The Public Service Industry: A constitutional blasphemy and a democratic perversion

The Public Service Industry: A constitutional blasphemy and a democratic perversion.

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Accountability and transparency demand that Freedom of Information requirements should be an essential corollary of receiving public funding, throughout the whole of the NHS

Posted: 30 Jan 2013 05:15 AM PST

Changing patterns of provision for public services can have serious implications for existing standards of public accountability, converting large swathes of previously open and published information into ‘commercially confidential’ material kept secret by for-profit companies. Grahame Morris MP argues that the solution to this creeping decrease in accountability is to require that FOI rules on public disclosure apply even-handedly to all service providers within the NHS, whether they are in the public or private sectors.

In late January 2013 the Department of Health announced the formation of an expert panel within the Department advising the government on ‘Strengthening the NHS Constitution’. Replacing the older NHS Future Forum working group, this panel would “oversee the consultation on strengthening the NHS Constitution” and “develop a set of proposals to give the NHS Constitution greater traction so that patients, staff and the public are clear what to do, and who to turn to, when their expectations under the Constitution are not”. The Department also disclosed the Commercial Director of Virgin Care (that Dr Vivienne McVey), has become a member of an expert panel within the Department advising the government on ‘Strengthening the NHS Constitution’. Now Virgin Care is actively involved in bidding for lucrative NHS contracts up and down the country, and is now controversially running some NHS services in Southern England. So Dr McVey’s company is just one of a number of private companies, from home and abroad, now bidding for an estimated £7 billion of NHS contracts that have in recent months been put out to tender. In common with other private healthcare companies, Virgin Care stated in an interview to the Financial Times that it intends to make an 8 per cent profit from NHS contracts, which are financed by us, the taxpayer.

The question any reasonable observer might ask is what possible interest could Virgin Care have in ‘strengthening’ the NHS constitution, when their business model would seem to be premised on public provision performing poorly? So taxpayers and patients may justifiably ask if Virgin Care’s Commercial Director is the best person to take up this important advisory position. Most people accept that transparency is a key tenet of a strong NHS. So what might Dr McKay have to say about the current bidding practices for NHS contracts that allow commercial organisations such as Virgin Care to withhold details of those bids under the cloak of ‘commercial confidentiality’, while NHS Trusts have to reveal all and are subject to the Freedom of Information Act? Does Dr McKay and Virgin Care support the extension of the FOI Act to follow the public pound to include private medical firms running parts of our NHS?

These considerations, together with substantial support from community activists campaigning against the fragmentation and privatisation of our NHS, lead me to table a Parliamentary Early Day Motion calling for private health care companies also to be subject to the Freedom of Information Act. It has attracted the signatures of 85 MPs from 7 different parties and it has received plenty of supportive comment in the media, including in The Guardian. If you, like me believe that our NHS should not be put up for sale through secretive bidding processes, please ask your MP to sign as well. Details of the motion (known as EDM 773) are as follows:

‘That this House notes that

the most significant development that has followed from the Government’s healthcare reforms has been the 7 billion worth of new contracts being made available to the private health sector;

further notes that at least five former advisers to the Prime Minister and the Chancellor of the Exchequer are now working for lobbying firms with private healthcare clients;

recalls the Prime Minister’s own reported remarks prior to the general election when he described lobbying as `the next big scandal waiting to happen’;

recognises the growing scandal of the procurement model that favours the private health sector over the NHS, by allowing private companies to hide behind commercial confidentiality and which compromises the best practice aspirations of the public sector;

condemns the practice of revolving doors, whereby Government health advisers move to lucrative contracts in the private healthcare sector, especially at a time when the privatisation of the NHS is proceeding by stealth;

is deeply concerned at the unfair advantages being handed to private healthcare companies; and

demands that in future all private healthcare companies be subject to freedom of information requests under the terms of the Freedom of Information Act 2000 in the same way as existing NHS public sector organisations’ .

Over the years there have been many campaigns launched to save our NHS, but never has there been a more important time as now, to do just that. Achieving a level playing field in bids for NHS contracts is only a start. In my own view, the next Labour Government needs to move to take the ‘for profit’ sector out of public health and our NHS, once and for all.

Note: This article gives the views of the author, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting.

About the author

Grahame Morris MP is the Labour Member of Parliament for Easington.

