When MD  asked health secretary Andrew  Lansley to reduce his unintelligible 358 page health bill to 140 characters or less, he wrote: ‘Putting patients and their doctors and nurses in charge, accountable for the results they achieve.’  Some staff were initially won over by the promise of liberation from political meddling,  less bureaucracy and more control over how the money is spent. But while most now long to be liberated from Lansley, they’ve now realised there is no freedom  if you’re  shackled to an unelected  economic regulator,  Monitor, and an unelected National Commissioning Board.  Worse still, the complexities of competition law and competitive tendering are likely to make the NHS more bureaucratic, not less.  And it’s the economists who’ll be in charge, stupid.

If Lansley had wanted evolution, rather than revolution, he would simply have slimmed down the existing Primary Care Trusts, put clinical staff on the board alongside the best of the NHS managers and let them figure out how best to spend the  money and focus on the quality and safety of care. By throwing all the cards up in the air, he’s created chaos, uncertainty and the perfect storm for another Mid Staffordshire scandal. The fact that even the more moderate  health unions – the Royal College of Nurses and the Royal College of Midwives – now oppose the Bill outright and are calling for its withdrawal should make the Government reconsider. But it won’t.

Equally alarming is the confusion at the very top. Monitor is the make or break organization of the government’s reforms.  David Bennett – an ex-McKinsey Blair adviser – is both chair and chief executive. Monitor was set up by Labour to be the independent regulator and assessor of NHS Foundation Trusts but under the Bill it becomes the sole economic regulator for the whole of healthcare – including the independent sector – in England. It has to regulate prices, licence providers, integrate care, prevent anti-competitive behaviour and support the continuity of services.

So Monitor has a special and long-standing relationship with NHS Foundation Trusts and yet also has to regulate the entire health sector. It sets the exam for everyone but has a vested and conflicting interest in ensuring Foundation Trusts pass it with flying colours. In an article in the Health Service Journal, Bennett warns that Monitor may face “numerous” allegations of improper conduct unless it can clearly separate its future healthcare regulatory role from its responsibility for Foundation Trusts. The revamped Monitor is hardly up and running in its new role and it looks as if the quango may have to split in two, or at least have two chief executives.

Given the financial climate, Monitor is going to have to make tough decisions and if it is perceived to have favoured Foundation Trusts over, say, the private sector than the NHS will be submerged in a succession of legal challenges. If a quango stuffed full of competition economists hasn’t got a handle on how competition law will affect the NHS, spare a thought for the virgin clinical commissioners. The bureaucratic complexity of having to make local decisions in the interests of patients while obeying national guidelines, regulatory rules and competition law will either make them panic and put everything out to competitive tender. Or they’ll spend a fortune on ‘commissioning support services.’ Or both.

The Scottish and Welsh NHS eschew a competitive market because there is insufficient evidence that it delivers better healthcare. In England, forty one ‘commissioning support organisations’ have already been proposed to help GPs make sense of the Health Bill. The only certainty in this chaos is that lawyers and management consultants will do rather well out of it. As for patients, Lansley’s promise of ‘no decision about me without me’ is beyond satire.

I am writing to you early this week as we are about to announce the results of our latest survey on the Health and Social Care Bill. I’d like to again thank the very many of you who took the time to respond; you have no idea how much this has helped me to determine how the College moves forward, as well as providing me with personal assurance that we are doing to right thing for our patients and our profession. We received more than 2,500 replies, and nearly three quarters of you who responded said that you felt that it is now appropriate to seek the withdrawal of the Health and Social Care Bill.

When asked if the College should call for the Bill to be withdrawn as part of a joint approach with other medical royal colleges, more than 98% of you strongly supported or supported such action. Even without a joint approach, more than 90% of you still said that you either strongly supported or supported the College in proceeding alone in calling for the Bill’s withdrawal. I expected a good return, but I am staggered at the level of response.

The results are very revealing, but we must look before we leap, which is why I have written again to the Secretary of State and given him another opportunity to meet with us, inviting him to suggests ways in which we can move forward. Ultimately, should the situation warrant it, we will call for the withdrawal of the Bill itself, but I really hope that these survey results will prompt some positive action, and tangible change to the Bill as it progresses to the Report Stage in the House of Lords. The three areas which remain of key importance – and which the responses to the survey reiterated are: The Secretary of State’s existing duty to provide, or secure the provision of, a comprehensive health service throughout England, must be retained Clarification on the face of the Bill that commissioners will not be required to open up services to competition unless it can be demonstrated that this would be in the patient’s best interests and compatible with the requirements of patient safety and the ability to provide integrated care

The introduction of further safeguards on education and training, including robust mechanisms to ensure the provision of sufficient post graduate training places, and the long term retention of post graduate deaneries But let me be clear. We are not a trade union. This is not about political point-scoring. It is about protecting the principles of the NHS for our patients now and in the future. I will of course keep you informed as things unfold. Other news this week in brief. You may have seen my comments responding to the second phase report from the independent NHS Future Forum. While it does concern me that questions about patients’ lifestyle choices are being proposed as part of every consultation, we did a fulsome response to the report in which we welcomed many of the recommendations. It contains some excellent proposals for strengthening the role of the GP within the NHS, and I am particularly delighted to see the emphasis on extended training.

