Achieving cost-effective and evidence based solutions to impact on whole populations.

Notes of a conference at the Kings Fund on 30.3.10, reported by John Kapp
22, Saxon Rd, Hove BN3 4LE, East Sussex
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The conference was attended by 115 people, of whom only 5 were commissioners, which was regretted, as it was primarily aimed at influencing commissioners to commission interventions that prevent sickness and reduce health inequalities. The NHS spend only 4% on prevention, which should be increased, but it will be difficult to do in the cold climate of cuts over the next few years.

A pre-recorded video by Michael Marmot was shown. He was the chairman of the ‘Strategic Review into Health Inequalities in England’, whose report was published on 11.2.10. He said that his aim was to avoid un-necessary suffering and fore-shortened lives. His proposed measures could extend the lives of 200,000 people (40%) His one sentence solution was: ‘to get people together to create a fairer society.’ He wants to ‘strengthen the role and impact of ill health prevention’ by nearly doubling the prevention budget of the NHS to 7%.

Dr Jessica Allen was one of his project directors, and gave us key findings in slides. She showed a graph of neighbourhood income deprivation on the horizontal axis, and life expectancy (LE) in years, and Disability-Free Life Expectancy (DFLE) on the vertical axis. Both lines have a sloping gradient, rising with affluence. They show that people in deprived areas tend to be more disabled and have shorter lives than people from affluent areas. The LE median line goes from 73-82, with 9 years difference. The DFLE median line goes from 52-70, with 18 years difference. Whatever the pensionable age may become makes little difference to public expenditure, as it just swaps pension for disability allowance.

The study was broken down into 6 sectors: A Early years.
B Education.
C Employment.
D Standard of living.
E Community.
F Prevention.
A useful concept is ‘lifestyle drift’ implying the tendency of people to drift into the habits of their communities. The EU has commissioned a similar inquiry which Michael Marmot is to chair over the next 2 years.

Prof Chris Bentley spoke next. He heads the national support team for health inequalities at the Department of Health. (DH) He quoted the 1997 Acheson report’s definition of public health: ‘The science and art of preventing disease, prolonging life and promoting health of whole populations through the organised efforts of society.’ He spoke of the ‘inverse care law’ in which the most deprived people have to ‘climb a cliff face’ to get prevention measures for obesity, smoking, alcohol abuse, high cholesterol (statins) Policy should be focussed on the have-nots. The latest DH objective is the acronym ‘QIPP’, standing for Quality, Innovation, Productivity, and Prevention. However, commissioning for prevention tends to be ‘pink and fluffy’ aspirations, whereas what is wanted is specific interventions which can be evaluated by how many lives they save.

Dr Neil Pease, Deputy Director of Earning, Learning and Innovation of Hull PCT, spoke on ‘A city wide approach to working in partnership: creating affordable, inclusive and sustainable interventions for prevention.’ He gave not ‘pink and fluffy’ ideas, but a specific costed example of prevention in practice, which was at first thought to be a ‘crazy idea’. He initiated a martial arts club, now used by 200 men (average age 50) which costs the taxpayer £30kpa, or £2.80 per head per week. Evaluation in focus groups has shown that this is reducing obesity and domestic violence in the whole community. His PCT have initiated about 40 similar projects.


1 What is ‘prevention’?
In the discussion, I said that asking NHS clinicians to prevent sickness is like asking garage mechanics (who fix crashed cars) to prevent crashes. They have not been trained to do this, so they wouldn’t have a clue how to start. The same is true the half million NHS clinicians. They have only been trained to fix crashed people, and haven’t a clue how to prevent people crashing, nor even know what prevention is.

The only speaker to give us a true example of prevention was Neil Pease - the martial arts club. How does it work? Martial arts teaches meditation, and has an evidence base of prevention efficacy going back thousands of years. By learning meditation we learn to ‘take care’. We become aware of what we are doing to ourselves and to other people, so learn not to beat ourselves or others up, so our whole community becomes healthier.

Chris gave an example of prevention which was untrue. He said that statins prevent heart disease. They don’t. If they did, CHD would not be the biggest killer. That myth (pedalled by the drug companies) is blown in the book: ‘The Great Cholestrol Con – The truth about what really causes heart disease, (stress) and how to prevent it’ by Dr Malcolm Kendrick, published by John Blake in 2007. A review of it in Doctors Magazine says: ‘This book confirms a nagging fear that the current cholesterol obsession may be utterly misguided’.

2 Complementary and Alternative Medicine (CAM)
I said that there is a huge industry out there whose sole objective is the prevention of sickness. It is the called ‘Complementary and Alternative Medicine’ (CAM) Unlike the NHS clinicians, the half million CAM therapists have been trained and qualified in the ancient art and science of prevention. This is why I urged the integration of (CAM) into the NHS, as Prince Charles’ charity Foundation for Integrated Health has been promoting since 1993.

The panel did not respond to my remarks, which is the normal reaction to any mention of CAM. As a patient representative, I have been saying this at NHS meetings for a decade. CAM is a taboo subject, on the far side of an iron curtain. It has been put there by drug company propaganda that there is no evidence for it, and it is quackery practiced by charlatans. To counter this myth I have written over 40 papers, which are published on section 9 of my website: I summarise my recommendations on how the NHS can prevent sickness and eliminate health inequalities below:

a) Prevention means learning to ‘take care’ (which words are so badly needed in society that they have replaced ‘goodbye’) The skill of taking care can only be acquired by learning to meditate. We then gradually change our attitude to life by becoming aware of what we are doing to ourselves, to others and to our environment. Meditation is the active healing ingredient in CAM, which is why it works to cure and prevent sickness.

b) You cannot become qualified to teach prevention to others on a weekend course. You first have to honour the maxim: ‘Physician heal thyself’. The only way that the NHS can commission interventions to meet the Darzi/Boorman targets of preventing sickness in patients and staff is by outsourcing the whole of its prevention provision (more than 7%) to CAM therapists, by integrating free CAM into the NHS.

c) Complementary Care Trusts (like Primary Care Trusts) should be formed to commission CAM from new Social Enterprise (SE) companies to provide CAM in each city.

d) The SE companies would provide free CAM by printing £50 vouchers to give to GPs to offer to patients, which would be tradable in any of about 100 existing CAM centres in each city.

e) I have formed a campaigning body to promote the idea of free CAM on the NHS, called Social Enterprise Complementary Therapy (SECT) We have a committee of 15 CAM therapists, and we are engaging with our NHS Brighton and Hove commissioners to pilot this in our city. Details are on the above website, including a business plan at 9.39.

