20 trusts set to miss foundation trust deadline

More than 20 hospital and mental health trusts have been warned they are entering an “end game” because they will not be ready to become foundation trusts before December 2010.

Those unable to meet the labour government’s deadline face either radical restructuring or becoming part of a “shopping list” for existing foundation trusts looking for takeover opportunities.

The list of trusts has been compiled by HSJ after NHS chief executive David Nicholson ordered strategic health authorities to estimate the date they expected each of the outstanding 111 non-foundations to apply to the regulator Monitor for authorisation.

“I’m sure there will be takers for these organisations. You focus on becoming a foundation or someone else will do it for you”

Even with two years of restructuring and investment to go, SHAs anticipate 20 trusts will not be ready by the deadline. An additional six have been scheduled for December 2010, leaving no room for delay.

Capital problems

The list includes some trusts with long standing problems, such as Royal Cornwall Hospitals, and others that are more surprising, such as Great Ormond Street Hospital and University Hospitals of Leicester. Of the 20 with no date at all, 12 are in London – a further indication of the scale of the capital’s problems.

Foundation Trust Network director Sue Slipman told HSJ: “This will concentrate minds. I’m sure there will be some takers for some of these organisations. Either you focus on becoming a foundation trust or someone else will do it for you. The Department of Health is saying this is the end game and we need to get things moving now.”

HSJ understands that Mr Nicholson’s instruction to SHAs to draw up “foundation trajectories” followed behind-the-scenes pressure from foundation trusts. They wanted the DH to be explicit about trusts in trouble so they could start negotiating takeovers and, where appropriate, government subsidies for this.

Recently, chief executives at two of the 20 – Barts and the London and West Middlesex University Hospital – resigned amid performance problems. This has sparked concerns that SHAs could try to clear out chief executives to make way for takeovers or enforced mergers.

Outright failure

Foundation trust leaders contend that being on the list is tantamount to outright failure. There are three times more on the list than the six trusts deemed “financially challenged” by the DH.

North Bristol trust chief executive Sonia Mills said her trust had no anticipated application date as it had reached an “impasse” over its historical deficit. It will not clear it until 2012 and is in the middle of difficult planning for a large private finance initiative hospital, she said.

Monitor rules out applications from trusts with deficits.

“The clash of rules is out of our hands,” Ms Mills said. “At the moment we are not discussing it with the board because we want to get our private finance initiative through first.”

The trust is not exploring any merger or takeover options.

A spokesperson for Great Ormond Street Hospital for Children trust said its main sticking point was the pending legal challenge to the private patient income cap, which could see its private income radically curtailed.

The list includes district general hospitals seen as too small to survive the migration of patients to either community or specialist tertiary services. NHS North West director of healthcare systems Alison Tonge said Trafford Healthcare trust fell into that camp.

She said the SHA was exploring whether it could be merged with its primary care trust provider arm to form an organisation focused on community services.

Only one SHA – NHS North East – expects all its trusts to be ready before the deadline.

A DH spokesperson said: “SHAs are continuing to work with trusts to achieve foundation trust status and are identifying those who need more support.”


Health Direct is not surprised by the impending failure of labour’s NHS red tape.
On NHS managers voice worries over ‘Stalinist’ SHA tactics we posted:

The zero tolerance culture for failure has made some chief executives fear for their jobs as a “Stalinist” culture is draining the NHS of experienced chief executives and making trusts insular and risk averse, Health Direct has learnt.

“If someone asked me for views as to whether they should apply for a chief executive’s post, I’d say I wouldn’t touch it with a barge pole”.

Hospitals ration caesarean births to save money

NHS trusts have for the first time barred women from routinely having elective caesareans because they cost too much.

The procedure, which costs twice as much as a natural birth, will be rationed in Greater Manchester so that it is only available to women with specific medical conditions.

Some top obstetricians condemn the decision, arguing that, while it will curb the fashion for choosing caesareans to reduce the pain of childbirth, it will also penalise those who opt for them on the grounds that they are safer for the mother.

Caesareans have been placed on the same lists for rationing by the NHS trusts in Greater Manchester as infertility treatment, cosmetic surgery and acupuncture.

The lists, called Effective Use of Resources Policies, state that planned caesarean sections should only routinely be offered to women in particular categories. They include women who have previously already had at least two caesareans.