Getting more GPs, who are trained for longer, and spending more time with their patients through longer consultations, are our priorities and it is reassuring to see them gaining wider support. Its really good to see Steve Field continuing to lead the Forum. The Forum is increasingly becoming a driving force for Government policy making, so it can only be to our benefit to have a former Chair of Council, and practising GP, at its helm, particularly as we progress with our bid for extended training.

 Best wishes,

Clare Gerada, Chair RCGP

January 1 saw the launch of a new whistleblowing hotline – 08000 724 725 – for NHS and social care staff. It’s free, publically funded and available at weekdays between 08.00 and 18.00 with an out-of-hours answering service.  It’s run, for no obvious reason,  by the Royal Mencap Society. The charity understands the importance of protecting vulnerable patients but whether it has the advocacy and employment expertise to support staff  in what is often a suicidal career move remains to be seen.

Health Secretary Andrew Lansley is very keen on his new gimmick – “This will play an important role in creating a culture where staff will be able to raise genuine concerns in good faith, without fear of reprisal” – but it beggars belief that he can glibly promise both confidentiality and protection from retribution given how whistleblowers have been hunted down in the past (see Shoot the Messenger  Eye ). As soon as concerns are raised, the NHS pretty soon draws up a list of who the secret snitch might be in an attempt to shut him or her up. Threatening, counter smearing, paying off and gagging the source is far easier than investigating the allegations.

Theoretically, the hotline could be a force for good. It should document that an employee legitimately raised concerns through channels approved by the employer and demonstrate that the employer had knowledge of the concerns on a certain date. But there is no guarantee that NHS and social service employers will properly investigate the concerns or do anything other than pay lip service to promises of accountability and transparency. And if the concerns implicate those at the very top of the organization – such as the Mid Staffs scandal and the Gary Walker case (Eyes passim) – the NHS protects the most powerful at all costs.

Lansley would have been better advised to wait for the findings of the Mid Staffs inquiry before launching his hotline. Hundreds, perhaps thousands, of patients died as a result of substandard care, the chief executive claimed the mortality statistics were wrong and the strategic health authority and Care Quality Commission were complicit in the cover up. Only one nurse, Helene Donnelley, blew the whistle by reporting on the appalling care she witnessed on 50 occasions. She got no help from her union, was bullied by other staff and was sometimes too afraid to walk to her car in the dark. One consultant had also seen many patients put at risk and had reported it up through the organisation but again got no action. When asked at the Inquiry why he had not blown the whistle he replied: “Because I’ve got a mortgage to pay.”

Whistleblowers shouldn’t have to live in fear or remain anonymous on distant phone lines. They – along with patients and relatives – should be able to raise concerns openly and in person – and then be acknowledged if they help expose and prevent poor care. Each year, the chief executive of every NHS trust should be giving awards to those who have raised concerns and protected patients. Without a change of culture, a phone-line is pointless.

Meanwhile, solicitors representing a group of NHS whistleblowers may launch judicial reviews against the Care Quality Commission, NHS London and two London acute trusts – Ealing Hospital NHS Trust and South London Healthcare NHS Trust -  for failing to comply with their duties in supporting whistleblowers under the Department of Health guidance. (www.patientsfirst.org.uk). Just having a whistleblowing policy and a hotline does not make whistleblowers safe, and a professional duty to speak up is pointless if there isn’t a commensurate duty on managers to listen and act.

This point cannot have escaped Robert Francis QC, chair of the Mid Staffs inquiry, who sat through 139 days of public hearings, warned of a ‘tsunami of public anger’ and heard some limp buck passing between the Department of Health and the Care Quality Commission. He’ll also have discovered  how an organization that purports to care can be so brutal to those who challenge the system and put patients first. If you want a career in the NHS or social care  it’s often  safer to keep your head down and ignore bad care. That has to change in 2012.