I’ll always be grateful to the GP who eased Mum’s pain – even if it hastened her death

By Nick Maes

Nick Maes's mum Wil lived with a diagnosis of dementia for three yearsNick Maes’s mum Wil lived with a diagnosis of dementia for three years

Earlier this month, Dr William Lloyd Bassett, a Shropshire GP, was hauled in front of a disciplinary panel at the General Medical Council.

It was alleged that he’d deliberately hastened the death of a terminally-ill man by giving him a huge dose of morphine.

The case made headlines across the country, and prompted debate about the fine and treacherous line between aiding a patient in distress and hastening death.

But for me, this case was especially shocking. For I had witnessed Dr Bassett in action: he gave my mother morphine as she was about to die.

The recent General Medical Council hearing centred on an incident in May 2009 when Dr Bassett went to the home of a man dying from lung cancer and treated him with a high dose of diamorphine.

This led to him being questioned over his fitness to practise; a serious charge that could have ended his career.

Crucially, though, the family of the man who died would have nothing to do with the charges against him, and supported Dr Bassett 100 per cent in his actions.

The patient had become deeply distressed in his final hours. Although Dr Bassett accepted that the 100mg dose of morphine was too high and a mistake, it led, in all likelihood, to a more peaceful death

Last week, the hearing decided that Dr Bassett should continue to practise, but issued a warning of serious misconduct against his name.

Such cases mean many GPs are now nervous about administering pain relief to people in the final hours of life, in case they find themselves in a situation similar to Dr Bassett’s.

Dr Clare Gerada, chair of the Royal College of GPs, agrees that doctors are frightened to administer powerful opiate drugs.

‘It’s very difficult for doctors to offer palliative care because of the threat of manslaughter charges should the patient die soon afterwards. When one hears of a patient dying after a dose of morphine, there’s a sense of relief that you’re not the one who has administered it.’

Dr William Bassett gave Wil morphine as she was about to dieDr William Bassett gave Wil morphine as she was about to die

But after witnessing Dr Bassett at work in a similar situation as he attended my dying mother three years ago, I can only thank him for his caring, professional intervention.

At 83, my mother Wil — the name she was known by to all her family and friends — had been living with a diagnosis of dementia for three years.

Yet she managed to remain at home because of the stalwart support of her family, and carers who came in a couple of times each day.

Mum was determined to stay put. That was her resilient, forthright character — some would call it bloody mindedness, but it made her who she was.

When a social worker pushed for her to enter a home, the idea was swiftly rejected — by Mum and by us as a family. She’d cling to her staunch independence, a trait compounded by losing her husband Arthur nearly 40 years earlier.

But Wil’s general health was suddenly complicated as her vital organs began to fail: heart failure, water retention, high blood pressure and immobility intensified the problems.

Our family GP had no sure way of telling how long she might live, although it was suggested she might survive for another two weeks.

Mum’s condition rapidly deteriorated. Within 24 hours, she looked intensely frail and was hallucinating.

But that evening she seemed to rally. She sat up in bed and enjoyed an impromptu party, drinking brandy, laughing and chatting with all those closest to her.

Mum loved a good party and I think secretly enjoyed being the centre of this particular one. Our spirits were raised, even though we sensed, deep down, this would be the final stage of her illness.

At midnight, as my three sisters and I prepared Mum for bed, she had a seizure. Her eyes rolled into the back of her head, her body became a dead-weight and any colour that might have been there drained from her complexion. It was as if she’d imploded.

We eased Mum back into bed, tacitly understanding the end was close. Yet none of us really quite knew what to do. We’re not a foolish or mawkish family by nature, yet confronted by our mother’s inexorable slide towards death we found ourselves helpless.

It was eventually decided to call Shropdoc, the local out-of-hours doctor’s service. Dr Bassett isn’t our family doctor; it was sheer luck that he happened to be on call that night. His response was quick, and after examining Mum he suggested sending for an ambulance.

Nick Maes, aged four, with his mum WilNick Maes, aged four, with his mum Wil

We didn’t want Wil to go to hospital; there was no logical reason to send her. Dr Bassett respected our wishes and left, urging us to call again if there were any change.

We took it in turns to sit with Mum. But as the night drew on, Wil became restless, pointing into space, trying to shift her tiny frame off the bed. Mum’s agitation and distress became more marked and then she was sick.

At 4am we called Shropdoc again and Dr Bassett returned. It was obvious that neither I nor my sisters knew what we were doing. Dr Bassett’s presence was a huge reassurance to us, and more importantly to Mum, towards whom he was compassionate. He was with us for an hour all told and his manner was exemplary.

