately for patient welfare, the crude use of the profit motive also incentivises refusal to refer patients for services justified on the basis of medical need.<span> </span><o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 25.1pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">Criteria for assessing efficiency in medical service provision should involve the correct and timely treatment of medical conditions which are amenable to treatment. Instead, managed care applied to profit-making provision simultaneously gives rise to both under-treatment (exclusion from medically needed care because of denial of referrals<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn27" name="_ednref27" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[27]</span></span></span></span></a>) and over-treatment (medical procedures undertaken for the benefit of providers not patients<a href="" name="_Ref305605181"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn28" name="_ednref28" title=""><span><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[28]</span></span></span></span></span></a><span></span>).</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">These mismatches occur because the choices triggered by the profit motive map poorly on to the priorities set by the meeting of medical need. It is known that financial incentives raise doctors' activity levels<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn29" name="_ednref29" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[29]</span></span></span></span></a> but this does not translate to better health outcomes unless doctors paid this way are underprovided in a community, in which case more activity might improve outcomes. If they are oversupplied and competing for business, then providers’ need to make a living incentivises overtreatment</span><span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">28</span></sup></span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn30" name="_ednref30" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[30]</span></span></span></span></a></span></sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">. Since no treatment is devoid of adverse effects, poorer outcomes ensue</span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">28</span></sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">.<span> </span>If the market competition that the government insists is central to the reform<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn31" name="_ednref31" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[31]</span></span></span></span></a><sup>,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn32" name="_ednref32" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[32]</span></span></span></span></a> </sup>is introduced throughout the system, we will be in the second situation, where competition between providers for enough patients to cover their fixed costs (rent, salaries, etc) will create motive and opportunity for exploitation of patients.<span> </span>As noted by a concerned QC, it is also likely to create stresses on staffing caused by cost-cutting which could result in many more medical errors<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn33" name="_ednref33" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[33]</span></span></span></span></a>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">In contrast, the Beveridge system does not encourage overtreatment, overcharging or denial of needed care, because doctors are under no financial pressure to over-treat patients. It scores highly on value for money</span><span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">8</span></sup></span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">,<a href="" name="_Ref305605568"></a><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn34" name="_ednref34" title=""><span><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[34]</span></span></span></span></span></a></span></sup><span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">, quality of health outcomes<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn35" name="_ednref35" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[35]</span></span></span></span></a><sup>,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn36" name="_ednref36" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[36]</span></span></span></span></a></sup>, and patient satisfaction<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn37" name="_ednref37" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[37]</span></span></span></span></a>, and produces a system where clinician efforts are expended on addressing medical need not on generating income. The proposed reform involving two extra layers of profit and a great deal of unnecessary administration being extracted from the NHS budget for hospital treatment appears to be in the interests of neither patients nor taxpayers; it may however produce a bonanza for foreign corporations<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn38" name="_ednref38" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[38]</span></span></span></span></a> and plenty of new work for accountants and lawyers<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn39" name="_ednref39" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[39]</span></span></span></span></a><sup>,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn40" name="_ednref40" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[40]</span></span></span></span></a></sup>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: "Arial Narrow"; mso-fareast-font-family: "Arial Narrow";"><span>6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Privatisation will increase the costs of regulating adequately; failure to do so will result in abuse of patients</span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto; text-indent: -10.35pt;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">It should be noted that once the reform has loaded our health system with incentives to over-treat patients, deny referrals, falsify or withhold information on patient outcomes and to maximise corporate profits, the cost of regulating adequately will rise.<span> </span>Failure to do so will save money on “red tape” but at the cost of harming vulnerable people and squandering taxpayers’ money.<span> </span>We can see how this works in practice from the poor record of the Care Quality Commission, for example at Winterbourne View<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn41" name="_ednref41" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[41]</span></span></span></span></a><span class="MsoEndnoteReference"> </span>, mainly due to an underfunded regulatory system which operated largely on the basis of self-certification and not inspection.<span> </span>It should be noted that recruitment advertising for the CQC over the past year has not required any medical qualification for any post<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn42" name="_ednref42" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[42]</span></span></span></span></a>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><br />