Dr Christoph Lees, an obstetrician and gynaecologist at Addenbrooke’s hospital in Cambridge, said: “I strongly disagree with this prescriptive condition setting. Sometimes well informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed.

About 23% of deliveries in Britain are by caesarean section, and, of these, more than half are emergency operations.

A spokesman for NHS Manchester said: “Where caesarean section is likely to be the safer option for the mother or baby, it will be the mother’s choice how the baby is delivered.”


Lord for hire Moonie, the Labour peer, is caught up in NHS fraud inquiry

Police have been asked to investigate the involvement of Lord Moonie, the Labour peer, in a company at the centre of a National Health Service fraud inquiry.

The former minister – one of four peers named in the “lords for hire” scandal – is a paid consultant to Americium Developments, a company being investigated by Scotland Yard.

It is alleged that Americium boasted about Moonie’s government links and friendship with Gordon Brown to secure business with CombineMed, a health firm that is cooperating with police inquiries. Moonie is paid up to £40,000 to act as a consultant to Americium, an Edinburgh-based information technology company.

Last week Campbell Martin, a former Scottish National party member of the Scottish parliament, wrote to the Metropolitan police asking detectives to investigate what, if anything, Moonie knew about the business activities of Americium. “Given the current police investigation into the actions of the company that pays him . . . Lord Moonie must disclose exactly what he does for them that justifies £40,000 per year,” he said.

The Sunday Times revealed last month that Moonie was one of four peers who indicated they were prepared to help amend a law in return for consultancy fees.

Scotland Yard’s investigation is looking into allegations that Americium unfairly or fraudulently helped CombineMed win a tender to supply information technology services to Imperial College NHS Trust in London.

Americium may have breached British and European Union competition regulations, including a requirement for tenders to be awarded in a fair and transparent manner.

While there is no suggestion that Moonie knew about or was involved in the alleged fraud, former employees of CombineMed, who left the business after raising concerns about Americium’s activities, allege that the Edinburgh company used Moonie’s position in the Lords as a blatant marketing tool.

He hosted a lunch at the Palace of Westminster in 2007 where representatives of both companies met. Tom Finn, a former president of CombineMed who attended the lunch, said the use of Westminster and Moonie had reinforced the company’s view that Americium had connections to government and the NHS that could help commercially.

“One of the representatives [of Americium] was constantly talking about his connections with the UK government,” Finn said. “He was selling everything from the connections with Brown to his intimate knowledge of the procurement selection process within the NHS.”

Sean Martyn, a former project manager with CombineMed, said Americium’s link to government was “the biggest reason” why CombineMed agreed to work with it. “He [the Americium representative] said that ‘if we did things right we would have access to Brown’.”

The Imperial College NHS Trust, formerly Hammersmith Hospitals NHS Trust, had hired Americium to organise a tender for a new internet system that would cut its procurement costs. It terminated the relationship after allegations that the firm was also receiving £34,200 a month to promote CombineMed.

It is alleged that employees of Americium coached CombineMed staff on how to prepare their tender and how to answer crucial questions. An Americium employee also sat on the selection panel that awarded the contract.

Four CombineMed whistle-blowers raised concerns about the legality of the arrangements in a memo to their employer in October 2007. It stated: “We wrote the request for proposal [the invitation for bidders] which allowed us to answer our own questions, we were prepped by the two members of the selection committee who were working on our behalf, and we collaborated with Americium on how the official public notices (part of the EU process) were written.”

Last week CombineMed said it had no reason to believe Americium broke any law and the full disclosure of Americium’s work for CombineMed to the NHS trust “ensured the propriety of the arrangements”. The spokesman said an internal investigation had concluded that the whistle-blowers’ concerns “lacked merit”. The company, he said, had met Moonie twice to describe the services it offered.

He added: “We are aware of an investigation by the Metropolitan police relating to Americium in which we are a witness. We will of course cooperate fully.” Neither Moonie nor representatives of Americium were available to respond. Imperial College NHS Trust declined to comment.


High Stakes- Spice legal highs from the lab

Health Direct continues from yesterday’s posting the Financial Times’s review of labour drugs policy.