 Politicians hate variation in healthcare. Anything that hints of a postcode lottery inevitably means bad press. Labour’s 1998 White Paper – ‘A First Class Service’ – opened with a very bold promise. ‘All patients in the National Health Service are entitled to high quality care. This should not depend on the geographic accident of where they happen to live. The Government is determined that all patients should receive a first class service. The unacceptable variations that have grown up in recent years must end.’ Thirteen years later, the NHS Atlas of Variation has found that disparities in treatment and funding across the service are as wide as ever.

There will always be some variation in the NHS. By random chance alone, some services do better than others and at any point in time, half of all doctors/ nurses/ managers will be below average. What the NHS needs to do is to ensure all services reach defined standards of quality and – given the money that has poured into the NHS – what’s most unacceptable is that this has yet to happen.

There has been a longstanding time lottery in the NHS – if you’re fortunate enough to have your life-threatening illness ‘in hours’, the chances of survival are greater than if you have it ‘out of hours’.  The notion that there are designated hours for illnesses that predict whether you make it out of the NHS alive is ridiculous yet, even in the twenty first century, you don’t want to get sick at Christmas. Department of Health research has found that you’re 11% more likely to die on a Saturday and 16% more likely to die on a Sunday compared to being admitted on a Wednesday. As one DH source put it: ‘We’re thinking of renaming every day Wednesday.’

The major predictors of unnecessary death were the fact that diagnostic equipment and experienced, senior staff tend not to be used at the weekend. The NHS needs to concentrate resources in fewer hospitals with high tech equipment and senior staff available around the clock. London would be much safer if it had nine  properly funded super hospitals rather than thirty not-so-super ones struggling for survival , yet no politicians – least of all Lansley and Cameron before the election – have had the balls to argue for hospital closures. So the NHS is stuck with a few centres of  excellence in a sea of mediocrity.

At least it now publishes the Atlas of Variation to show just how mediocre care can be. Last year, the Atlas found that 70 amputations a week are carried out in type 2 diabetic patients in England, that 80% of them were probably preventable and that if you lived in the South West you were almost twice as likely to get one than if you lived in the South East. The variation in the treatment of mini-strokes was equally shocking, with some areas treated 100% of patients within 24 hours and some treating virtually none.

The treatment of strokes in London has at least improved dramatically, with patients going to eight designated centres of excellence offering round the clock expertise rather than any one of thirty variable quality hospitals. This rare example of life-saving hospital reconfiguration encountered some political opposition, and the equally important centralisation of child heart surgery services – something MD has been advocating for nearly 20 years – has been delayed by judicial review. But ask any doctor where they’d send their baby for heart surgery and they’d choose a unit with round the clock expertise, safe staffing levels and top of the range equipment, not some small unit that mixes adult and child surgery and where the survival of the child depends on who’s on holiday that week.

This year’s Atlas has found patients in North Lancashire are prescribed 25 times as many anti-dementia drugs as those in Kent. There were also wide variations across England and Wales in the length of hospital stay after breast cancer surgery, access to care homes and angioplasty. Understanding what the variations mean is more complex, as is knowing how to tackle them. America has even wider variations in healthcare which suggests that Labour’s experiment with a market system – and the government’s persistence with it – may not be the answer.  Benchmarking services, publishing the results and concentrating services in centres of excellence that remain excellent at weekends and bank holidays  is likely to do far more good.

Several Private Eye readers have pointed out that NHS whistleblowers can only be gagged by their employers if they consent to it, and that a true whistleblower would forgo any pay-off to get their story in the public domain (Eye last). The Government argues that – under protection offered by the Public Interest Disclosure Act (PIDA) – all such gags are legally void and that whistleblowers who are persecuted for speaking up may gain unlimited damages at an employment tribunal. So what’s the problem?

Alas, the NHS at its Stalinist, bullying best uses public money and a host of dirty psychological tricks to destroy whistleblowers long before they make it to an employment tribunal (see Shoot the Messenger,  Eye 1292). And those who refuse to be gagged find any compensation swallowed up by legal fees. Consultant surgeon Ramon Niekrash was suspended from Queen Elizabeth Hospital, Woolwich for 10 weeks after raising concerns about the impact of closing a urology ward was having on patient care. The tribunal found in his favour but left him a  £160,000 legal bill.

The NHS is a monopoly employer and any employee who goes public with safety concerns can find it hard to get work elsewhere. Whistleblowers are often counter-smeared, suspended on spurious grounds, referred to the GMC, isolated them from their friends and repeatedly fobbed off in their attempts to get the NHS to release  information to help them prove their case. Their battle for justice can drag on for years while they face career and financial ruin.  Unsurprisingly, many take the money and sign the gag. The gag may be theoretically void, but few have the strength or financial security to test it.

