This post is about the new Condem coalition’s healthcare WhitePaper and what it says about end-of-life care and social care.

Department of Health (2010) Equity and excellence: Liberating the NHS. (Cm 7881) London: TSO.

On the web: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf

You can find consultations and other documents at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

There has been a lot of press comment that the Conservatives promised no top-down reorganisation of the NHS and in Andrew Lansley’s White Paper (WP below) on healthcare reform, have done exactly that. Gone are the days when White Papers were white, or at least cream: this one is covered in tasteful tones of mauve. However, the design is the same and the contents are mainly high-level generalisations about policy direction. Here’s a bit of a novelty: an analytical strategy (AS below) has been published alongside it. This means they’re telling you why they’re thinking what they’re thinking; fancy that. In reality, it sets out the things they’re consulting on: there are several consultations on the main philosophies that close in early October.

There’s another tranche of detailed stuff on information management (i.e. cutting the IT budget) and so on to come later.

General

The main aims are stated as:

i. Putting patients and the public first;

ii. Focusing on improvement in quality and healthcare outcomes;

iii. Autonomy, accountability and democratic legitimacy; and

iv. Cutting bureaucracy and increasing efficiency. (AS, p 2)

This is the vision: an NHS that:

Is genuinely centred on patients and carers;

Achieves quality and outcomes that are among the best in the world;

Refuses to tolerate unsafe and substandard care;

Eliminates discrimination and reduces inequalities in care;

Puts clinicians in the driving seat and sets hospitals and providers free to innovate, with stronger incentives to adopt best practice;

Is more transparent, with clearer accountabilities for quality and results;

Gives citizens a greater say in how the NHS is run;

Is less insular and fragmented, and works much better across boundaries, including with local authorities and between hospitals and practices;

Is more efficient and dynamic, with a radically smaller national, regional and local bureaucracy; and

Is put on a more stable and sustainable footing, free from frequent and arbitrary political meddling. (WP, 8-9)

It then goes on to some political meddling, and judging by the three-year programme set out, this will be frequent, although because it’s a programme, perhaps it won’t be arbitrary.

This leads us on the the main points: more patient choice and greater control of their records, GP commissioning (emerging from present experiments) and less bureaucracy, PCTs reduced in size, local authorities responsible for public health: we’ve seen it all in the press. You can’t imagine GPs doing more than sitting on a few advisory boards, so presumably this means that staff in the PCTs will divide themselves up among a larger number of local bodies and try to administer the system. A few central offices and strategic thinkers will be got rid of.

There are three things to say about this. One is, it will be conservative (with a small ‘c’, you notice). This is because people involved in day-to-day stuff will go with the things they know, not with new-fangled nonsense. So the cancer, renal, heart and chest physicians will retreat to not thinking about the reality that their patients are dying from their conditions, but will carry on doing more and more to cure them rather than making sensible judgements about when they’ve come to the end. And of course they will persuade a lot of patients that that’s what they want too. So end-of-life care that thinks: ‘what will give the best quality of life for someone who is dying’ will go out of the picture.

Second, overall planning and strategic thinking will reduce because smaller groups covering smaller areas will have less incentive to look at the big picture, and the local authorities will concentrate on stopping people smoking to get their health premium (there are more ways of political meddling than normal people can conceive of).

And third, most important, it is easier to save money when you have a larger number of spenders because they all try to keep within their budgets, whereas large spenders have more flexibility to vire resources between budgets.

How does it deal with the interests of this blog, palliative, end-of-life and social care? Not surprisingly, given the high level of generality of this mainly policy statement, they are not offering a lot of detail on particular specialities, but there’s some on end-of-life care and some on social care.

End-of-life care

The material on extending choice contains this on end-of-life care:

The Government will…

Introduce choice in care for long-term conditions as part of personalised care planning. In end-of-life care, we will move towards a national choice offer to support people’s preferences about how to have a good death, and we will work with providers, including hospices, to ensure that people have the support they need; (WP, p 17)

So hospices get a mention, naturally because they are the best example in healthcare of independent organisations actually making a large contribution, and this supports the Conservative ‘big society’ agenda. Choice is supposed to be not about just what treatment you get and where, but what that treatment feels like to the patient (and family, I hope, although it’s not too good on family participation because it’s stuck like the medical model on patients).

End-of-life care also comes up under quality improvement, because they are thinking about financial incentives for improving quality:

The government will…

review payment systems to support end-of-life care, including exploring options for per-patient funding; (WP, p25)

So we’re back to this again. Will this mean GPs who choose to do it will get some money? Or does it mean cheapo will win? This foundered the last time on the difficulty of defining what palliative care might mean and it got down to numbers of days, and completely got lost when the Treasury found out they didn’t pay for most of palliative care, so they would have to pay outside bodies to do the job. But note they’re not talking palliative care here, it’s end-of-life care, which will not primarily mean funding high-end palliative care, So if anything at all, it’s a small subvention for hospices or hospital palliative care, but some extra for (mainly private sector) care homes who save the NHS some money.

That’s it on end-of-life care.

Social care

The executive summary includes social care into democratic legitimacy:

To strengthen democratic legitimacy at local level, local authorities will promote the joining up of local NHS services, social care and health improvement. (WP, p 4)

This means giving local authorities the responsibility to promote partnership between health and social care, not the NHS. This realistically assesses the chance of the medically-lef NHS doing anything about social care as nil, so they’re letting the more community-led local authorities have a go. This also includes health improvement: again, realistically bearing in mind the NHS culture, this is turning the NHS into an illness service and putting positive public health with the local authorities. You can see the possibility, if it goes well, of other policy development for health going to the local authorities in the future. They need to grasp the opportunity, at least partly because the main point of the White Paper is GP commissioning. There is, therefore, not going to be a lot of public policy making among the local commissioners. For one thing, they will have a lot of detailed fish to fry. Also, they will be covering areas that are too small and too non-coterminous with anybody else’s areas to have much influence.

Also on this area:

We will strengthen the role of the Care Quality Commission as an effective quality inspectorate across both health and social care. (WP, p 5)

As it’s only just started, and so they have no real evidence that a giant multi-purpose regulator is going to work, you could see this cynically as making sure that the mass of private sector providers that we have and the bigger mass that we’re probably going to get are not going to be properly regulated. However, it’s more likely to be because they are against quangos and they’ve got to have a regulator, so they might as well have a supergirl. My sense is that regulators who really know their professional territory are likely to be much more effective; this one is going to be too amorphous really to have a handle on the huge range of its responsibilities, and because it’s so large it will have so much bureaucracy to keep it on track it will never get anything done. Ask me if I’m right in three years time.