John Ramsey was intrigued by one item in a haul of suspicious substances gathered by police at the Creamfields dance festival in Cheshire last August. A pre-rolled cigarette packaged as “Spice” contained something that looked like cannabis – and was bought in the belief that it would deliver the same effect as the illicitly smoked plant extract.

Ramsey, director of Tictac Communications, a London-based consultancy that identifies fake medicines and real narcotics alike, is able to track trends in drug use across the UK. His main source of information is a partnership between police and the organisers of clubs and music festivals.

“The promoters agree to keep drug use down by carrying out searches by their door staff, who put anything they find into ‘amnesty bins’ that we go through,” he says. “As long as any drugs found are for personal use, the police do not prosecute.”

By the time Ramsey saw his first sample of Spice, others were already on to it. The Early Warning System, an electronic network that links police, customs officials and drug specialists around Europe, had been circulating questions about the new product for some time.

Alerted by discussion on internet message boards and growing imports of the product, Sweden, Switzerland and Jersey had begun to seize batches for analysis in 2006, but had failed to identify any banned substances within it.

In early 2008, the European Monitoring Centre for Drugs and Drug Addiction, based in Lisbon, which co-ordinates the Early Warning System, identified a dozen online distributors of Spice across the European Union, half based in the UK and another third in the Netherlands.

The product, which is also offered for sale in a growing number of high street “head shops”, seemed to be the latest in a long line of suspicious-looking but largely innocuous tobacco-like substances dubbed “herbal” or “legal highs”.

“They have always been pretty much a rip-off and never done anything,” says Ramsey, whose scrutiny of amnesty bins in recent years has more usually unearthed troubling new variants of ecstasy and other illegal stimulants. “Our antennae were not sufficiently high to be suspicious about Spice till recently. But then people started saying that it works.”

Slickly presented in small sealed pouches and ever more widely smoked, Spice has sparked growing concern among officials who have learnt much more about the substance in recent weeks, triggering bans last month in Austria and Germany, and customs seizures in the US. Yet in most countries, including the UK, where it seems to have been marketed first, its promoters have been able to generate substantial income and stay several steps ahead of regulators.

On Greenwich Church Street in south-east London, set apart from the neighbouring cafés and boutiques by its bright orange decor, is a shop called Shiva. Its window is piled high with resin skulls, stone gargoyles and silver rings with druidic motifs.

Posters on the wall next to the door advertise the Vortex bong, pocket bong and other “high quality herbal accessories”. Alongside, another promotes Spice. “The only herbal smoke that actually works,” it says. “Nicotine and tobacco-free. Anytime, anyplace (except when operating heavy machinery).”

Inside, a few youthful customers drift between stands of batik clothing, Buddha statues and a tattoo parlour at the back. Behind the till, packets of Spice and similar products are displayed on small plastic shelves, like cigarettes in a newsagent. “Spice Diamond is much stronger than Spice Gold,” explains the well-spoken sales assistant with a stud in her lip. “Here’s a smaller sample pack if you want to try it first.”

Travel 30 minutes from Greenwich to the heart of north London, and Spice is hard to avoid. Turn right out of Camden Tube station, push through the milling crowds, and you will spot Spice on sale in almost every shop on Camden High Street leading up towards Regent’s Canal. Taped to the shelves in one – next to a sign saying “no photographs” – are small sachets.

There is San Pedro Cactus, EcSess, Amsterdam Gold, Devil’s Weed, Hyper?X. But most slick is a series of products wrapped in silver, gold and green foil, bearing the trademark stylised eye logo above the brand name. “Enjoy the enchanting aroma of Spice,” reads the blurb on the back. “Not for human consumption”.

The shopkeeper, his voice half-drowned out by techno music, tells a different story. “It’s like marijuana,” he says to three curious French teenagers. Shortly after, when I try to buy a sachet, he asks me for £30, then, after some haggling, drops to £22, eventually throwing in a packet of Rizla cigarette papers, which leaves little room for doubt about the product’s use.

Even with the discount, bringing it down to the price at which it is offered online via sites such as growhigh.co.uk and alternativemind.co.uk, Spice is substantially more expensive than cannabis. A 3g packet – enough for half-a-dozen joints – is several times the price of weed bought on the street.

But it has one obvious advantage for sellers and buyers alike: it isn’t illegal. Outside the shop, two police officers in fluorescent jackets and bulletproof vests walk by, scrutinising the crowds. They show no interest in stopping the transactions taking place within a puff of smoke of them.