The Department of Health insists that such gags are strictly against policy and that  ‘before an NHS employee considers signing a compromise agreement, the employer is required to pay for the employee to have independent legal advice on the terms of the agreement.’ But NHS Trusts that ignore whistleblowers also ignore PIDA and DH policy, safe in the knowledge that most employees lack the resources to pay for a prolonged legal challenge.  

So who monitors the pay offs and the gags? In a response to Peter Bottomley MP, health minister Simon Burns confirms that  ‘All non-contractual ‘special’ severance payments for employees or ex employees must be approved by HM Treasury. NHS trusts are required to ensure that any proposals to make such payments are sent to the Department of Health initially for scrutiny.’

So the large sum of public money paid to former United Lincolnshire Hospitals NHS Trust chief executive Gary Walker in combination with the gag that prevents him, or any of him employment tribunal witnesses,  speaking publically about the serious safety concerns he reported to NHS chief executive (Sir) David Nicholson and director of commissioning (Dame) Barbara Hakin was a) scrutinized by the Department of Health who failed to spot that a high profile whistleblower was being silenced and b) approved by the Treasury. Either the Treasury and DH were fully aware of this legally dubious attempt to protect the reputation of the NHS’ two most senior managers or – like News International – they simply rubber stamp huge pay-offs to make problems go away without investigating their legality or morality.

When Great Ormond Street hospital tried to silence Baby P whistleblower Dr Kim Holt, it offered her £120,000 not just to sign a gag but to withdraw all of her allegations, sign a document to say GOSH was never aware of her concerns and hand over all her evidence.  Dr Holt bravely refused and should be summoned as first witness when the Health Select Committee considers compromise payments and gagging clauses this month. Closely followed by Gary Walker, David Nicholson, Barbara Hakin, Andrew Lansley and whoever it is at the Treasury who signs the cheques.

Phil Hammond, general practitioner, broadcaster, and journalist hamm82@msn.com

The UK at last follows other countries in providing the Gardasil vaccine

Health campaigning, like much of public health, can be a slow, repetitive business. The media will break a big story once and then tend to lose interest unless a fresh scandal surfaces. But to change culture, opinion, or behaviour the same message may have to be drip fed over many years. And if the story doesn’t lend itself to a cute front page photo the chance of success is remote. Genital warts will never make the headlines in the Daily Mail or indeed any other newspaper—which makes the government’s decision to switch to a multipurpose vaccine against human papillomavirus all the more remarkable.1

 The Lancet kicked off the campaign in October 2006, with an editorial titled “Should HPV vaccines be mandatory for all adolescents?”2 It argued that Gardasil, which protects against HPV types 6, 11, 16, and 18, could dramatically reduce not just the incidence of cervical cancer but unpleasant conditions such as genital warts, anal cancer, and other malignancies affecting both sexes. It concluded, “EU member states should lead by making the vaccinations mandatory for all girls aged 11-12 years.” Australia, the United States, and many European countries promptly introduced vaccination programmes, but the NHS dithered—doubtless taken aback at the cost of £241.50 (€280; $357) for a pack of three doses—and in 2008 went with the bivalent vaccine Cervarix, which protects against cervical cancer only.

My daughter was due to join the vaccination programme at the time, but every sexual health consultant I knew recommended the wider coverage offered by Gardasil. Despite the Labour government’s commitment to patient choice, my primary care trust would not provide it or allow me to top up the difference in price. So I paid for it privately and recouped the money by writing a personal view in the BMJ.3 It attracted a surprising number of responses, indicating that the mainstream media’s lack of interest in genital warts had left a large gap in the market.

Warts are far more common than cervical cancer, can be devilishly difficult and expensive to treat, and, although they won’t kill you, can destroy your sex life, which seems a compelling reason to prevent them if you can. In Private Eye magazine I kept drip feeding the same message, often triggered by the excellent campaigning of the British Association for Sexual Health and HIV (BASHH), which—in the run up to the latest tender—conducted a survey that found that “93% of UK sexual health clinicians would advise friends and colleagues to obtain the multi-purpose vaccination for their daughters, and that 63% with teenage daughters had paid privately for the multi-purpose vaccine rather than accept the free single-purpose vaccine provided at schools.”4 This allowed me to be especially pompous: “If Andrew Lansley is to be a credible Secretary of State for Public Health, he must offer all patients the same protection against disease as the daughters of doctors.”4

And what of the evidence? In Australia 70% of women under 28 have been vaccinated with Gardasil. New cases of genital warts among young women started falling after six months, and now, three years into the programme, they have fallen by nearly 75%.5 Even cases among (unvaccinated) heterosexual men fell by one third, because of herd immunity. In contrast, since England’s school based HPV vaccination programme began in 2008 there has been no significant change in numbers of cases of genital warts, with some 91,000 new cases diagnosed each year and a further 70,000 cases undergoing repeat treatments. It costs the NHS £31m a year to treat genital warts, and preventing most of these would free up time for staff to prevent and treat other infections. In addition, Gardasil prevents 30% of minor smear abnormalities and a rarer but often fatal condition called recurrent respiratory papillomatosis, in which babies develop florid warts on the vocal chords and in the throat. Babies who survive face multiple and extremely unpleasant treatments, costing the NHS £4m a year.