Then, social care gets a mention in the ‘our values’ section on ‘liberating the NHS’, because the Condems have not yet managed to put a stop the Department of Health speak that says social care every time it says health care:

The NHS is about fairness for everyone in our society. It is about this country doing the right thing for those who need help. We are committed to promoting equality and will implement the ban on age discrimination in NHS services and social care to take effect from 2012. The NHS Commissioning Board will have an explicit duty to address inequalities in outcomes from healthcare services. (WP, p 7)

We’re now onto the main document from the exec. summary, by the way. Does this mean that nobody will have a duty to address inequalities in outcomes from social care services? I’m looking forward with interest when I retire (it may be longer than I think, judging by some of the decisions being made about retirement age) to mounting a court case or two on how equal the outcomes of local authority care are.

Another section is on ‘Improving the NHS and reforming social care’ – I wonder whether it’s worse to be improved or reformed? This section is about the Department of Health delegating to local authorities (localisation in action here) responsibility for public health, including the spending of a ‘premium’ (i.e. extra cash) to improve public health and reduce health inequalities. The question is, do you get your extra if you’ve been good and improved it, or if you’ve failed and you’ve still got a sickly population with lots of fat smokers? Remember this is about incentives. I think we should be told.

However, the Department is not giving up on social care (ostensibly a local authority responsibility so if it were really going for localisation, here is a good thing to delegate):

The Department will continue to have a vital role in setting adult social care policy. We want a sustainable adult social care system that gives people support and freedom to lead the life they choose, with dignity. We recognise the critical interdependence between the NHS and the adult social care system in securing better outcomes for people, including carers. We will seek to break down barriers between health and social care funding to encourage preventative action. Later this year we will set out our vision for adult social care, to enable people to have greater control over their care and support so they can enjoy maximum independence and responsibility for their own lives. The Department will continue to work closely with the Department for Education on services for children, to ensure that the changes in this White Paper and the subsequent public health White Paper support local health, education and social care services to work together for children and families. (WP, p 10)

It’s not clear but what this seems to be about is getting families to take responsibility for preventing problems in their own child and elder care. The question is just the same as it is with the health premium. Are you going to pay more for those who don’t because they have more problems or those who do, because they need an incentive for not having problems?

It covers their proposed commission on long-term care (every new government has to have one so that we can all be reminded how difficult it is and why they can’t do anything about it fro another Parliamnet because they won’t spend the money – perhaps you remember my prophecy that nothing will be done until the early 2020s, because that’s when the care home figures will start to bite):

The Department will establish a commission on the funding of long-term care and support, to report within a year. We understand the urgency of reforming the system of funding social care. The Commission will consider a range of ideas, including both a voluntary insurance scheme and a partnership scheme. As a key component of a lasting settlement for the social care system, we will reform and consolidate the law underpinning adult social care, working with the Law Commission. (WP 10)

Good to see the mention of the Law Commission report on adult social care law – an eminently sensible document covered before in this blog. This is easy to say of course because Law Commission reforms are supposed to be politically neutral, so it never says anything to upset anyone. But it does need to be done, and at least someone in the Department of Health has noticed and slipped it in. Finally:

The Government will bring together the conclusions of the Law Commission and the Commission on funding of long-term care, along with our vision, into a White Paper in 2011, with a view to introducing legislation in the second session of this Parliament to establish a sustainable legal and financial framework for adult social care. (WP, p 10)

Wait and see, then; by which time of course, bearing in mind the difficulties of keeping a coalition government in line, it might all have turned out to be too difficult again.

Moving on:

Here’s another quango system in the making then: Monitor (the people who check on the finances of foundation trusts) will look at financial information, HASCIC will check on the outcomes data and CQC will check on the quality of anything they manage to organise to get to see, when they’ve written their huge volumes of criteria.

We will ensure the right data is collected by the Health and Social Care Information Centre to enable people to exercise choice. We will seek to centralise all data returns in the Information Centre, which will have lead responsibility for data collection and assuring the data quality of those returns, working with other interested parties such as Monitor and the Care Quality Commission. We will also review data collections with a view to reducing burdens, as outlined in chapter 5. The forthcoming Health Bill will contain provisions to put the Information Centre on a firmer statutory footing, with clearer powers across organisations in the health and care system. (WP, p 15)

Social care turns up again in an unexpected place:

The government will…

Develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care. This will incorporate GP out-of-hours services and provide urgent medical care for people registered with a GP elsewhere. We will make care more accessible by introducing, informed by evaluation, a single telephone number for every kind of urgent and social care and by using technology to help people communicate with their clinicians. (WP, p18)

So social care emergencies will come through the health system. What does this mean for concerns that have elements of social care?  Before you say ‘jolly good thing’ to integrate the two, think about ‘Oh God not a palliative’ an article in this month’s Palliative Medicine (Vol 24(5): 501-9). This shows that emergency doctors do not like being presented with nasty things that involve spending time talking to people, instead of giving them pills and being off to the next thing (what one of the respondents called ‘proper doc’ work and then realised he shouldn’t have said it – even if he meant it). Their call centres pressurise them to get on to the next thing quickly. Moreover the study shows that patients do not trust or value the work of emergency doctors and that most out-of-hours doctors are motivated only by the good money. We do not want social care decision being made in organisations like this. Neither do we want anything that sounds as though it might cause problems to a ‘proper doc’ (i.e. human relationships) fobbed off onto the social care aspect of the service, when it really needs a doctor with the skills and motivation to do a good piece of interpersonal medical work.

A significant aspect of the patient-centred approach of the White Paper is picking up the social care practice of personalisation:

The previous Government recently started a programme of personal health budget pilots. International evidence, and evidence from social care, shows that these have much potential to help improve outcomes, transform NHS culture by putting patients in control, and enable integration across health and social care. As part of personalised care planning, the Department will encourage further pilots to come forward and explore the potential for introducing a right to a personal health budget in discrete areas such as NHS continuing care. We also recognise that introducing personal budgets is operationally complex and the Government will use the results of the evaluation in 2012 to inform a wider, more general roll-out. (WP, p 18)

Note the extreme caution about the possibility of a right to a personal health budget and only in discrete areas (i.e. nothing that’s going to cost us) and the particular mention of continuing care. That is, we’ll give you the money, you can add what you like so we’ll try not to give you too much, now go away and ‘take patient responsibility’.

Another new quango will be HealthWatch England with its local offshoots: community health councils are back again, to comment on the new commissioning arrangements:

Local HealthWatch organisations will ensure that the views and feedback from patients and carers are an integral part of local commissioning across health and social care; (WP p 20)

HealthWatch England will provide advice to the Health and Social Care Information Centre on the information which would be of most use to patients to facilitate their choices about their care. (WP. P 20)

Note the integration of social care into local commissioning arrangements (and so therefore dominated by the interest of GPs, instead of the broad social resilience role of local authorities?) and information about patients and their care, not broader social issues. A recipe for the medicalisation of social care, whose objectives are not to help GPs when they can’t or don’t want to cope with longterm care needs, but to promote social solidarity.