Spice may be legal, but does it offer the same effect? According to some internet forums, yes. As long ago as September 2006 – an eternity in the twilight zone of new recreational drugs – a user named “Mexican Seafood” posted this message on the bluelight site, which specialises in drug discussions: “So, an old friend of mine told me that he and some of my other friends have been buying this stuff called ‘Spice’, which is a legal smoking herb blend. He said he only had a little bit, and he found the high pretty impressive, and several other friends I know and trust swear by it.”

The anonymous recommendations – whether genuine or fabricated by those with a commercial interest – have spiralled since. Last December, on The Vaults of Erowid site, “Ottomatic” wrote, presumably while inhaling: “I hit it once, felt a head change. After the second hit i deffinately felt something reminsicent of a weed high. 10 minutes and a third hit later, i was stoned. Not 100% like good old pot but damn close. Lethargic, red-eyed, and i got the munchies. What more could i ask for. I will smoke this product untill THE MAN makes it illegal.”

“Legal highs?” scoffs David Carter, as I hand over the pack of Spice. “I’d call them illegal medicines or illegal highs. Some of them are garbage. They are only called legal highs because the Misuse of Drugs Act has not caught up with them. There’s a lively market in these products. A lot of them work on the basis of hype.”

A soft-spoken man with a forensic eye, Carter is head of the “borderline section” at the Medicines and Healthcare Products Regulatory Agency (MHRA) in Vauxhall, London. The agency’s job is to authorise new medicines and medical devices according to the Medicines Act. It is also responsible for enforcement against counterfeits and other products that do not meet its standards of safety and efficacy. Each year, Carter’s team receives more than a thousand referrals about substances on the edge of the law.

He peers at the label, rubs the mixture of herbs between his fingers, sniffs deeply and calls it “chocolatey” as though he is sampling a vintage wine. He carefully reads the contents label on the back, which lists a concoction of a dozen exotic plants, and nods in recognition. Last autumn, the MHRA received a referral from the manufacturer concerning Spice.

The MHRA’s response, citing the main ingredients listed on the packet, concluded: “Baybean is smoked on the Gulf Coast of Mexico as a marijuana substitute; Blue Lotus [flowers] are smoked for a mild sedative effect; Dwarf Skullcap is said to be as potent as marijuana; Indian Warrior [buds] are smoked for their psychoactive effects; Lion’s Tail is good for inducing a deep meditative sleep, calming, relaxing and enhancing dreaming because of its euphoric effect; Maconha Brava dried leaves are smoked by Indians in Brazil as a visionary aide, it is also known as ‘false marijuana’; Pink Lotus has narcotic and euphoric effect; Siberian Motherwort is commonly used in Brazil and Chiapas [with] the nickname ‘little marijuana’.”

Officials decided that Spice was subject to the Medicines Act. The MHRA wrote a stern letter back to Psyche Deli, the manufacturer, concluding that it needed to apply for a licence. Most companies the MHRA contacts with similar decisions withdraw their products at this point, but the warning had no effect. Sales continued to grow, and there is little current sign of – or potential for – enforcement.

“Medicines legislation is not a good tool for trapping substances of abuse,” says Carter. “You have to prove something is a medicine. You’ve got to show that the product is presented by the seller for use in human beings; or that it can modify physiological function. You need decent scientific information on the substances and have to show a significant effect. If it’s not presented as something to be administered in humans but someone takes it, you can’t blame the person marketing it.

“There’s no claim for treatment or prevention of disease,” he says, turning over the pack in his hands.” The text describes Spice as incense. “It’s difficult to say it’s marketed for administration to human beings. Also, we have not had reports of the effects on public health. Poisons units have not said that the corpses are piled high.”

The problem, Carter concedes, is that such products fall into a regulatory hole. The herbs cited could have legitimate uses and are not always provided in the form that has hallucinogenic effects. They are not currently included in the periodically updated list of banned narcotic substances in the Misuse of Drugs Act, supervised by the Home Office.

But are the contents listed on the Spice label accurate and comprehensive? Do they tally with the high that its users describe? Elizabeth Williamson, professor of pharmacy at the University of Reading, and a specialist in herbal medicines, has never seen Spice before. Sitting in an office piled with papers and decorated with elaborate botan-ical drawings, she studies the information on the packet with interest. “The people who have done this know the law. None of the herbs are illegal,” she says.