</div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Conclusion</span></b><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">While it is clear that ways exist to improve the Beveridge system NHS, it is equally plain that replacing it with a market-driven health system is a move in the wrong direction which is likely to harm patients and waste scarce resources.<span> </span></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">Market competition in healthcare does not produce desirable results, a conclusion evident from inspection of medical systems which rely upon it and also from economic theory. Despite the highest spending in the world both as a proportion of GDP and as a per capita figure, health outcomes achieved in the USA are mediocre: for instance, in 2010, the US was 44<sup>th</sup>/193 in the world ranking for the probability of dying by age five</span><span><sup><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">34</span></sup></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">. In the past decade, <span> </span>the American health care system has made minimal progress in reducing deaths from causes amenable to medical care (the UK Department of Health’s chosen high level indicator of health system performance), falling increasingly far behind other industrialised nations; in the UK, progress on this measure has been among the fastest<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn43" name="_ednref43" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[43]</span></span></span></span></a>.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">This “reform” serves only corporate interests. They will gain new profit opportunities, as recently explained by Earl Howe to an audience of private sector investors<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn44" name="_ednref44" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[44]</span></span></span></span></a>, and by past NHS Director Mark Britnell to a group of US private equity companies<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn45" name="_ednref45" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[45]</span></span></span></span></a> as follows:</span></div><div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; mso-add-space: auto; mso-margin-top-alt: auto;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p> </o:p></span><i><span style="font-family: "Arial Narrow","sans-serif";">“In future, the NHS will be a state insurance provider not a state deliverer. In future ‘any willing provider’ from the private sector will be able to sell goods and services to the system. The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.</span></i></div><h2 style="margin-bottom: 5.0pt; margin-left: 1.0cm; margin-right: 26.05pt; margin-top: 5.0pt;"><i><span style="font-family: 'Arial Narrow', sans-serif; font-size: 11pt;">GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process. <o:p></o:p></span></i></h2><h2 style="margin-bottom: 5.0pt; margin-left: 1.0cm; margin-right: 26.05pt; margin-top: 5.0pt;"><i><span style="font-family: 'Arial Narrow', sans-serif; font-size: 11pt;">The monolithic arm of state control will be relaxed which will provide a huge opportunity for efficient private sector suppliers.”<o:p></o:p></span></i></h2><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; mso-add-space: auto; mso-margin-top-alt: auto;"><span class="Apple-style-span" style="font-family: 'Arial Narrow', sans-serif; font-size: 16px;">We believe the Bill as presently worded is largely unworkable, while attempts to implement it are likely to increase costs and reduce the level and quality of care that is provided. It is laden with incentives for opportunistic behaviour. Furthermore, as noted by the House of Lords Constitution Committee,<a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_edn46" name="_ednref46" title=""><span class="MsoEndnoteReference"><span><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[46]</span></span></span></span></a> it is potentially unconstitutional. The Secretary of State has condemned his critics for relying on anecdote rather than evidence. In this paper we have presented the evidence that, we argue, he must respond to if he is to make a convincing case that his Bill should be passed.</span></div><div class="MsoNormal"><br />
</div><div> <hr align="left" size="1" width="33%" /> <!--[endif]--> <div id="edn1"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref1" name="_edn1" title=""></a><b><span style="font-size: 12.0pt;">REFERENCES <o:p></o:p></span></b></div><div class="MsoEndnoteText" style="margin-bottom: 3.0pt;"><br />
</div><div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[1]</span></span><!--[endif]--></span></span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Smith A. 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Competition and the 1987-2011 NHS reform. BMJ 2011 http://www.bmj.com/content/343/bmj.d4136.full/reply#bmj_el_267122<o:p></o:p></span></h2></div><div id="edn4"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref4" name="_edn4" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[4]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Cooper Z, Gibbons S, Jones S, McGuire A. Does hospital competition save lives? Evidence from the English patient choice reforms. 2010. http://eprints.lse.ac.uk/28584/1/WP16.pdf.<o:p></o:p></span></div></div><div id="edn5"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref5" name="_edn5" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[5]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Gaynor M, Propper C, Serro RM. Death by market power: reform, competition and patient outcomes in the NHS. 2010. www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdf.<o:p></o:p></span></div></div><div id="edn6"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref6" name="_edn6" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[6]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span> </span>Bloom N, Propper C, Seiler S, van Reenen J. The impact of competition on management quality: evidence from public hospitals. Centre for Economic Performance discussion paper No 983, 2010. http://cep.lse.ac.uk/pubs/download/dp0983.pdf.<o:p></o:p></span></div></div><div id="edn7"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref7" name="_edn7" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[7]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Pitches D, Burls A, Fry-Smith A. 