Another healthnsocialcare omnibus:

The current performance regime will be replaced with separate frameworks for outcomes that set direction for the NHS, for public health and social care, which provide for clear and unambiguous accountability, and enable better joint working. The Secretary of State, through the Public Health Service, will set local authorities national objectives for improving population health outcomes. It will be for local authorities to determine how best to secure those objectives, including by commissioning services from providers of NHS care. (WP, p 22)

So are the outcomes for social care an element of public health? Social care disappears from the rest of this paragraph. It should have its own performance criteria and they should not be commanded by health needs, either public health objectives (which are mainly about smoking and obesity) of NHS needs (which are mainly about medical and nursing treatment).

It is essential for patient outcomes that health and social care services are better integrated at all levels of the system. We will be consulting widely on options to ensure health and social care works seamlessly together to enable this. (WP, p 23)

Yes, well after 50 years of trying to do this, I’m sure we’ll believe everything they suggest. Of course, they’re politicians who have to believe that their policies change the world.

The next attempt to change the world is to set policy standards:

Each standard is a set of 5-10 specific, concise quality statements and associated measures. These measures act as markers of high quality, cost-effective patient care. They are about excellence, derived from the best available evidence and are produced collaboratively with the NHS and social care professionals, along with their partners, service users and carers. The standards will be developed in a way that makes sense for patients, and they will extend beyond NHS care, informing the work of local authorities and the Public Health Service. They will include information for clinicians and patients on relevant and ongoing research studies that are key to improving evidence for better outcomes. (WP, p 23)

With the increasing importance of coherent joint arrangements between health and social care, the standards will cover areas that span health and social care. We will expand the role of NICE to develop quality standards for social care. The Health Bill will put NICE on a firmer statutory footing, securing its independence and core functions and extending its remit to social care. (WP, p23)

There has been comment in the social work press about what this means for the Social Care Institute for Excellence (SCIE), and the stupid comment made by the minister apparently was that it was a charity so they couldn’t give it statutory responsibilities (tell that to the NSPCC). Actually, it was set up with similar intentions, hence the similar name, but social care knowledge is not in  the same place as healthcare knowledge, mainly due to successive governments not bothering to spend much money on social care research. This might begin to change as recent developments in research have influence over the next 20 years. However, SCIE (and its Scottish equivalent IRISS) has done a good job at collecting and making available knowledge resources and this ought to be continued.

I also think that there is a lot to be said for the extension to NICE responsibilities, because they have developed a very good decision-making model. What I would want to be sure, however, is that social care decision-making is not dominated by doctors, who know nothing about it and mostly couldn’t care less, and is prepared to look at some of the softer areas of knowledge where robust collection of information and knowledge could be very beneficial. One is not given much hope by the inane example of a NICE standard quoted in the White Paper, but the record of NICE is reasonable in this regard.

Then an attempt to produce more incentivisation in the payment by results system leads us to this:

The Department will…

implement in 2011/12 further incentives to reduce avoidable readmissions and encourage more joined-up working between hospitals and social care for services following discharge; (WP p 25)

Yes, but what about some joined up working in making the decisions about service-planning during periods in hospital and about discharge. If you had an adequate social work provision in hospitals and really engaged it in people’s care, you’d get a lot further than leaving it to hospitals to decide when to throw people out, with never a concern for integrating health and social care throughout. Remember, most of the medical care is done by GPs and community health services, not hospitals, and the hospitals should not be taking the lead in decisions about the use of community health services for their organisational and financial benefit (particularly when they are encouraged to be independent profit-making stand-alone bodies that can decide to do what they like for financial rather than total care system reasons).

Now on to the responsibilities of GP consortia:

GP consortia will have a duty to promote equalities and to work in partnership with local authorities, for instance in relation to health and adult social care, early years services, public health, safeguarding, and the wellbeing of local populations. (WP, p 29)

Well that’ll be a new one, GPs having a duty to work in partnership on safeguarding; who is the most common absentee (they’re so busy, poor dears, unlike anyone else of course) from case conferences and strategy meetings? But of course only the consortia have the duty, so they can approve the policy and still not bother to take part.

Now the responsibilities of our national leaders on the National Commissioning Board:

setting commissioning guidelines on the basis of clinically approved quality standards developed with the advice of NICE in a way that promotes joint working across health, public health and social care; (WP, p 31)

and the NHS role of the Secretary of State:

The legislative and policy framework. Responsibility for Department of State functions will remain with the Secretary of State. This includes determining the comprehensive service which the NHS provides, and developing and publishing national service strategies which will enable the roles of NHS, public health services and social care services to be better coordinated. (WP, p 33)

Accounting annually to Parliament for the overall performance of the NHS, public health and social care systems. (WP, p 34)

Finally, on democratic legitimacy:

The Government will strengthen the local democratic legitimacy of the NHS. Building on the power of the local authority to promote local wellbeing, we will establish new statutory arrangements within local authorities – which will be established as “health and wellbeing boards” or within existing strategic partnerships – to take on the function of joining up the commissioning of local NHS services, social care and health improvement. These health and wellbeing boards allow local authorities to take a strategic approach and promote integration across health and adult social care, children’s services, including safeguarding, and the wider local authority agenda. (WP, p 34)

These arrangements will give local authorities influence over NHS commissioning, and corresponding influence for NHS commissioners in relation to public health and social care. While NHS commissioning will be the sole preserve of the NHS Commissioning Board and GP consortia, our aim is to ensure coherent and coordinated local commissioning strategies across all three services, for example in relation to mental health or elderly care. The Secretary of State will seek to ensure strategic coordination nationally; the local authority’s new functions will enable strategic coordination locally. It will not involve day-to-day interventions in NHS services. The Government will consult fully on the details of the new arrangements. (WP p 35)

Then on local authorities’ responsibilities:

Each local authority will take on the function of joining up the commissioning of local NHS services, social care and health improvement.

Local authorities will therefore be responsible for:

- Promoting integration and partnership working between the NHS, social care, public health and other local services and strategies;

- Leading joint strategic needs assessments, and promoting collaboration on local commissioning plans, including by supporting joint commissioning arrangements where each party so wishes (WP, p 35)

This set of arrangements does provide a useful possibility of local democratic involvement with an understanding of and involvement in social care in healthcare; in the long-term, will the hospitals become independent and all community health be back with the local authorities? It’s a possible model if things go in that direction, and it’s what a lot of Europe does; why not us too? Britain is too centralised. But it’s against the trend of British politics and government over the past sixty years. It might be the end of separation between community health and local government, which go logically together. And that might mean a more rational engagement between community health and social care. But only if you stop the hospitals seeing it as their right to dominate the use of resources in favour of acute treatment, and to evade responsibility for long-term conditions and care.