As for the economics, BASHH predicts that “if we continue to vaccinate just 70% of 12 to 13 year old girls, genital warts should be eradicated in heterosexual women and men within 20 years, through the herd immunity effect.”6 A health economics analysis in the BMJ was slightly less gushing, concluding that Gardasil may have an advantage over Cervarix in reducing healthcare costs and the number of quality adjusted life years lost but that Cervarix may have an advantage in preventing deaths from cancer.7 It also concluded that significant uncertainty remains about the differential benefits of the two vaccines.

Policy decisions often have to be made against a backdrop of imperfect science and should be changed as the evidence accrues. In a statement GlaxoSmithKline, the manufacturer of Cervarix, said that it chose not to participate in the latest NHS HPV vaccine tender process because the criteria show that “the government’s priorities have shifted from cervical cancer to also incorporate HPV-related non-cervical cancers and an increased focus on protecting young girls against genital warts.”8 However, it’s worth remembering that the UK’s HPV vaccination programme has been a huge success, achieving higher rates of coverage than in any other country. If the same coverage continues, the incidence of cervical cancer and genital warts will be markedly reduced.

This is a time not just for celebration but also to launch the next campaign. We should make the vaccine freely available to young homosexual men, so they can benefit from protection against anal and oral cancer, as well as anogenital warts. Any takers?

Notes Cite this as: BMJ 2011;343:d7779

References

1.Kmietowicz Z. UK will use Gardasil in its HPV vaccination programme from next September. BMJ2011;343:d7694.FREE Full Text

2.Should HPV vaccines be mandatory for all adolescents? Lancet2006;368:1212.Medline

3.Hammond P. (Not) warts and all. BMJ2008;337:a2186.FREE Full Text

4.Hammond P. Warts and all (again, again). Private Eye 1282 (18 Feb 2011):12.

5.Fairley CK, Hocking JS, Gurrin LC. Rapid decline in presentations for genital warts after the implementation of a national quadrivalent human papillomavirus vaccination program for young women. Presented at 2010 Australasian Sexual Health Congress, Sydney, 18-20 October 2010.

6.British Association for Sexual Health and HIV. BASHH welcomes HPV vaccine decision, and calls for vaccination of young homosexual men at sexual health clinics (media statement). BASHH, 24 Nov 2011.

7.Jit M, Chapman C, Hughes O, Choi YH. Comparing bivalent and quadrivalent human papillomavirus vaccines. BMJ2011;343:d5775.FREE Full Text

8.GlaxoSmithKline. GlaxoSmithKline statement on UK HPV immunisation programme. http://hcp.gsk.co.uk/therapy-areas/vaccines/cervarix/product-news/glaxosmithkline-statement-on-uk-hpv-immunisation-programme.

Link to BMJ

http://bmj.com/cgi/content/full/bmj.d7779?ijkey=oyGUNqWaPQ0EoL0&keytype=ref

Shoot the Mesenger

(Not) Warts and All

British Medical Journal  2008  

Phil Hammond

General practitioner, writer, and broadcaster

‘You’d be mad not to protect your daughter against genital warts if you can afford to.’ So advised Peter Greenhouse, a sexual health consultant inBristol, when I asked him which human papilloma virus (HPV) vaccine I should choose for my daughter. The NHS vaccination programme may have opted for the bivalent vaccine (Cervarix) to concentrate resources on preventing cervical cancer, but every doctor I’ve spoken to has chosen the quadrivalent vaccine (Gardasil) for their own daughters (and the odd off-licence son).

Genital warts genital warts are common (100,000 new cases inEnglandeach year) and they’re on the increase, particularly amongst the young (60% of warts in women occur in the 16-24 year old age group). They don’t kill you, but they can kill your sex life and in some people they can be recurrent and extensive. Health minister Dawn Primarolo claims warts are ‘preventable’ but meticulous condom usage only cuts HPV transmission by 50%. A far safer option is to vaccinate.

The NHS Choices (sic) website promotes Cervarix but doesn’t return a single hit for Gardasil. Having chosen one vaccine for us, the government has decided we don’t need information about another that could prevent 90% of warts (as well as 70% of cervical cancer). Those administering Cervarix at my daughter’s school offer no information about Gardasil. Whatever happened to informed choice?