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BMJ 327 : 1436 doi: 10.1136/bmj.327.7429.1436 (Published 18 December 2003)<o:p></o:p></span></div></div><div id="edn8"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref8" name="_edn8" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[8]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Pritchard C, Wallace MS. Comparing the USA, UK and 17 Western countries' efficiency and effectiveness in reducing mortality. J R Soc Med Sh Rep 2011;2:60; doi: 10.1258/shorts.2011.011076<o:p></o:p></span></div></div><div id="edn9"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; tab-stops: 14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref9" name="_edn9" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[9]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>New Zealand Government http://www.pharmac.govt.nz/<o:p></o:p></span></div></div><div id="edn10"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref10" name="_edn10" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[10]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Cumming J, Mays N, Daubé J. How New Zealand has contained expenditure on drugs. BMJ 2010;340:c2441. </span><a href="http://www.bmj.com/cgi/cR"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt; text-decoration: none;">http://www.bmj.com/cgi/c</span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">ontent/extract/340/may18_1/c2441<o:p></o:p></span></div></div><div id="edn11"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref11" name="_edn11" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[11]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> 2011 Milliman Medical Index: healthcare costs for American families double in less than nine years. May 2011. http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf</span><span style="font-size: 12.0pt;"><o:p></o:p></span></div></div><div id="edn12"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref12" name="_edn12" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[12]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Watt N. NHS chief challenges Andrew Lansley's foundation hospitals plan. 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Health Policy Insight 14 September 2011. http://healthpolicyinsight.com/?q=node/1227<o:p></o:p></span></div></div><div id="edn14"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref14" name="_edn14" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[14]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> http://www.unitedhealthuk.co.uk/WhatWeDo/GPCommissioning.aspx<o:p></o:p></span></div></div><div id="edn15"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref15" name="_edn15" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[15]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> </span><a href="http://www.justice.gov/opa/pr/2004/December/04_civ_788.htm"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">http://www.justice.gov/opa/pr/2004/December/04_civ_788.htm</span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> , http://www.californiahealthline.org/articles/2004/8/13/travelers-unitedhealth-settle-medicare-fraud-lawsuit-for-206-million.aspx<o:p></o:p></span></div></div><div id="edn16"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref16" name="_edn16" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[16]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Simborg DW. 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Extract from: 'The Future of Health and Public Service Regulation' Speech 09 July 2005. http://www.andrewlansley.co.uk/newsevent.php?newseventid=21<o:p></o:p></span></div></div><div id="edn32"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref32" name="_edn32" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[32]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Johnstone R. 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Andrew Lansley accused of burying poll showing record satisfaction with NHS: Ministers are said to be withholding survey results that undermine health secretary's case for urgent radical reforms Guardian 19 March http://www.guardian.co.uk/society/2011/mar/19/nhs-andrew-lansley-healthcare-reform<o:p></o:p></span></div></div><div id="edn38"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref38" name="_edn38" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[38]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Player S, Leys C. 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Hospital Dr 22nd November 2010 http://www.hospitaldr.co.uk/features/the-people-behind-liberating-the-nhs-reform-part-3<o:p></o:p></span></div></div><div id="edn39"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref39" name="_edn39" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[39]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Munro R. Emergency Service. Accountancy Magazine. June 2011. http://www.accountancymagazine.com/croner/jsp/Editorial.do?BV_SessionID=@@@@1340474970.1308684704@@@@&BV_EngineID=cccgadfdljdkkfgcflgceggdfnfdgfg.0&channelId=-305535&contentId=1571525<o:p></o:p></span></div></div><div id="edn40"> <div style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref40" name="_edn40" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[40]</span></span><!--[endif]--></span></span></span></a><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">Reynolds L, McKee M. GP commissioning and the NHS reforms: what lies behind the hard sell? Journal of the Royal Society of Medicine, in press<o:p></o:p></span></div></div><div id="edn41"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref41" name="_edn41" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[41]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> The Press Association. CQC publishes critical report of Castlebeck abuse failings. Nursing Times19 July, 2011. http://www.nursingtimes.net/nursing-practice/clinical-specialisms/public-health/cqc-publishes-critical-report-of-castlebeck-abuse-failings/5032741.article</span><span style="font-size: 12.0pt;"><o:p></o:p></span></div></div><div id="edn42"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref42" name="_edn42" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[42]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> <span> </span>Bousfield A. The Care Quality Commission and Turkeys. Medical Harm. September 15, 2011. http://medicalharm.org/uncategorized/the-care-quality-commission/</span><span style="font-size: 12.0pt;"><o:p></o:p></span></div></div><div id="edn43"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref43" name="_edn43" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[43]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Nolte E, McKee M. Variations in amenable mortality </span><span style="font-family: "MS Gothic"; font-size: 12.0pt; mso-ascii-font-family: "Arial Narrow"; mso-bidi-font-family: "MS Gothic";">‑</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: Calibri;"> trends in 16 high</span><span style="font-family: "MS Gothic"; font-size: 12.0pt; mso-ascii-font-family: "Arial Narrow"; mso-bidi-font-family: "MS Gothic";">‑</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; mso-bidi-font-family: Calibri;">income nations. Health Policy 2011; doi:10.1016/j.healthpol.2011.08.002</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><o:p></o:p></span></div></div><div id="edn44"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref44" name="_edn44" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[44]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Pulse Online. ‘Big opportunities’ for private sector in health bill, says minister PULSE 7 September 2011 http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/12663018/big-opportunities-for-private-sector-in-health-bill-says-minister<o:p></o:p></span></div></div><div id="edn45"> <div class="MsoEndnoteText" style="margin-bottom: 3.