On to regulation. The intresting feature here is using Monitor, the foundation trusts regulator, as an economic regulator for the proposed market and choice system:

As now, the Care Quality Commission will act as quality inspectorate across health and social care for both publicly and privately funded care. In addition, we will develop Monitor, the current independent regulator of foundation trusts, into an economic regulator from April 2012, with responsibility for all providers of NHS care from April 2013. Providers will have a joint licence overseen by both Monitor and CQC, to maintain essential levels of safety and quality and ensure continuity of essential services. (WP, p 37)

Monitor will be turned into the economic regulator for the health and social care sectors, with three key functions: (WP, p 38)

Monitor’s powers to regulate prices and license providers will only cover publicly-funded health services. However, its powers to apply competition law will extend to both publicly and privately funded healthcare, and to social care. (WP, p 39)

Here, we can see that private sector social care (mainly care homes at the moment) will also be regulated by Monitor. If the plan to increase engagement by NHS organisation in social enterprise, so that your local hospital might be a John Lewis Partnership of its staff, can social care organisations or groups of social workers be far behind? Mainly, they are talking here about fairly large organisations, but there is some mention of local community organisations becoming social enterprises. These will need economic regulation, too. You could not have the local safeguarding body disappearing because it got its finances wrong. And to round it all off nicely:

We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management. Within that context, we are committed to reducing the overall burdens of regulation across the health and social care sectors. We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions. (WP, p 44)

They’ve started this in their bonfire of the social care quangos. More on that in a later post, because I think it’s not so easy.

Local authorities’ new functions will help unlock efficiencies across the NHS, social care and public health through stronger joint working. (WP, p 45)

I’ve suggested that I think this is possible and hope it will happen. Legislation will include:

Placing the Health and Social Care Information Centre, currently a Special Health Authority, on a firmer statutory footing, with powers over other organisations in relation to information collection; (WP, p 49)

Making the National Institute for Health and Clinical Excellence a non-departmental public body, to define its role and functions, reform its processes, secure its independence, and extend its remit to social care; (WP, p 49)

Giving local authorities new functions to increase the local democratic legitimacy in relation to the local strategies for NHS commissioning, and support integration and partnership working across social care, the NHS and public health; (WP, p 49)

Establishing HealthWatch as a statutory part of the Care Quality Commission to champion services users and carers across health and social care, and turning Local Involvement Networks into local HealthWatch; (WP, p 49-50).

In summary then

It’s quite hard to see how palliative care and, separately, end-of-life care will come out of this. GP consortia may want to do more themselves. Will they want to pay for it in hospitals? Some of my colleagues in hospitals think not. Will they want to commission more from hospices because they are cheaper than hospitals and cause less work for the GPs? Perhaps, but will they think hospice in-patient units are too expensive and only pay for home care or will they think that district nurses could do it all? I think hospices had better start finding ways to prove what their CNSs offer that a well-trained district nurse doesn’t.

For social care, we can all support the aim to get greater engagement in healthcare, provided you don’t let the financial needs of hospitals to throw their patients out when it suits them dominate how you run community services in both health and social care. And provided you incorporate social care objectives aiming at social resilience and solidarity into health care objectives: that way really lies the ‘big society’.

The absence of anything much being done in health and social care by the government at the moment leads me into the byways of healthcare, and I have comne across a research review for the Forestry Commission on the health benefits of forests, which was obviously an attempt to get some money predicated on health inequalities for a largely irrelevant agency. This example of tree-hugging policy development is about how walking in the woods is good for you and it concludes:

In reviewing the evidence from research undertaken to date we suggest that an urban forestry approach to targeting health and inequalities could focus on the:

• Restorative benefits of urban forests particularly those in immediate residential surroundings including street trees
• Social contact encouraged and facilitated by urban forest use.

Two groups that could especially benefit from a focus on urban forestry and health are children and poor communities.

I yield to nobody in my enthusiasm for social contact in the woods, but if we’re going to be cutting some healthcare expernditure, studies like this are my first prioirity. You have to say this was a pointless waste of time.

But if you want to know, here is the website: http://www.forestry.gov.uk/pdf/urban_health_and_forestry_review_2010.pdf/$FILE/urban_health_and_forestry_review_2010.pdf

The New Zealand journal Social Work Now arrives; you can see it on the internet at:

http://www.cyf.govt.nz/documents/about-us/publications/social-work-now/final-social-work-now-april-2010.pdf

It is mainly about children and youth social work in New Zealand, but often has more general articles. This month there is an interesting discussion about social work not being dominated by legalism; the legal system and legal thinking are only one among the things that social workers have to balance in their decisions.

And a nice American piece discussing creating community partnerships particularly to combat disparity and disproportionality between services and their impact on different groups in a community, Interesting ideas, and useful definitions of what really constitutes partnership.

First, two of the parties in government in particular nations of the UK.

Of those I have not previously looked at, the DUP (the Democratic Unionists in Northern Ireland) have a quite detailed manifesto compared with many others. It wins out on palliative care, among all the manifestos I have seen:

The World Health Organisation recognizes that palliative care incorporates physical, psychological and spiritual needs and it is important that all elements are properly resourced.Three quarters of people indicate that they would prefer to die at home, and this must be respected as services are commissioned.Those in receipt of such care should be informed about benefits available to them and given sound advice around finance and other personal matters as they plan for the end of their life. (p 45)

Can’t say fairer or more thoughtful than that. Then, their final objective on health:

• greater delivery of end of life care in primary and community settings rather   than secondary care (p 32)

Then, mentions of social care:

Opportunities should be freed up for charities and other providers with a proven track record to deliver services.The third sector has much to offer
in social care provision in areas such as mental health,dementia,learning
disability and acquired brain injury. (p 29)

The recommendations of the Bamford Review of Mental Health should be implemented. Approximately 24,000 people currently suffer dementia in Northern Ireland, and this figure is expected to climb to 50,000 by 2051. Health and social care costs for dementia of £200 million will double within twenty years.We need to be well-equipped to treat and support these individuals. A comprehensive dementia strategy for Northern Ireland is required. (p 45)

As well as these specific points, they are good examples of the way the health agenda is markedly preventive and community oriented; it rather nicely recommends asking NICE to identify existing practice that is non-cost-effective, as well as new things that are. There’s a fairly positive section on valuing older people. There’s also a lot on poverty and inequality -  of course they’re sticking up for the protestants against the catholics.