The NHS vaccination site (www.immunisation.nhs.uk) is also a Gardasil-free zone. An editorial in Sexually Transmitted Infections describes the government’s decision as ‘a sad day for sexual health.’¹ It also doesn’t seem to make long-term economic sense. Within 3 or 4 years, the use of Gardasil ‘would begin to have a big financial payback, as the current estimate of treating genital warts inEngland every year is £23 million.’

So why did the government opt for Cervarix? The Joint Committee on Vaccination and Immunisation is most illuminating.² ‘If the vaccines were offered at similar prices, then the committee recommended choosing the quadrivalent vaccine, which protects against cervical cancer and genital warts.’ According to the British National Formulary, the two vaccines are exactly the same price (£80.50 for each of three injections), so GSK (the makers of Cervarix) must have offered a huge discount to undercut Sanofi Pasteur (makers of Gardasil).

I have no issue with this. New drugs are ludicrously expensive and the NHS deserves credit for beating GSK down. Or perhaps GSK was desperate to break into a market dominated in most other developed countries by Sanofi Pasteur. The size of the discount is ‘commercially confidential’, according to my MP, Dan Norris. I asked him because I wanted to ‘top up’ the difference so that my daughter can have Gardasil with her classmates, within the NHS programme. But this choice, apparently, is not allowed.

Parents who choose Gardasil will almost certainly have to pay privately for it. £350-£400 seems to be the going rate in local GP practices. We can (reluctantly) afford this, but many parents can’t. My Primary Care Trust (BANES) allows those in the vaccine programme to have Gardasil if there is ‘a specific clinical need’, without defining what this means. For girls particularly at risk of genital warts (e.g. those with type 1 diabetes or extensive verrucae or hand warts) or skin conditions that make genital warts particularly unpleasant (e.g. extensive psoriasis or eczema), it seems unethical not to offer them Gardasil.³ And how long will it take for a woman with warts to sue the NHS for not offering her the choice? Women who later develop warts or cervical cancer may also sue if they were denied an NHS vaccine because they were ‘outside’ the screening programme. Doctors are supposed to use clinical judgement in individual cases, but the pressure to reduce prescribing costs is relentless.

The cheap GSK deal only applies to vaccines used in the programme – the vaccines are the same price when offered outside it. Many doctors will recommend Gardasil in these circumstances, so we may end up with all women in the programme getting Cervarix and most outside it getting Gardasil. This clearly has the potential to undermine the programme (or at least it would if anyone was brave enough to shout about genital warts).

For any licensed treatment, the public (and NHS staff) need quick and easy access to unbiased efficacy and safety data, updated as it emerges. The NHS website would seem a logical gateway for this, but currently restricts information about treatments it doesn’t wish to fund. Vaccination programmes have a coercive flavour but some parents, quite legitimately, may want to delay vaccination until more comprehensive safety and efficacy data emerge.⁴ Others simply don’t trust data presented and controlled by drug companies. They should not be made to feel guilty if they decide against vaccination

I’ve worked in sexual health and seen plenty of people whose warts have been successfully treated. I’ve seen others with extensive, recurrent warts requiring prolonged and fiddly treatment, and florid ano-genital warts that resisted just about every treatment. We’ve opted to pay for Gardasil. Unlike the Blairs, I’m happy to go public about vaccination (but not point of conception). I tell patients if they ask me, would prescribe it on the NHS and I’ve written about it in Private Eye. If it was breast cancer, there would doubtless be an industry-supported march on Downing Street, but the genital warts lobby is largely undercover. There are no letters to the Times, and warts have never made it to the cover of the Mail. But follow this link⁵ to see what we could be preventing.

1. O’Mahony C. Government decision on national human papilloma virus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008; 84: 251

2 http://www.advisorybodies.doh.gov.uk/jcvi/HPV_JCVI_report_18_07_2008.pdf

3 http://sti.bmj.com/cgi/eletters/84/4/251

4 http://content.nejm.org/cgi/content/full/359/8/861

5 http://www.chestersexualhealth.co.uk/genitalwarts.htm

November 24, 2011

BASHH welcomes HPV vaccine decision, and calls for vaccination of young homosexual men at sexual health clinics

The British Association for Sexual Health and HIV (BASHH) today welcomed news that the Government are switching to a multi-purpose HPV vaccine.

Peter Greenhouse, spokesperson for the British Association of Sexual Health and HIV commented:

“All of us atBASHHare delighted by the news that the next generation of teenage girls will receive a multi-purpose HPV vaccine which will protect them against cervical cancer AND genital warts.