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref45" name="_edn45" title=""><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[45]</span><!--[endif]--></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Apax Partners conference, Opportunities Post Global Healthcare Reforms, October 2010 http://www.powerbase.info/images/f/fe/Apax_Healthcare_conference_2010.pdf<o:p></o:p></span></div></div><div id="edn46"> <div class="MsoEndnoteText" style="margin-left: 14.2pt; text-indent: -14.2pt;"><a href="file:///C:/Users/Martin/AppData/Local/Temp/XPgrpwise/NHS%20reform%20-%20competition%20yields%20worse%20value%20for%20money%20061011.docx#_ednref46" name="_edn46" title=""><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"><span><!--[if !supportFootnotes]--><span class="MsoEndnoteReference"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-GB; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">[46]</span></span><!--[endif]--></span></span></span></a><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;"> Ramesh R. NHS shakeup poses threat to political control, Lords committee claims URL: </span><a href="http://www.guardian.co.uk/society/2011/sep/30/nhs-shakeup-political-control-warning"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 12.0pt;">http://www.guardian.co.uk/society/2011/sep/30/nhs-shakeup-political-control-warning</span></a></div></div></div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com2tag:blogger.com,1999:blog-37603352.post-52422345041975347832011-06-22T16:23:00.000+00:002011-06-22T16:23:28.173+00:00Some time ago we wrote a widely cited <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60241-9/fulltext">Lancet paper</a> setting out what we considered a reasonable way forward for public health in England. However, it was clear that the Secretary of State rejected our arguments and he said so, very clearly, in a letter to the Lancet in response to our paper. We then responded to his letter and expected to see both in print very soon. unfortunately he has decided to withdraw his letter, so neither will appear in the pages of the Lancet. Obviously we can't publish his now withdrawn letter, but we thought you might like to read our reply:<br />
<br />
Dear Editor,<br />
<br />
We were surprised by the Secretary of State‟s summary dismissal of our arguments for an alternative approach to public health in the reformed NHS in view of the government's decision to “pause, listen and engage”. Mr Lansley states that our concerns around fragmentation of the service as a consequence of his plans are unjustified. Yet our apprehension is supported by detailed evidence and our proposals have been endorsed explicitly in responses to the Public Health White Paper consultation by professional bodies, 1,2,3,4 all raising specific concerns about fragmentation. The Secretary of State provides no evidence as to why all these concerns are wrong; nor does he clarify how his plans overcome the problems we describe arising from the division of public health between the Department of Health, local authorities and, potentially, commissioning consortia.<br />
<br />
Although he re-affirms the independence of Public Health England, he does not respond to the widespread scepticism this claim has generated or explain how it will be achieved.<br />
<br />
His assertion that public health budgets will be ring-fenced within local government is difficult to reconcile with the speech by his cabinet colleague Eric Pickles that the government is “scrapping ring-fencing”.5 We know that some councils, such as Westminster, have already identified cuts from 2012-3.<br />
<br />
We are disappointed that he has not „engaged‟ with our clearly thought through concerns about the capacity of public health teams in small local authorities, the trading activities of the Health Protection Agency, training and loss of workforce expertise.<br />
<br />
In grasping “the unique opportunity to prioritise public health and work in partnership with [the government] to realise it,” we have built upon the government‟s proposals to suggest modifications to address the adverse consequences we have highlighted.<br />
<br />
We hope to continue to engage constructively in this process.<br />
<br />
Yours sincerely,<br />
Martin McKee<br />
Robert W Aldridge<br />
Rosalind Raine<br />
Louise Hurst<br />
Ingrid Wolfe<br />
<br />
<br />
<div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">1 Academy of Medical Sciences. Response to the consultation on the public health</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">white paper ‘Healthy lives, healthy people’ URL:</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">http://www.acmedsci.ac.uk/p100puid215.html (accessed 3rd May 2011)</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">2 UK Faculty of Public Health response to Healthy lives,</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">healthy people: our strategy for public health in England URL:</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">http://www.fph.org.uk/White_Paper (accessed 3rd May 2011)</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">3 Association of Directors of Public Health – response to consultation on White Paper</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">Healthy Lives, Healthy People: strategy for public health in England URL:</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">http://www.adph.org.uk/downloads/ADPH_response_Healthy%20Lives_Healthy_People_W</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">P.pdf (accessed 3rd May 2011)</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">4 BMA response to Public Health White Paper URL:</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">http://www.bma.org.uk/healthcare_policy/public_health_white_paper/index.jsp (accessed</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">3rd May 2011)</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">5 Eric Pickles: We will let councils make their own decisions. URL:</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">http://www.conservatives.com/News/Speeches/2011/03/Eric_Pickles_We_will_let_councils</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">_make_their_own_decisions.aspx (accessed 3rd May 2011)</div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com1tag:blogger.com,1999:blog-37603352.post-73508942565204408632011-05-22T17:13:00.000+00:002011-05-22T17:13:26.755+00:00<div class="MsoNormal"><span class="Apple-style-span" style="font-size: 16px; line-height: 18px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">David Cameron is right. The NHS must change as the population and its health needs change. Yet this is what it has been doing since its inception. Once orthopaedic (literally child straightening) surgeons spent their days treating young people misshapen by polio and spinal tuberculosis. Now they replace the joints of old people disabled by arthritis. Cardiac surgeons once treated hearts damaged by rheumatic fever; now they treat hearts damaged by poor diets and smoking. These and many other health professionals and managers have never had any illusion about the need to change and even, when called upon, to do so quickly. The emergence of AIDS in the 1980s gave rise rapidly to new approaches to infection control, data protection, and patient involvement, as well as major reconfigurations of hospitals, first to open new dedicated AIDS wards and then, as treatment became available, to close them. The question is not whether the NHS must change. Rather it is what it must change into.