The Scottish National Party has a smallish manifesto; however its summary puts older people right up there at the front:  a fair deal for pensioners with pensions rising in line with earnings and a guarantee to protect free personal care and concessionary travel (Page 4 after the photos). A lot of the manifesto is about being champions for the interests of Scots people; for example:

we believe Scots must not lose out as a result of policy decisions for england. That means there should be no new taxes or contributions, or changes to attendance allowance or Carer’s allowance that will impact on Scots, to pay for reform of care for the elderly down south.

Referring to Sinn Fein, the other power-sharer in Northern Ireland, there still seems to be no manifesto, but there are campaign statements:

Website for these: http://www.sinnfein.ie/election-campaign-statements

I’d like to comment on the Respect Party manifesto, but my browser will not download it. However, the website does not reveal much interest in health and social care, or older people; it mainly focuses on anti-racism and equality issues, particularly around housing, education and work; a party for the working man, I decided.

The website: http://www.therespectparty.net/breakingnews.php?id=864

The British National Party has now published its manifesto; searches for palliative, end of life and social care drew a blank. However, it does mention ’social work’; apparently the police are doing too much of this, politically correctly, and it’s got to stop.

Looking more broadly at the manifesto, NHS funding would be increased if there (in your dreams) were a BNP government by removing the foreign aid budget, and old age pension and public sector pensions would be sorted out. Housing and other public services would be relieved by not having to provide services to any immigrants, and human rights and equality legislation and organisations would be removed. Serious criminals will be similarly removed to South Georgia (the little British colony miles from anywhere in the Atlantic) and the death penalty would be applied to lots of nasty people, especially rapists.

They are also into compulsory volunteering: ‘a Community Award Scheme for our young people which will take the form of a compulsory one year period for all school leavers during which they will work in the community as the final element of their education. This scheme will allow young people to choose between a variety of community service options which might include, for example, caring for the elderly or disabled people, environmental or heritage restoration projects or military training. The final choice of direction in this regard will be dictated by the school leaver’s scholastic record, preferences and suitability. These courses would be character building and would instil discipline, social and community values and work ethics in all young people.’

That’s going to be popular with the gap year middle classes. Yes, when I’m elderly, I want to be cared for by some lout forced to look after me. Volunteering should mean what it says; you should want to do it.

You would laugh at all this, or weep about the attitude to other human beings. But these views are the attitudes of many pub bores across the country. You can imagine them poking you in the chest to emphasise their points, as they down yet another pint. How is it that we are educating people in social and personal understanding so badly that this sort of approach to the world still exists?

Website: http://bnp.org.uk/pdf_files/BNP-Manifesto-2010-online.pdf

This post is an evaluation of YouTube vieos on palliative care and palliative care social work. It briefly tells you how to find YouTube, assuming that there will be some of my readers who have never done that. There is then some comment on the top videos the week I did these searches, and this is followed by some overall comment, which you could sum up as ‘could do better’.

Finally there a sort of appendix which tells you how to use the YouTube video viewer, again assuming I might have some readers who have never used one of these things.

People who don’t use YouTube probably just know it as that controversial site that teenagers are supposed to look at to find unsuitable videos of unknown rock bands, which then shoot to popularity, or films uploaded by oppressed groups in countries who don’t have much access to the internet.

In fact there is a very wide range of material uploaded, including stuff on medicine and social work, and a lot of members of the public might well look there for information about palliative care, and might be more used to visual presentations than reading documents or leaflets. Some alive organisations have obviously realised that, because there are a lot of ‘what is palliative care?’ type presentations. Obviously there aren’t any alive organisations in palliative care social work, because I didn’t find much about that.

By the way, St Christopher’s does not allow staff or me to view YouTube at work – this is to stop us wasting our time and Hospice resources watching rock videos at work. So I had to do this at home. You might find your workplace does the same.

Using YouTube

If you’ve never used YouTube, it’s a simple process. Search on your browser for the site. As with a lot of internet sites, it’s about being up to the minute, so it shows you a list of recently uploaded stuff. If you use the YouTube search engine to search the site, you simply put in “palliative care” or any topic you fancy, and it comes up with the most recently uploaded stuff with that computer tag. When I did this for “palliative care” this week I’ve noted the first ten things I got; there were only three for “palliative care” and “social work”. It would change over time, although my experience is that it hasn’t changed all that much over several weeks; palliative care obviously isn’t the hot topic among the tuberati.

Palliative care search comes first, then “palliative care” “social work”.

The Palliative Care search

First up came a German film that looked very hospital, but I couldn’t understand it, so I’ve left that one out.

Student Volunteers in Palliative Care in Kerala

http://www.youtube.com/watch?v=gfdUKcH-ZPg

This is an Indian man talking briefly about how wonderful it is to volunteer in palliative care in Kerala, India. It’s not clear what they do, how they got involved or anything practically useful, so it’s a bit of a pointless puff for volunteering in principle.

Cancer and Palliative Care Video.mp4

http://www.youtube.com/watch?v=KSVljzqeKBA

A UK video showing GPs how to find things about palliative care on the internet; it shows you how to click on various sites. Boring presentation but useful, I learned some things from it.

Palliative Care: What is it and who is it for?

http://www.youtube.com/watch?v=ttW8pxF__g4

This is an American film, presenting palliative care as something that hospitals do, a medical treatment for pain and other symptom relief done in hospitals alongside curative treatment; it does mention social workers, but all the speakers are doctors, even the patient experience. There’s a mixture of people talking to camera and pretty pictures.

Pain and Palliative Care: What the Future Holds

http://www.youtube.com/watch?v=Ai-MbsANxHY

A film of an American lecture from a university somewhere (they tell you the initials of the University at the beginning, obviously the rest of the world will know what it is) by Katherine Foley, an eminent American palliative care physician. It was obviously such an important lecture that she had a hair styling for the occasion: it doesn’t move. Neither does she, much, she was obviously told to stay in view of the camera. She reviews the progress of palliative care and has an international focus. You see the PowerPoints filmed as she talks, which are not easy to see in this format and some of them you can’t read. The presentation is very comprehensive, but very professional i.e. boring. It goes on for nearly an hour, so I haven’t watched the whole thing, and therefore I don’t know if it mentions social work. She does talk about palliative care as a human right.

Canadian Virtual Hospice Palliative Care Video

http://www.youtube.com/watch?v=ZWLoQkJD0WA

A 7 minute film about a Canadian information website, introduced by Chochinov, a well-known beardy in supportive care; it describes the site – you can submit questions for an expert to answer, and it has discussion bulletin boards and the usual information. There is an affecting account by the adult daughter of a cancer patient. Nice film, lots of variety.

Right to Relief: Palliative Care in India

http://www.youtube.com/watch?v=0_FK-5aMkEo

A 4-minute Human Rights Watch video complaining about how the Indian government and most of Indian medicine does not make pain relief through cheap morphine available. Good photos and video and presents a range of settings, including home care, so it gives a picture of what is probably quite a good Indian palliative care service. Presents the international human rights issue of availability of morphine succinctly and caringly.