3 Doctors suffer the worst health inequalities
One remarkable fact that nobody mentioned is the health inequality of being a doctor, as they have high addiction rates and a decade less life expectancy than average. This is even more than the 9 years difference between the affluent and deprived. Doctors are affluent, so the reason for this health inequality is not that they are deprived of money. I have written many papers on this subject which are on my website.

To prevent sickness and eliminate health inequalities, we have to eliminate their cause. The vital questions (which nobody asked) are:

4 What is the root cause of sickness?
Our attitude to life, because we create our own reality and become what we believe. Doctors are sick because their job requires them to believe the materialist paradigm, which is life-negating. Prof Ernst and Simon Singh, writing on behalf of the whole medical profession, say in their book ‘Trick or Treatment? – Alternative Therapy on Trial’: ‘There is no evidence for a life force’. If doctors do not believe in life, how can they be healthy? And with 200,000 sick doctors, how can the nation be healthy?

Prevention means changing these negative attitudes (life negating) to positive ones. (life affirming) This is what CAM does, but as it costs about £40 per hour for one to one, and £6 for groups, only the affluent can afford it. I am lucky to have accessed CAM for an estimated average of 3 hours per week for the last 20 years, costing me about £4kpa, total £80k. This cured various sicknesses (osteoporosis, obsessions, cataract, arthritis) and prevented others (depression, diabetes, cancer etc) by changing my attitude from materialism (consumerism) to holism. I now see my body as my hardware, my mind as my software (which needs frequent downloads of updated programmes through meditation) my soul as my operator and my consciousness (spirit, life force) as my internet.

5 What is the root cause of health inequalities?
The inaccessibility of CAM to the deprived. You have to be rich (like me) to afford regular CAM. Most of the population cannot afford £4kpa for CAM, so are denied effective prevention through learning CAM’s positive (holistic) attitude to health. Society can eliminate health inequalities at a single stroke by making CAM free at the point of use to all the population, through integration.

6 ‘Pink and fluffy’ commissioning
This expression of Chris accurately describes the woolly nature of commissioning today, and throughout the 20 years since it was introduced. It was picked up by Kevin Barron MP’s Health Select Committee report on commissioning (30.3.10) calling it: ‘a box ticking exercise’. Quoting from the summary:
Furthermore there are concerns that World Class Commissioning will be no more than a “box ticking” exercise whereby people expend a lot of energy merely demonstrating they have the right policies in place, rather than actually transforming patient outcomes and cost effectiveness.

I too have been complaining about woolly commissioning. SECT recently (11.3.10) had a meeting with our director of commissioning. I complained about her Strategic Commissioning Plan (SCP) using metaphor:

‘You are like a railway company who publishes strategic plans stating: ‘The trains will run on time’, but without publishing timetables, destinations, or ticket prices. For example, your latest SCP entitled ‘Improving Health and Developing World Class Healthcare 2010-15 is a 175 page document containing many statements such as: ‘We will empower staff, patients and the public…….We will be customer-focused……..We will take our responsibilities seriously……We will promote innovation, and be confident to try new things……….We will do more to support Practice Based Commissioning…’

However, it does not contain the detail that is needed to fulfil its primary purpose of saying how much public money you budget for each and every treatment in each year. The absence of this detail prevents existing providers from planning their provision of services. It also prevents alternative providers (such as CAM providers, whom SECT represents) from entering the market for publicly funded treatments. This is unfair discrimination against alternative providers, and is against the interests of the patients and the public who pay for the NHS’.

7 What will happen to commissioning after the election?
I am pleased that Kevin Barron MP calls for the reversing of the absurd decision of DH to cut PCTs budgets by 30% by 2013. They should cut the cart, (providers) not the horse (commissioners). Commissioners should be promoted to be part of the regulatory system of the NHS, whose job is to ensure that providers provide safe, effective treatments. They are failing to do so, but cutting their budget per se will not improve health outcomes for patients.

I am pleased to note that the Conservative health manifesto states: 'We will turn the DH into a Department of Public Health so that prevention of illness gets the attention from government that it needs. Prevention is better than cure, so we will provide separate public health funding to local authorities, which will be accountable for - and paid according to - how successful they are in improving their local communities' health. We will weight this so that extra resources will go to the poorest areas with the worst health outcomes through a new 'health premium'. (quoted from section 1.3, chapter 1 of Draft Manifesto 2010)

This policy is good and should be implemented whoever wins the election. One of the causes of woolly commissioning is the ‘democratic deficit’. This can be filled by putting Health under the Local Authorities, (like Social Services and Education) Local councillors could then enforce commissioning in the interests of patients, rather than providers.

Another cause of woolly commissioning is ‘regulatory capture’ of commissioners by providers. They should be separated to ‘arms length’, and not be allowed to belong to the same trade union, which would end their cosy relationship which maintains the provider-centred NHS. Mrs Thatcher did this to all the other former nationalised industries, and an incoming Tory government should do this to the commissioners of health.

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