</span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The government’s current proposals provide little clarity. The 450 page Health and Social Care Bill is written in a way that would deter all but the most persistent, with its seemingly endless list of changes to words in previous legislation making it almost impossible to understand what is being proposed. Inevitably, many people simply assumed that it would reflect what was set out in the preceding White Paper. That made many reasonable points, such as the need for more clinical engagement. Yet, when a few dedicated individuals did manage to plough through the text of the Bill it was clear that what was being proposed was very different indeed. Many will agree with Liberal Democrat MP John Pugh who described a "vision of a bill being drafted during the daytime by a sane, pragmatic Dr Jekyll-like minister, but during the night some … Mr Hyde jumps in with a rightwing ideology, breaks into Richmond House and changes many of the sentences." It was not even clear what problem the reforms were trying to solve as the government’s “dodgy dossier” on cancer and heart disease that sought to justify change was rapidly discredited. <o:p></o:p></span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">So what are the challenges facing the NHS in the future? The Prime Minister has now abandoned his claim to have ring-fenced the NHS budget and admits that his main goal is to cut it by £20 billion, much of which must go before his reforms can be implemented. He sees his task as complicated by an ageing population, which he blames for driving costs upwards. Yet he overlooks how we are living longer in good health and that the main driver of expenditure is how close we are to death, whenever it occurs, rather than how old we are.<span style="mso-spacerun: yes;"> </span>The real challenges posed by an aging population are how to promote healthy aging through lifestyle changes and how to manage the combination of chronic disorders that we will accumulate, but which advances in treatment now allow us to control. A typical 80 year old may have five or six conditions each requiring specific treatment, involving a wide range of health professionals in different facilities, all of which must be co-ordinated. But this is only the start. We can begin at the other end of the age spectrum, where again we see the effects of medical advances. No longer do we have wards full of children with jaundice and chest infections. The NHS must now look after children with chronic diseases, such as diabetes and genetic disorders, cancer, and a wide range of behavioural disorders and must manage their transition to adulthood. Then there are those whose numbers are likely to increase as a direct consequence of the government’s other policies. These include homeless people, hit by a combination of rising unemployment and reduced welfare benefits, and those with mental illness. Suicides are already up almost 8% from 2007. One word, complexity, encapsulates the needs of all of these groups. The NHS of the future must be able to provide a comprehensive, integrated service through which those with complex disorders are able to navigate with ease. <o:p></o:p></span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">So how can the NHS create such a system? A first step is to achieve integration. This requires some organisation responsible for ensuring a comprehensive package of care for everyone living in a geographically defined population, whether they live in a home or on the streets, and whether they have registered with a GP or not. That organisation, even if it is no longer called a Primary Care Trust, must work with health care providers to ensure that appropriate, evidence-based services are in place and must monitor the results they are achieving. This will often mean the establishment of networks, such as those that have achieved major advances in cancer care but which have been threatened (their recent reprieve raises enormous questions about how this is compatible with the free market envisaged in the government’s reforms). These networks must include all providers, avoiding imposing artificial divisions between general practitioners and hospitals. It will require clarity about training, to ensure that skilled staff are available. It will require embedded public health expertise, with efforts devoted to prevention as well as to cure. Finally, it will also mean avoiding quick fixes, such as primary care walk-in centres and Independent Sector Treatment Centres that may undermine the viability of specialist services. <o:p></o:p></span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A second step is to build in the flexibility required to respond to changing circumstances. This means finding some solution to the ruinous Private Finance Initiative deals that have locked hospitals in stone for 30 years or more. It also means revisiting the idea of Foundation Trusts. At present, to transfer services from one hospital to another it is seems necessary to merge them into a single Trust. When circumstances change again, as is already happening in London, it may be necessary to break them up and merge them with other Trusts. <span style="mso-spacerun: yes;"> </span>Yet we know that organisations on this scale take several years to recover their previous level of performance. It will exclude the big corporations with their one size fits all approach but it does allow involvement by non-profit organisations that have brought responsiveness and innovation into niche areas, such as palliative care and substance abuse. And it requires avoidance of disruptive large-scale reorganisations that divert managerial attention from the real problems. Just like football teams, hospitals do better when they have managerial stability.