What Is Palliative Care? – Dr. John Mulder

http://www.youtube.com/watch?v=QIF99iKnVcU

This American (?) doctor for a private sector health service describes palliative care as a consultative service for the longterm quality of life consequences of being treated for a life-limiting illness. He’s interviewed by an extremely thin, blonde, glossy woman in red, and in the 2-and-a-half minutes it does mention bringing in social workers. Talking heads stuff, presumably to advertise their services.

What is Palliative Care?

http://www.youtube.com/watch?v=Uy5PDoPfmWQ

Brief film, Diane E. Meier, Director of the American Center to Advance Palliative Care, talking about the kind of patients who might be helped by palliative care. Talking head stuff again. Going down the list further, there are several short films from the Center of the same sort and format, all about the American system as though the rest of the world does not exist, so it makes it peculiarly irrelevant.

The social work and palliative care search

Then I searched for “palliative care” and “social work”. This is what I got:

Social Work and Health Palliative Care – Care Accolades 2009 finalist

This is a one and a half minute film about Angus social work department (they’re not called social services or social care in Scotland, but that doesn’t mean that everyone involved are social workers). They obviously nearly won the prize for this competition for good services. The scheme is about generalist palliative care: it refers to a two-day training the trainers project to give training to it-wasn’t-clear-who, and they gave training to 122 (count them) front-line carers, who then said they were much more confident with advance care planning and talking about death and dying, presumably either with people in care homes or receiving community care services, it’s not clear. Professional film, but not really much information, and as it’s a prize competition, it’s not really a critical discussion of the issues.

Hospice San Miguel

http://www.youtube.com/watch?v=JFWNL9z8_wk

A five and a half minute ‘promo trailer’ for this hospice – it turns out it’s in Mexico, but you wait a long time to find that out, and it rather feels as though it’s an American city with a lot of Latino/a people. They would clearly like to influence American palliative care with their experience. Don’t be put off by the start, which is in Spanish, because most of it’s in English and there are subtitles when people speak Spanish.

It seems to be an American neo-colonialist project run by Americans for Mexican people (although the volunteer coordinator of the bereavement service may be British) and the comparisons made are with the American medicare system for funding hospice care; they claim they are going to show America how to be more flexible. It seems this is just about not having government interference. It’s not clear whether there is an in-patient unit or whether it’s a community service only, since they don’t actually say what they do, just tell you how wonderful it is. There is some patient and carer ‘testimonial’. There is a strong focus on bereavement groups and family work, which is achieved by getting social workers and volunteers in early (more or less the same thing as far as the speaker is concerned – it’s not clear who most of the speakers are, but they present as very do-gooding). The message of the film is mainly: ‘don’t be frightened of hospices, come early for care’. We can all appreciate the need for this, and it is well-filmed and produced.

End of Life Care Panel (10/30/09)

http://www.youtube.com/watch?v=t7g1WO68KYE

This is a panel of four people, one of whom is a social worker, answering questions; she talks well from experience about working with people with a different ethnic background. It looks as though it’s a public event by the Commonwealth Club of California explaining palliative care to the masses (well, poorly informed professionals really, I would guess; I suppose they are the masses). It’s led off by an extremely boring (male) medical professor with a grating voice and a very long job title saying how other medical specialities need palliative care. But it (and he) get better; there’s a very warm and practical nurse, a glossy, severe lawyer and a frizzy social worker. Most of the discussion is about assisted dying and advance care planning. It’s very long, more than an hour, and a very boring straight filming, with the occasional mid-shot of a panel sitting crammed unmoving behind a small table. I haven’t watched it all.

The Evaluation

There is some material on palliative care on YouTube, but not a lot and it’s mainly talking heads or educational. It’s mainly American, so there’s an opportunity for British organisations or individuals or people in other countries to make a good impact. In fact British viewers are likely to be seriously misinformed by the American stuff. And the American stuff is very American; there’s no attempt at international coverage in the American material, except in the lecture by Katherine Foley.

However, her lecture and the panel discussion from California illustrate the other problem with academic material on YouTube, they’re very long, very static and very boring. I cannot imagine anyone being prepared to sit through the whole thing. However, there is useful material in this stuff, but it should be carefully edited. At least cut out the doctor moderator with the two-minute job title (I’m exaggerating but not by much). Academic presentation like this also needs to be interspersed with appropriate illustration. The lecture had very interesting material, but it needed to be animated and shown properly. This requires work, guys. Not just slapping it on the internet.

You can put up with talking heads for a minute or two but not much more than that. Come on, we’ve seen the BBC or CNN, we know what it should be like.

Another weakness of some of the material is that it is promotional and it really does not make clear what it is promoting, so you don’t get to know what the volunteers do, just that (for a couple of minutes – it was so repetitive I almost switched off but I couldn’t believe he could say so little again and again) it’s wonderful that it’s there. It’s even easier to switch onto the next thing on the internet than it is with a television set or radio, so your material really has to be focused.

On the other hand, some of the short films which wanted to make just one point with interesting film or photos and lots of variety are really informative. Going for that makes a good impact. Less is more.

It was assisted dying day on tv last night and in the press in the last week. To sum up:

The controversialist, novelist Martin Amis, advertising a book, complained about a tsunami of older people with dementia.

The original interview was in the Times:

He is painfully aware that his time as a writer is running out. “Writers die twice: once when the body dies, and once when the talent dies,” he wrote recently in a review of Nabokov’s The Original of Laura. “Medical science has again over-vaulted itself,” he says now, “so most of us have to live through the death of our talent. Novelists tend to go off at about 70. And I’m in a funk about it. I’ve got myself into a real paranoid funk about it, how talent dies before the body.”

I can’t help feeling he’s being a leedle dramatic here, but his hatred at not feeling “100%” is genuine. He is disgusted at the problem of the ageing population: “How is society going to support this silver tsunami? There’ll be a population of demented very old people, like an invasion of terrible immigrants, stinking out the restaurants and cafes and shops. I can imagine a sort of civil war between the old and the young in 10 or 15 years’ time.”