He spoke with Mum as she drifted in and out of semi-consciousness, asking her how he could help. Eventually he suggested that she might like morphine as a drip and as an oral dosage to ease her pain and relax her. (Wil hadn’t had any other medication until that point.)

Mum was unequivocal and nodded agreement. Wil was a woman who’d always said she wasn’t afraid of death, and now her old resilience flashed back. I felt an innate sense of relief, as did my sisters, that a decision had been made and a course of action taken.

Dr Bassett didn’t shy away from explaining what would happen, not to Mum nor to us, her children. The morphine would calm her and relax her; as the drug worked she’d probably slip away with less fight, drifting inescapably into a deep sleep.

He attached a line to Wil’s leg and placed the morphine drip-feed device on the dressing table — an incongruous addition to the knick-knackery of mirrors, perfume and jewellery usually found there.

Ensuring Mum was comfortable, Dr Bassett slipped quietly out of the house, leaving us to sit and gently talk with her.

The morphine quickly took effect, and she drifted off into a calm and deep sleep. We sat around her bed, holding her hands, stroking her hair, reminiscing about the marvellous times we’d had together and telling her how much we loved her.

Just after 9am the next day — a little over five hours later — Mum stopped breathing; she’d died with dignity and in peace.

The nature of her death was due to Dr Bassett’s seemly and humane intervention.

Her suffering had been minimal and she’d had the great good fortune to die in her own bed surrounded by all of her children.

Because of this experience, I’m under no illusion that assistance for those in the final stages of dying should, if requested, be given by doctors without fear of reprisal.

I’m not advocating wholesale euthanasia, or ending life along the lines practised at centres such as Dignitas in Switzerland. But when life is undeniably ebbing away, it is surely our responsibility, as a kind and caring society, to alleviate unnecessary suffering.

Doctors are rightly governed by a strict code of conduct. Key to the principles of medical ethics is that the doctor acts in the best interest of the patient. This would include giving pain relief to ease the suffering of the dying patient.

But this action can conflict with another key principle: do no harm. Even small doses of morphine suppress breathing, and there is a point where adequate doses may, inevitably, stop the breathing.

Dr Clare Gerada explains: ‘There’s no guidance regarding the amounts of diamorphine to be used on patients. This is because some cancers require hundreds of milligrams and others maybe just 10 or 20. It makes it very difficult for doctors because it’s difficult to predict.

‘Morphine is a very good drug, not because it kills people, but because it calms people down; and in the case of lung cancer makes it easier to breathe.’

Yet I would argue that if someone was on the verge of death, then what difference would alleviating the pain and hastening the inevitable make?

It’s a pragmatic approach, due in no small way to the practical influence of my mother.

‘We all have to go at some time,’ my mother would say. ‘No exceptions. There’s nothing to be scared of.’

Of course, the real fear is of dying in anguish. But the use of morphine to ease this fear still conjures up — almost unavoidably — awful memories of Dr Harold Shipman.

However, we shouldn’t make these nervous connections and demonise the drug. It’s vital that we have open and honest dialogues with GPs, patients and families in order to make informed decisions.

Until recently, it was common knowledge that the family GP, when tending the dying at home, might help shorten the suffering with morphine.

Maybe this was more an implicit arrangement — an unofficial, yet profoundly caring intervention that was acknowledged but not openly talked about.

Perhaps in previous generations there was a greater level of interaction between doctor and patient than we have today.

Each year, approximately half a million people die in Britain. A recent report from the think-tank Demos shows two-thirds of us would like to die in the peaceful and familiar surroundings of our own homes.

This is an infinitely preferable option to the noisy and frightening environments found in over-stretched and busy hospitals.

Yet, in reality, barely 18 per cent actually manage to achieve this last wish — which equates to more than 190,000 dying in hospital each year when they would rather die at home.

The Dying for Change report suggests that by 2030, just one in ten will have the opportunity to die at home.

Charles Leadbeater, the report’s co-author, said: ‘It’s not just that we’re living longer; part of this means that people are dying over a longer period, losing first their memory and then their physical capacities in stages.

‘If we put in the right kind of supports for people to cope at home, many tens of thousands of people could have a chance of achieving what they want at the end of life; to be close to their family and friends, to find a sense of meaning in death.’

From sitting in those final moments with my mother, I know nothing is as intimate or as personal as being with someone as they die. It is a great and intensely private honour.

And when my time comes, I can only fervently hope that someone as caring and as compassionate as Dr Bassett will be at my bedside.