<o:p></o:p></span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Unfortunately, the proposed reforms take us in the opposite direction, to commissioners responsible only for those who register with them, purchasing only those services they think appropriate while avoiding anyone whose problems are “difficult”, and to providers competing for whatever services are most profitable. We don’t need a crystal ball to see the consequences. We need only look to the USA, where such a system is in place. There it is those with complex needs who suffer. Someone with diabetes is five times more likely to die before the age of 40 than in the UK. And it won’t save the money the Prime Minister wants. The American health system costs almost twice as much as a proportion of national income as the British one yet still fails to provide coverage for over one in seven people.<o:p></o:p></span></span></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Unfortunately, there is now a danger that the model that will emerge from the current listening exercise will be a political compromise between the two coalition parties, designed to avoid either loosing face with their supporters. This is no way to design a health system. The only sensible course is to go back to the drawing board, agree what problems we are trying to solve, and design a system that is fit for purpose in the 21<sup>st</sup> century. Paradoxically, it may turn out to look rather like what was in place in the 1980s, before an internal market was even thought of, but with the possible inclusion of social care. And once the new system has been put in place, then perhaps it can be left alone, so that those working in it can get on with adapting successfully to changing health needs, just as they have done in the past, rather than to changing political whims.</span></span></div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com2tag:blogger.com,1999:blog-37603352.post-27376774995521986662010-09-01T09:45:00.000+00:002010-09-01T09:45:27.505+00:0025 years ago the Rockefeller Foundation convened a group of scholars to explore the concept they termed Good Health at Low Cost. It was somewhat of a misnomer, as it was less about cheap health care and more about the ability of countries that had limited resources to achieve good health outcomes. The group met at the <a href="http://www.rockefellerfoundation.org/bellagio-center">Rockefeller Centre in Bellagio</a>, Italy, and examined in detail the experience of four jurisdictions, China, Costa Rica, Sri Lanka and the Indian state of Kerala. Cuba would have been included but wasn’t, for political reasons. The project identified several key features of the successful countries. These included a strong political commitment to health as a social goal, a social welfare orientation in development policies, widespread political participation, a commitment to equity, and intersectoral linkages. <div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc9gIgof5T9ieCRxRZw9LWvLARn84Q_WKOFvVL2VDFMBgsL1zcOq-vCZd1rsiqbIsHVYOlkVNKP9tHdvAspuMASaE1cxuzwNxn0eciM5AOIE0v-pvL1pbPOZYP-SBmElQTETl8Sw/s1600/bellagio.jpg" imageanchor="1" style="clear: right; cssfloat: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" ox="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc9gIgof5T9ieCRxRZw9LWvLARn84Q_WKOFvVL2VDFMBgsL1zcOq-vCZd1rsiqbIsHVYOlkVNKP9tHdvAspuMASaE1cxuzwNxn0eciM5AOIE0v-pvL1pbPOZYP-SBmElQTETl8Sw/s320/bellagio.jpg" /></a>Last week, another group of scholars came together in Bellagio to revisit this concept. The team, led by my colleague <a href="http://www.lshtm.ac.uk/people/balabanova.dina">Dina Balabanova</a>, has been updating the experiences of the original jurisdictions, which have had mixed fortunes, and has looked at the experiences of five new ones. These are Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu. Although diverse, each stands out from its neighbours in one or other aspect of health system development. For example, Kyrgyzstan, despite (or perhaps because of) lacking the natural resources of some of its neighbours, has achieved a single payer system, reduced informal payments, and made major strides in improving the quality of care. It has done so even though it has undergone several quite turbulent changes of government. Ethiopia has overcome the challenges of a highly fragmented country to develop a Health Extension Programme that has already had major success against malaria. Tamil Nadu stands out for its progress in maternal health. And so on....</div>So what lessons can we learn from these examples. We are still working through the rich discussions that took place but initial thoughts highlight the role of:<br />
<ul><li>individuals, especially politicians with vision and drive; </li>
<li>institutions, that can support a process of change and, in particular, learn from experience at home and abroad;</li>
<li>events, such as political changes or even natural disasters, which those with vision can take advantage of to bring about change; and </li>
<li>context, which includes the system of political representation, culture, and beliefs.</li>
</ul><br />
<div>We will be presenting the initial findings at the <a href="http://www.who.int/alliance-hpsr/alliancehpsr_symposiumbrochure_2010.pdf">Global Forum on Health Systems Research</a>, in Montreux in November, and will be publishing a book in the New Year.</div>For further reading, check out the <a href="http://blogs.bmj.com/bmj/2010/08/27/tracey-koehlmoos-good-health-at-low-cost-the-importance-of-political-commitment/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29&q=w_bmj_podblog">blog by Tracey Koehlmoos</a>, one of the Bangladesh team members, on the BMJ website.<br />
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<div> </div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-34389028855305454382010-08-16T08:42:00.000+00:002010-08-16T08:42:26.450+00:00I was born in Belfast on the 12th of July, famous in Northern Ireland as a day of marches. A colleague writing from Belgium today, on another matter, asked: <em>"does the fact there is now fighting on the streets of Ulster mean I have forgotten your birthday?"</em> At my age, I am perfectly happy to forget birthdays, but it did remind me, in the light of the current upsurge in violence, of some words of Winston Churchill's in 1922. <br />
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<em>“Then came the Great War: every institution, almost, in the world was strained. Great Empires have been overturned. The whole map of Europe has been changed. The position of countries has been violently altered. The modes of thought of men, the whole outlook on affairs, the grouping of parties, all have encountered violent and tremendous changes in the deluge of the world. But as the deluge subsides and the waters fall short, we see the dreary steeples of Fermanagh and Tyrone emerging once again. The integrity of their quarrel is one of the few institutions that has been unaltered in the cataclysm which has swept the world.”</em><br />