Amis’s solution is typically extreme: mass euthanasia. “There should be a booth on every corner where you could get a Martini and a medal,” he says. In fact, he was thinking about it only last year, when his stepfather died “very horribly”, he says. “He thought he was going to get better. But he didn’t. I think the denial of death is a great curse. We all wanted to assist him… It was clearly a lost battle.”

http://entertainment.timesonline.co.uk/tol/arts_and_entertainment/books/article6996980.ece

The  Guardian has a video of him talking about this afterwards; he says he is a fan of euthanasia:

http://www.guardian.co.uk/commentisfree/belief/video/2010/feb/01/martin-amis-euthanasia-assisted-suicide

What is particularly striking about this comment is that it is more about ageing and dementia rather than assisted dying. This is a very negative view about ageing and its impact on society, and a very excluding view about older people and people with dementia. However, he has had some sympathy for this point of view, as opposed to the reaction to his euthanasia comment. It’s alright to feel that all the older people are a blot on the landscape then? I think there might actuially be a majority for this. Our media do not seem to have realised what, sixewise,  an important population group we are; they are still into the importance of catering fro youth because they are the future. Well just remember that older people of 60, like Martin Amis are the future, probably fro the next thirty years.

Then there was quite an interesting debate reported in the Observer:

http://www.guardian.co.uk/society/2010/jan/31/assisted-dying-debate-euthanasia

This included Ilora Finlay doing her defence of care and palliative care; a sample:

IF: The whole of palliative care is about trying to help people to make choices that are right for them, to enhance the quality of their life when they have it. That is hard work. The minute you start saying you can take shortcuts in care or you can leave people or give them the impression that things can’t be done for them, then you drive them further into despair. What you’re presenting them with is not about real choices in care, you’re giving them a choice of either staying in despair or being dead. I don’t think that is a choice.

I think this is a really good point: it is important not to polarise the issue between despair and death; there are other alternatives.

Listening to her on Today, on BBC Radio 4 on Monday morning, as they were promoting both the Panorama and Terry Pratchett programmes on BBC1 that night, I found it interesting that she was arguing to take the issue out of healthcare; make it a legal process, so that trust in doctors is not affected by providing assisted deaths. Is she recognising that the public and media pressure for some sort of provision for assisted dying makes a change in the law inevitable, and she’;s beginning to set out the stall for the way it should be organised. Of course. she was also connecting with Pratchett, because he is arguing for a tribunal to make the decisions, including medical and legal involvement, as you can see in my excerpts from his speech below.

The Panorama programme then had an extended interview with Kay Gilderdale, found not guilty of attempted murder of her daughter last week (she has previously been found guilty and sentenced for assisting suicide). The 31 year old daughter was very disabled by serious and chronic ME and had injected herself with large doses of morphine, explicitly trying to kill herself. When she seemed distressed her mother crushed up more tablets and did other things, including getting advice about how to follow through. Because she did this at her own decision, rather than just accepting the course of her daughter’s actions, this put her outside the Director of Public Prosecutions’s guidelines for deciding not to prosecute. See my post on Saturday, October 10th, 200 for information.She is not the only person recently, since Frances Inglis was given a life sentence for a ‘mercy’ killing of her brain-damaged son.

There are excerpts from Kay’s interview on the Panorama website:

http://news.bbc.co.uk/panorama/hi/

This is a news account, including an interview with a neighbour who speaks of Frances’s feelings, of the Frances Inglis case: http://news.bbc.co.uk/1/hi/uk/8466140.stm

Panorama also commissioned a public opinion poll which showed that for a terminally ill patient, 75% of people thought that family and friends (or medical professionals) should not suffer prosecution; opinion was evenly balanced where there was chronic pain. This suggests that for many people, the issue of whether patinet is terminally ill is an important factor. This reflects an unreal perception, since as Ilora Finlay said in the Observer debate cited above that deciding when someone is terminally ill is quite hard.

Article about the poll: http://news.bbc.co.uk/panorama/hi/front_page/newsid_8487000/8487768.stm

Poll details here: http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/01_02_10_Poll_results.pdf

The main event last night was Terry Pratchett’s Richard Dimbleby lecture (mostly actually read by the actor Tony Robinson, since Pratchett was not well enough to be able to get through such a long )text. It was a beautifully turned speech, and there is a shortened version in the Guardian today:

http://www.guardian.co.uk/society/2010/feb/02/terry-pratchett-assisted-suicide-tribunal

The new thing about this, to me, is the suggestion of an assisted dying tribunal:

That is why I and others have ­suggested some kind of strictly non-­aggressive tribunal that would establish the facts of the case well before the ­assisted death takes place. This might make some people, including me, a little uneasy as it suggests the govern­ment has the power to tell you whether you can live or die. But, that said, the government cannot sidestep the ­responsibility to ensure the protection of the vulnerable and we must respect that…

The members of the tribunal would be acting for the good of society as well as that of the applicant – horrible word – to ensure they are of sound and informed mind, firm in their purpose, suffering from a life-threatening and incurable disease and not under the ­influence of a third party. It would need wiser heads than mine, though heaven knows they should be easy enough to find [no, I think actually is will be tough to come up with a procedure that is not horrifically bureaucxratic], to determine how such tribunals are constituted. But I would suggest there should be a lawyer, one with ­expertise in dynastic family affairs who has become good at recognising what somebody really means and indeed, if there is outside pressure. And a ­medical practitioner experienced in dealing with the complexities of serious long-term illnesses.

I would also suggest that all those on the tribunal are over 45[bit ageist that; many young people are sensitive to these issues too], by which time they may have acquired the rare gift of wisdom, because wisdom and compassion should, in this tribunal, stand side-by-side with the law. The tribunal would also have to be a check on those seeking death for reasons that reasonable people may consider trivial or transient distress. I dare say that quite a few people have contemplated death for reasons that much later seemed to them to be quite minor. If we are to live in a world where a ­socially acceptable “early death” can be allowed, it must be allowed as a ­result of careful consideration.

Let us consider me as a test case. As I have said, I would like to die peacefully with Thomas Tallis on my iPod before the disease takes me over and I hope that will not be for quite some time to come, because if I knew that I could die at any time I wanted, then suddenly every day would be as ­precious as a million pounds. If I knew that I could die, I would live. My life, my death, my choice.

This proposal speaks to one of my concerns about possible changes in the law, because I think that once these things become official in some way they also have to become bureaucratised, so that they are no longer personal decisions by those involved, but will mean officials, no matter how qualified and experienced, having to go through complex and time-consuming procedures to implement intricate guidelines. Ilora Finlay’s point in the Observer debate is also relevant, that a legal change will also lead to a change in social attitudes, which will make killing more acceptable in a variety of ways.

Amis’s point and another Finlay insight is that really this is all about care. people do not much want to be cared for for a substanital lump of their life, the care we can provide is not good enough; resources are limited and will increasingly be rationed. So are we proposing to assist in people’s deaths because we are not willing to provide the best care? At least in these cases a person providing outstanding care and clearly, as with Frances Inglis, ‘with love in their heart’ they are reacting to a personl predicament. But will official assisted dying become an acceptable practice in a policy context where we are not prepared to provide enough care services and good enough care serviecs.