If there were to be a prosecution, it would be necessary to identify precisely what the product contains. “These things are remarkably expensive and difficult to analyse,” she adds. Herb mixtures contain hundreds of complex chemicals. Unless researchers know precisely what they are looking for – and have the “fingerprint” of the compound that they are trying to find with which to compare their results – it can prove almost impossible to produce the necessary breakdown. Opening a well-thumbed manual, Williamson points to the distinctive pattern of colours and positions on a chromatography chart that indicates cannabis.

She promises to analyse the contents of the sachet to determine whether they contain any real cannabis, which might explain the reported effects. A few days later, she sends an e-mail. A postgraduate student conducted a spot test, which gave a “faint positive”.

Because the test is not entirely specific, she then used the more sophisticated technique of thin-layer chromatography. “There was no sign of any cannabinoids,” she said. Williamson followed up with her own expert examination under the microscope, looking for telltale signs of the cannabis plant. “I couldn’t find any of the features associated with the herb, so I think we can be confident that they don’t contain cannabis.”

Holger Rönitz is business development director and co-founder of THC Pharm, a rather unusual pharmaceutical company based in Frankfurt, Germany. In the early 1990s, his business partner had a severe car accident that left him in a wheelchair, and was struck by how many other patients in rehabilitation around him were using cannabis. Tetraplegics, people with multiple sclerosis, those with terminal cancer and others seeking control of pain and spasms turned – often reluctantly – to the weed when prescription drugs failed.

Until the 1930s, pharmaceutical companies offered cannabis extracts for sale. The 1899 edition of Merck’s Manual lists 50 ailments for which cannabis could be prescribed, from asthma and bronchitis to seasickness and uterine cancer. But then shortages during the second world war, a shift away from natural substances towards inorganic chemistry, public suspicion of mind-changing drugs, and the fact that a naturally occurring plant couldn’t be patented, meant that the companies turned their backs.

“We knew there was a market and we talked to some of the big companies, but they didn’t want to touch it,” says Rönitz. “There was a stigma.” In response, he helped set up THC Pharm in 1996 as a “patient initiative”. It derived THC, the principal hallucinogenic compound in cannabis, from legal hemp, persuaded doctors to offer it to patients with a long history of chronic pain, and even managed to get a number of Germany’s health insurers to offer reimbursement informally. Rönitz’s organisation is also studying synthetic compounds that can reproduce the plant’s effects.

In November last year, the Frankfurt drug department approached THC Pharm after local universities failed to identify the compounds in Spice. “We had a hunch,” Rönitz says. By early December, THC Pharm was proved right, finding at least two artificially manufactured chemical substances that had been added to the product’s herbal ingredients.

The company’s researchers were able to recognise them because they already had the “fingerprints” of these compounds: both were among dozens of synthetic cannabinoids already described in academic journals, and which THC Pharm had synthesised as it experimented with potential manufactured variants of cannabis. One is called JWH 018; the other CP 47,497.

John W. Huffman lent his initials to the first compound. A chemistry professor at Clemson University, South Carolina, he first described it in a paper published in 1998. The letters of the second compound stand for Charles Pfizer – the giant US pharmaceutical company that developed this and many similar potential drugs in the 1970s that they then abandoned. “They were looking for analgesics but all they got were extremely potent cannabinoids,” says Huffman.

He confirms that JWH 018 could prove tempting to manufacturers. It acts as an “antagonist”, triggering the CB1 receptor in the human body that simulates the calming effect of cannabis. It is many times more potent than the natural plant, and will probably remain in the body much longer.

Yet because its structure and behaviour is different, it would not be detected in conventional police or workplace urine or blood tests for cannabis. Furthermore, it is cheap and easy to make from widely available raw materials, and involves only a two-step process. “A good chemistry undergraduate could do it,” says Huffman.

What he doesn’t know is the dangers that his compound could pose to humans, beyond the carcinogenic effect of herbal smoke itself. “We had no idea that anyone would be stupid enough to use it,” he says. “If you want to get high, marijuana is easily available.” One concern is quality. He stresses that synthesising JWH 018 – an amber gel – requires a purification process.