Unfortunately, we have two groups of people living side by side, but with elements of each group not recognising the other as part of the same human race. Until that changes I fear that we will simply continue to have a resurgence of violence with each generation. One thing that might help would be to educate children of both religions together. Falling birth rates may help as many existing schools, in rural areas, are no longer viable and are even (shock...) merging boys' and girl's schools. the few inegrated schools remain largely the preserve of the middle class, who when I was growing up there mixed socially anyway. But it will take at least another generation....Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-6071468027717086432010-08-13T08:39:00.000+00:002010-08-13T08:39:43.479+00:00Why we need effective government<br />
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The coalition government in the UK is engaging in an unprecedented dismantling of government functions. We are constantly told that nothing is sacred (although when the public health minister suggested removing free milk for toddlers, the Prime Minister, recalling the reaction to Margaret Thatcher’s axing of milk for older children, <a href="http://www.bbc.co.uk/news/uk-10904958">quickly stopped her</a>). Yet it is easy to forget why we need government until it is too late. In an excellent <a href="http://blogs.bmj.com/bmj/2010/08/11/vasiliy-vlassov-on-the-heatwave-in-russia/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29&q=w_bmj_podblog">blog on the BMJ site</a>, Vassilly Vlassov describes how the Moscow forest fires followed Putin’s cutbacks in the state forestry service. After Hurricane Katrina, Pail Krugman wrote in the NY Times (5th Sept 2005) “…the federal government's lethal ineptitude wasn't just a consequence of Mr. Bush's personal inadequacy; it was a consequence of ideological hostility to the very idea of using government to serve the public good. For 25 years the right has been denigrating the public sector, telling us that government is always the problem, not the solution. Why should we be surprised that when we needed a government solution, it wasn't forthcoming?. “ Also a few years ago, I wrote an article in the Medical Journal of Australia entitled <a href="http://www.mja.com.au/public/issues/187_11_031207/mck11253_fm.pdf">“What are governments for?".</a> It may be worth a re-read.Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-59310720061605493032010-08-12T16:17:00.002+00:002010-08-12T16:17:46.575+00:00At first I thought I must be wrong. Why would any government pursue policies it must realise would create a recession? Every time there is a major policy development, like the emergency budget, forecasts of growth are reduced further. Yet, day by day, I have searched for an explanation and failed to find one that makes sense. Over the past few months the new coalition government in the UK has been pursuing policies that seem inexplicable. <br />
<br />
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There are clearly two messages being promoted. First, we have an unprecedented deficit that has to be reduced. Fair enough, but the question is over how long? Much of the deficit is temporary, as a consequence of the bank bailouts, a policy that the two governing parties supported when in opposition) yet ignores the fact that our debt is much lower than most other industrialised countries and the average period before it reaches maturity is about twice as long (we have a paper out soon in the Journal of Public Health explaining all this). The second is that all of this is the fault of teh last government. Again, fair enough – New Labour blamed everything on the conservatives for years after they came to power in 1997. But it is difficult to explain why forecast growth is falling as the government sets out its policies and not rising.<br />
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In fact, it seems totally uninterested in growth even though it is one of the most important ways that it could reduce the deficit. It is explicitly pursuing the same policies seen in Ireland and Greece that have arrested economic growth there. <br />
<br />
Another way to promote growth would be to provide targeted support to British industry through export guarantees and the work of the regional development agencies. All that is going. Worse, it seems to celebrate the fact that countries like Germany are retrenching when it should be horrified. Where does it think we will export to? <br />
<br />
Growth will certainly not come from domestic demand, as it is planning to put about 1.3 million people out of work (about half each in the public and private sector), increasing the cost of welfare payments (and it must know that, for many of those over 50, the chances they will ever work again are remote). The chances of significant job creation are limited given the shortage of credit, and it seems unwilling to act to make the banks lend more. <br />
<br />
It is also abolishing as many QUANGOs as possible, bringing key functions within government departments. They will no longer be able to profit from their trading activities – the Health protection Agency will lose the third of its budget that comes from this source. Will the government pick up the bill or will it just allow health protection to weaken?<br />
<br />
Then there are the short term costs, of redundancy and redisorganisation. Kieran Walshe, in a BMJ editorial, estimated that the (incomprehensible) redisorganisation of the NHS would cost at least £3 billion, as well as paralysing it for 3 years. <br />
<br />
The only explanation I can find is that the government’s true aim is the ideological one of cutting the size of the state to that in Victorian times. The view that George Osbourne is now the “minister for cuts”, as suggested in today’s Guardian, is supported by his decision to maintain the independence of the Bank of England, so denying him any say over monetary policy, and to give many of his remaining powers to the soon to be leaderless Office for Budget Responsibility. Most of the traditional economic levers have been passed to the governor of the bank of England whose main quality is consistency, in being wrong. The rest have gone to a totally untried body, unsure even of who it reports to. All that the Chancellor has left is to chair a competition among ministers to see who can wear the hairiest of hair shirts. <br />
<br />
We see the evidence every day. The government seems to have gone to war with its civil servants, publicly humiliating them at every opportunity. Yet, one thing finally convinced me that there was a single ideological goal to cut the size of government. Surely they must know that the creation of a generation of school leavers with no prospects of employment, with reduced university places, and without even the possibility of joining the armed forces is very likely to lead to civil disorder? Remember the early 1980s? In such circumstances, surely it is madness to reduce the police force?<br />
<br />