“The UK-wide school cervical cancer vaccination campaign has produced higher rates of coverage than achieved in any other country – if we can keep this up we should expect to see genital wart infections start to reduce in teenage girls within five years, and slightly later in boys: If we continue to vaccinate just 70% of 12-to-13 year-old girls, we can predict** that genital warts should be eradicated in heterosexual women and men within 20 years, through the herd immunity effect.

“We would also want to make sure that the vaccine is made freely available to young homosexual men on their first visit to Sexual Health clinics – along the same lines as the successful Hepatitis B vaccination programme – to make sure that they can also benefit from protection against anal & oral cancer and genital warts.”

BASHHhave been making the case for the multi-purpose vaccination since the previous purchasing decision in 2008: A survey conducted earlier this year found that 93% of UK sexual health clinicians would advise friends and colleagues to obtain the multi-purpose vaccination for their daughters, and that 63% with teenage daughters had paid privately for the multi-purpose vaccine rather than accept the free single-purpose vaccine provided at schools.

** Prediction of genital wart eradication – please see reference over page

Visit: www.bashh.org

• The single-purpose vaccine (Cervavix) protects patients against strains 16 and 18 of HPV which are responsible for around 70% of cervical cancer cases.  The multi-purpose vaccine (Gardasil) additionally protects against over 90% of genital warts, minor (non-serious) cervical smear abnormalities, and Juvenile Onset Recurrent Respiratory Papillomatosis (warts on the vocal cords) which is passed from mother to baby.

• The British Association for Sexual Health and HIV – BASHH– is the professional organisation for clinical staff and researchers working in the UK’s sexual health clinics. It sets standards for clinical care, training and education, and supports Public Health by treatment and prevention of infections and care of other conditions related to sexual health. For more information please visit www.bashh.org

• BASHHmedia spokespersonPeter GreenhouseFRCOG FFSRH, Consultant in Sexual Health at Bristol & Weston, is available for comment via the number above.

• Reference for vaccine coverage rates: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123826.pdf

• Reference for prediction of eradication of genital warts in heterosexuals within 20 years:

http://www.ncbi.nlm.nih.gov/pubmed/20924049

The repeated refusal of the Government to publish its ‘risk register’ for the Health and Social Care Bill is unsurprising given the culture of secrecy and cover-up in the NHS. Information commissioner Christopher Graham has now judged that the document should be published, but health secretary Andrew Lansley is likely to sit on it for 28 days before deciding whether to launch an appeal. The Bill is littered with risks, most notably that billions of pounds will be spent on another massive, rapid, ill thought-out restructure that ends up roughly where we started but with staff demoralised and patients neglected.

As one GP commissioner put it: ‘We were initially told we could choose the size of our consortium, so we went small so we could be flexible. Then we were told we had to be much bigger to have any clout so we merged with other local consortia, which was a huge hassle.  Now we’ve been told we’re the wrong shape and have to mirror the local authority boundary. That’s three reorganisations in under a year. Are they making it up as they go along?’ The GP consortia (now renamed clinical commissioning groups) will be advised by ‘commissioning support organisations’ which – miraculously – are shaping up to be the same size as the Primary Care Trusts they will replace. But many PCT staff have now left the NHS so management consultants such as McKinsey and KPMG are being called in, which was probably Lansley’s plan all along. Amidst the confusion, 20,000 forgotten patients have waited over a year for treatment – slightly longer than the 18 week pledge.

Meanwhile, staff who try to raise concerns about poor patient care are being scared off by lawyers. The super-gagging of former United Lincolnshire Hospitals NHS Trust (ULHNT) chief executive and all of his employment tribunal witnesses (Eye last) prompted Peter Bottomley MP ‘To ask the Secretary of State for Health if he will instruct each part of the NHS to lift any gagging restrictions on (a) present and (b) former NHS staff that (i) have and (ii) have had the effect of withholding from the public and the media information, evidence or justified concerns about levels of care in the NHS.’

Health Minister Anne Milton replied that ‘the Public Interest Disclosure Act provides that any clause or term in a contract, or other agreement between a worker and their employer is void in so far as it purports to preclude the worker from making a protected disclosure. Health Service Circular 1999/198 made it clear that local NHS trusts should have in place policies and procedures which prohibit confidentiality “gagging” clauses in contracts of employment which seek to prevent the disclosure of information in the public interest, which includes information, evidence or justified concerns about levels of care in the NHS.’