And a social work view? Social workers are going to be involved, because whatever the decision-making process, social information and social records will be used as part of it. Either they will be sent out to make a report, like adoption, guardian ad litem, and social histories, or their past records will be sued to see what family attitudes are, because they will be the profession that has kept records of families.

And these matters are social and policy matters: how much care are we prepared to provide to increasing numbers of people whom the media, like Amis, find smelly and not very interesting? And who is going to provide it? There will not be enough carers and care serviecs to go round; there are not enough now. So is no services the reason we want to go for assisted dying?

I think most social workers instinctively agree that people should have the choices. but how far does poor care mean that the reality of their choices is ‘no choice’. And most of the people arguing for assisted dying currently are strong-minded middle-class people who can think through and support their own opinions. Pratchett talked about granny going and banging he stick on the tribunal’s desk. Not of lot of dying people have that capability. He talks about early decisions, but that’s only relevant to a few well-prepared, long-term disabilities; what about most of the people that I meet that are not thinking in the long-term about what is going to happen to them? Will the tribunal clog up with bureaucracies and not be able to deal with urgent cases. Or will we all say what grade of assisted dying we want in our lasting powers of attorney when we register them with the Public Guardian, as he is urging us all to do?  What about not-very-articulate people who do not have the confidence to apply to one of Pratchett’s tribunals, or need someone to prepare their case? The Government is cutting back on legal advice and aid in many socially important legal situations: is this going to be another where you either make it on your own or not at all? Will there be class inequality in making your case for assisted dying?

Even if you support assisted dying. there’s still a lot to be thought about.

David Cameron the Conservative opposition party leader, made a speech last week on the ‘Big society’, which put forward his thinking on poverty and social intervention generally. As always, they’re against the state doing it, and many people can accept that there is a considerable degree of state failure in social provision. The problem for the Conservatives is that there’s a high degree of market failure in social provision as well. Often everyone accepts that the market is not the place for social interventions, or they have to set up some convoluted quasi-market system that is not really a market, and institutionalises complex state controls over voluntary action.

Voluntary organisations may be wonderful, but to rely on voluntary organisations to deliver wide-scale state services is inappropriate; it twists voluntary action by making it involuntary.

You can see this in the hospice movement. Hospices in the UK are mainly in the voluntary sector because St Christopher’s was originally a demonstration of what was possible in care for the dying and their families at a time when not a lot was done. Now Conservatives routinely say how wonderful voluntary hospices are as an example of how lots of other services should be run. But proper care for dying people and their families is a responsibility of society where government should take a lead and make sure that a high standard of care is widely available. They should not be pleased that they can offload that responsibility because enough sentimental and well-off people will make donations to support it,

Cameron’s speech on the web: http://www.conservatives.com/News/Speeches/2009/10/David_Cameron_The_Big_Society.aspx

The Touchstone blog by Richard Exell has a useful discussion of the speech, with references to many of the past Conservative documents on the topic that many people will not be aware of and rehearses the arguments against it; however, be aware that Touchstone is a TUC (ie trade union) blog:

http://www.touchstoneblog.org.uk/2009/11/david-cameron%E2%80%99s-big-society-speech/

It seems that the Department of Health and the Charities Commission are having a row about NHS charities. A new international accounting standard for public bodies requires the accounts to be consolidated with the NHS accounts, whereas the Charities Commission thinks a charity’s accounts should never be part of a public body’s accounts.

Web information on the issue:

http://www.thirdsector.co.uk/News/DailyBulletin/948049/Charity-Commission-takes-stand-NHS-charities-accounts/63AA077707931EC526211C5DD9F168F7/?DCMP=EMC-DailyBulletin

Trust them to have an argument about the pointless end of the issue. This is a sign that NHS (and therefore public) bodies are controlling charities. You have to ask why? I realise that the history of this is that many of these are leftovers from when the healthcare system was turned from a largely charitable system to a public system (only 60 years ago, so of course we haven’t dealt with the problem yet). People gave charitable monies to (mainly) hospitals, so hospitals hung onto it; it gives them a bit of freedom of manoeuvre. What this means is that the historic NHS trusts, now mainly foundation trusts, have extra cash to do what they like with, instead of participating properly in local planning. This also gives an advantage to the richly endowed hospitals, in stead of spreading money around the country in accordance with needs.

What has this to do with social care and palliative care. It means that some hospitals can promote their internal palliative care without any concern for the planning of other local services, and advantage people where there is a rich inheritance when others might need it more. It’s time this source of inequality was ended and these charities floated off to be truly independent.

Another pic of the new St Christopher’s. You may think this is just like a commercial gym, and that’s the point of it. Patients visitng the new Anniversary Centre can book into this or take part in a regular physiotherapy programme; the fitter you are, the more you can combat your illness and its effects on you.

The EU has published a strategy for global health policy, with  focus on maternal and child care, responding to climate change and talking about support for issues such as malaria prevention. Obviously major problems of ill-health and health inequalities remain. Buit this is very much a policy about achieving the Millennium Development Goals, and ignores that element of health and social care which is about care, not just about widespread changes will prevent or treat diease, which tend to focsu on the young. Inequalities affecting older peopleand dying people because they are not our future are ageist and in the end uncaring.

On the web: http://ec.europa.eu/development/icenter/files/europa_only/EU_role_global_health_issue_paper_en.pdf

The NHS Evidence Update on cancer rates has been published, and gives you an idea of the accumulated evidsence on what kinds of cancer differentially affect particular minority ethnic groups. It says:

Overall cancer incidence was found to be lower in South Asian, Chinese and mixed race groups than whites.  However, some important specific differences were also identified:

• Black males of all ages were more likely to have a diagnosis of prostate cancer than white males. (Age standardised Relative Risk (RR) between 1.26 and 2.48, based on different assumptions regarding patients with unknown ethnicity)

• Black males and black females had higher rates of cancers o f the stomach. (RR 1.14 – 1.74)
• Black males and black females had a higher rate of liver cancer than white males and females. (RR 1.47 – 2.67)
• Black males and black females had a higher rate of myeloma than white males and females. (RR 1.79 – 2.80)
• Black females aged 65 and over were at a higher risk of cervical cancer than white females of the same age. (RR 1.13 – 2.50)
• South Asian men and women had a higher rate of liver cancer than white males and females. (RR 1.47 – 2.43)
• South Asian females 65 and over had an increased risk of cancer of the mouth (RR 1.18 – 1.97), whereas South Asian men may have a lower risk of getting cancer of the mouth than white men.
• South Asian females aged 65 and over had a higher risk of cervical cancer than white females. (RR 1.15 – 2.29)

Worth a look at the whole thing and links to the evidence:

http://www.library.nhs.uk/ETHNICITY/ViewResource.aspx?resID=326764&tabID=290