Of course, there may be a better explanation, in which case could someone let me know.Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com1tag:blogger.com,1999:blog-37603352.post-82305816422286214172010-06-29T10:31:00.000+00:002010-06-29T10:31:48.202+00:00<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0RpsX7vWGIkZ32FZUHZODTGLxPudJPscXvn_VJQepfZEoQG7v30HYufnGbODPe0gDleTTXl2otpEI7DPLwfmQtTGUXDErn63ssc34pLHgcuImzymjyTN_xqzmOm8MG-HCstbXtQ/s1600/commission_event_10june2010.gif" imageanchor="1" style="clear: right; cssfloat: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" ru="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0RpsX7vWGIkZ32FZUHZODTGLxPudJPscXvn_VJQepfZEoQG7v30HYufnGbODPe0gDleTTXl2otpEI7DPLwfmQtTGUXDErn63ssc34pLHgcuImzymjyTN_xqzmOm8MG-HCstbXtQ/s320/commission_event_10june2010.gif" /></a></div>1-11th June – Brussels<br />
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I’m speaking at a major conference on global health, organised by the European Commission, in a session on health research (organised by DG Research). Some great presentations in the session, expertly organised by Kevin McCarthy and Jan Paehler from DG Research, looking at what research has contributed to global health. My task is to talk about what Europe can offer the world. The answer is – a lot. Our strength is our diversity. The observation that heart disease is so much lower in southern Europe than in northern Europe led to the research identifying the importance of the Mediterranean diet. That led on to the EPIC study that has done so much to advance our understanding of the role of diet in cancer. Another is the EUROTHINE study, providing important new insights into health inequalities. Then there is the diversity in policy responses. Research such as that in the EUROCARE project, showing marked differences in cancer survival, has contributed greatly to how we deliver cancer care in several countries. And finally, there is the European expertise in developing capacity for health research, drawing on experience in central Europe in the 1990s and in the former Soviet Union more recently. There are relatively few opportunities for researchers in rich and poor countries to meet together. This was a rare and valuable example.Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-3945116971528299192010-06-29T10:17:00.000+00:002010-06-29T10:17:24.035+00:00<div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1O2RAiUY1XoKWDjmvXDsKsNTb9CBt2sKo6ZC_i7MzXVt8DwiopaB8HPGFrwSdZhqdbxF3TbATqnGT97gzxuCi92VDaEMXa8IWEYqNBOI3Sj_hZjKLJvAjn77vHWD6aEskSsiELA/s1600/ECHA.jpg" imageanchor="1" style="clear: right; cssfloat: right; float: right; margin-bottom: 1em; margin-left: 1em;"><strong><img border="0" height="80" ru="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1O2RAiUY1XoKWDjmvXDsKsNTb9CBt2sKo6ZC_i7MzXVt8DwiopaB8HPGFrwSdZhqdbxF3TbATqnGT97gzxuCi92VDaEMXa8IWEYqNBOI3Sj_hZjKLJvAjn77vHWD6aEskSsiELA/s400/ECHA.jpg" width="400" /></strong></a><strong>7th June – Rotterdam. </strong></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;">I’m giving one of the opening speeches at the <a href="http://ducha10.ducha.nl/smartsite.shtml?id=7397">European Congress on Healthcare Planning and Design</a>. We often hear that the hospital is doomed as healthcare moves into the community. Yet, rather like Mark Twain, reports of its death seem greatly exaggerated. Our two <a href="http://www.euro.who.int/en/home/projects/observatory/publications/studies/investing-in-hospitals-of-the-future">books</a> on hospital design have attracted far more interest than we could ever have imagined, with a seemingly endless list of requests to speak at conferences and write papers in scientific and professional journals. I made a three points. First, many existing hospitals are essentially dysfunctional, designed and built with little thought for what they have to do. The long period between conception and birth, coupled with the pace of change in health care, means that many are obsolete by the time they open. Second, we need to understand why and how hospitals are changing, taking account of changing patterns of disease and emerging therapeutic options, many of which have blurred the boundary between hospital and community. Third, hospital design must respond to the needs of those who are in them, both patients and staff. We often forget that it is the staff who spend most time in hospitals and, while we constantly urge them to find new ways of working, in multi-professional teams that communicate with one another effectively, we create buildings that do little to facilitate this process. <br />
These factors have three important implications for the hospital. The first is the importance of adaptability. The hospital has changed throughout its existence and will continue to change but many of those changes cannot be predicted so we should make change as easy as possible. This affects how we pay for hospitals, such as avoiding failed experiments like the UK Private Finance Initiative that locks hospitals into contractual straightjackets, and how we build them, ensuring that we can change the configuration of the buildings without knocking them down. There are some excellent examples of good practice, such as the variable acuity beds pioneered in Indianapolis, where which the patient stays in the same bed while modules are added or removed to take account of his or her changing needs. The second is design. Hospitals involve a lot of people on the move, from one department to another. In this respect they are like an airport. Yet in an airport the flow is in one direction. In hospitals they move in different directions, they loop back on each other, many have disabilities and some are confused. We recognise that the flow is erratic, and we even create places to store patients to stop them getting lost (waiting areas and wards). The challenge is to find ways to design hospitals that make these flows as easy as possible, something that a number of innovative designs (described in our book of <a href="http://www.euro.who.int/en/home/projects/observatory/publications/studies/capital-investment-for-health-case-studies-from-europe">case studies</a>) are doing. The third issue is capacity. It would be nice if the demand for hospital care was entirely predictable but it is not. The hospital must have the ability to accommodate peaks, troughs, and surges. It is clear that there is an audience for these messages. Let’s just hope that they can turn them into reality. </div>Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0tag:blogger.com,1999:blog-37603352.post-2438794954147605592010-06-11T05:52:00.000+00:002010-06-11T05:52:28.070+00:00OK, it had to happen. I've been persuaded by my good friend Eddie McCaffrey, owner of <a href="http://www.joose.tv/">JooseTV</a>, the excellent company that runs the website 3four50.com and that has managed the webcasting of some of the major public events in recent years, to sign up to <a href="http://twitter.com/">twitter</a> - I'm @martinmckee. No idea whether I'll manage to keep it up but it's a lot less work than adding all the hyperlinks to a blog! Let's see!Martin McKeehttp://www.blogger.com/profile/05654848515875160991noreply@blogger.com0