 Alas, NHS trusts often ignore both PIDA and DH circulars, knowing that a scarily worded legal letter will silence many NHS whistleblowers, especially those who have been sacked and find themselves unemployable and facing bankruptcy, without the resources to mount a legal challenge should they wish to test Milton’s theory that their gagging order is ‘void.’ The Times has unearthed 3 gagging clauses that prevent whistleblowers taking concerns about colleagues to the GMC. And Walker’s witnesses have received solicitors’ letters that state ‘Please ensure that you and your partner and immediate family do not disclose to anyone the terms of any agreement reached and we would ask that you undertake not to disclose in the future to anyone the terms of any agreement. We are instructed that our client requests that you take this request seriously and ensure you abide by this request. Further all the information and documentation our client or we passed to you was done so confidentially and is not to be distributed any further.’ As one witness put it: ‘I have seen much of the evidence which would have been heard in public in the Tribunal; in my opinion it would have been extremely damaging to a number of very senior officials within the NHS.’

 The DH didn’t listen when Gary Walker blew the whistle that patients were in danger and he was sacked. Care at ULHNT then became so bad that even the Care Quality Commission spotted it (Eye last). For Milton to claim NHS staff are free to speak up about poor patient care when her own department buries it is clearly nonsense. Something for Lansley’s secret risk register, perhaps?

The most keenly awaited NHS employment tribunal in years has ended in secrecy, making a mockery of the government’s commitments to transparency, accountability, patient safety and the protection of whistleblowers. Gary Walker, the former chief executive of the United Lincoln Hospitals Trust (ULHT), lost his job in February 2010 after blowing the whistle on how government targets were harming patient care.  The trust claims he was sacked for saying ‘fuck’ nine times over 2 years¹.

The tribunal was important because Walker had blown the whistle both to his SHA chief executive, Barbara Hakin – now the DoH’s Director of Commissioning – and the NHS chief executive David Nicholson. The allegation that the two most senior managers in the NHS may have played a role in the destruction of Walker’s career whilst failing to address patient harm should have been dissected under oath but the NHS legal machine ensured the claim was ‘settled’ on the eve of the tribunal.

Walker is now not able to speak about the case. Ever.  Neither can any of his many witnesses who were prepared to testify about serious cases of patient harm, fiddling of figures, the bullying behaviour of the strategic health authority and a whitewash external review that only looked for bullying ‘in writing.’ Neither will any witnesses confirm or deny the existence of any gagging clause. All those who were due to testify against the trust, the SHA, the DoH, Nicholson and Hakin – and substantiate allegations of ‘third world care’ and avoidable patient harm  -  have been so effectively silenced at public cost that they are too scared to say how or why.

So MD put five specific questions to the trust. 1.What was the precise claim that Mr Walker made against the trust? 2.What was the amount of the settlement and the precise terms? 3.Did anyone have to sign a compromise agreement (‘gagging clause’) as a result of the settlement? 4.How much in total has the trust spent in legal and other fees in preparing for and settling this claim? 5.What direction did the trust receive from the DoH settling this claim and enforcing any compromise agreements?

The trust’s response? “The parties reached an amicable resolution of the differences between them and agreed not to comment further.” MD asked the same questions of the DoH and for clarification of Nicholson’s written assertion that ‘there is no evidence whatsoever of bullying or harassment of the trust by the SHA’. The DoH said: “This is a matter between the trust and the individual”.  As for patients, specific allegations made by trust staff will not now be properly scrutinised. Walker missed targets to save patients, but after he was sacked, a woman allegedly suffered severe complications when a consultant was pulled out of the theatre to operate on another patient who was going to breach the 18 week target, and an otherwise healthy patient who died following a radical prostatectomy after extra cases were added to an operating list to hit targets.

In February 2011, the Care Quality Commission failed ULHT on 12 of 16 essential quality and safety standards. Two  statutory warning notices were issued and student nurses were removed from training posts. The CQC has just declared that ULHT poses “a current risk to patients of being exposed to poor care”¹. It has taken the trust “considerable time to investigate, respond to and resolve” serious incidents and “learning from these has been minimal”. In an NHS culture where even a chief executive can’t safely blow the whistle without having his career destroyed, it’s hardly surprising that no-one at Mid Staffs spoke up. The NHS needs to learn to value and support whistleblowers, and the NHS must stop using public money to suppress information in the public interest. The Public Accounts Committee (PAC) made precisely this point this year, and yet the NHS appears to have responded by issuing the mother of all gags, so powerful that no-one may acknowledge its existence. PAC must now investigate how much public money has been spent silencing Walker and his colleagues, protecting Nicholson and Hakin and covering up another scandal. And who signed the cheque? It’s inconceivable the health secretary, Andrew Lansley, wouldn’t be aware of a cover up on this scale, even if he doesn’t wish to be held accountable for it.

MD

¹ Shoot the Messenger, Eye 1292                      

 2 www.cqc.org.uk