Yet since word began to spread on the internet at the end of last year that Spice contained JWH 018, he has been contacted by a number of people describing the versions they have produced as powdery or like black tar. “I have had numerous calls and even more numerous e-mails,” he says. “It is clear that some people did not know what they were doing.”

Rönitz raises a further worrying issue about the use of JWH?018, that of concentration. “In different packages of Spice, it was between 0.2 and 3 per cent,” he says. “That is like drinking a pint with 4 per cent alcohol content and one with 60 per cent.” Even the weight of the herbs in Spice packets, all nominally 3g, varies widely.

“The real issue is that something is being sold without the consumer having any knowledge of what’s in there. It’s a bit like Russian roulette. I’m not a big fan of demonising it but I think it’s a bit scary. Thousands of people have consumed it,” he says.

Not all users enthuse about Spice. Posting on The Vaults of Erowid last month, “PippUK” wrote: “I went on to have a full on panic attack, the like of which I have never had before. The paranoid thoughts reached a crescendo of pointless gnashing of what if’s and other self loathing nonsense that seemed to suddenly embody themselves in my minds eye, and my breathing became shallow and fast … my heart beat began to ramp up frighteningly and I could feel the very sudden strong jerks of that poor muscle in my chest. And I felt that each breath was scarcely enough to deliver the oxygen I needed.”

Les King, the pre-eminent expert on cannabis, remains cautious in his judgment. An adviser to the Home Office who has been instrumental in monitoring and taking action to ban new substances, he unsuccessfully resisted efforts to have cannabis reclassified as Class B (after it was downgraded to Class C in 2004).

“Despite all the references on cannabis, there is still no absolute certainty that it leads to schizophrenia, although probably it does,” he says. “There is a danger in driving, and it can leave people disabled mentally for days, so you take decisions you may later regret.”

Asked about Spice, he says: “This is the first synthetic drug like cannabis. We don’t know the risks. Synthetics were only developed a few years ago, and not much is published on their effects. If it’s interacting with the natural cannabis receptors in the brain, it could cause short-term psychosis, and possible long-term psychotic illness. The government would likely take a precautionary line as it did with cannabis.”

But official action is slow. Following THC Pharm’s identification of JWH 018 and CP 47,497 – and a third possible compound HU 210, developed at the Hebrew University of Jerusalem – Germany and Austria both banned Spice in January. Elsewhere in Europe, including the UK, it is still not illegal. King describes the current EU regulatory system [see box, page 27] as a “lumbering giant”, with no likelihood of an EU-wide ban, even if the evidence is strong enough, until at least 2010.

So what of Spice’s producers? Working largely through intermediaries, online and in person, they give only a website address on their products: psychedeli.co.uk. The site has now disappeared, but official company records show that Psyche Deli does exist. Its two shareholders and directors are Richard Creswell and Paul Galbraith. The scant and tardy accounts give some idea of the size and growth of the business: assets rose from £65,000 in 2006 to £899,000 in 2007.

I head up Holloway Road in north London to find the registered office. Behind a security gate in the nondescript two-storey Archway Business Centre, neighbours point to an office without a nameplate. On the door, someone has scrawled “the nanny state says” above a printed No Smoking sign. A woman opens the door and explains she is a friend of Galbraith’s, closing up the office: Psyche Deli has been sold to a Dutch “head shop”, De?Sjamaan; the owners have moved to the Netherlands, too.

As I turn to leave, my eye lights on a pile of boxes. They carry the label “Sumos”. Inside, however, are packs of Spice. On the side of one box is an air waybill showing that the consignment was delivered to Heathrow from Qingdao in China. It looks as though all production takes place in the Far East. On top of another box is a roll of sticky labels for a product called Genie. “Release the magic of the enchanting potpourri aroma,” it reads.

While the regulators gear up to move against Spice, its purveyors are moving on to the next product, always one step ahead of the law.

Andrew Jack is the Financial Times’s pharmaceutical correspondent.


Health Direct reveals Labour’s drug problem

Health Direct asks what is the problem that labour has with drugs?

First off, when they took office in 1997 they created NICE- the National Institute for Curbing Expenditure.

The spin was that NICE would research and regulate new drugs treatments. In practice this was a clever wheeze to cut NHS costs by limiting access to new life saving treatments.

AKA the postcode lottery. AKA the killer quango.

The creation of nice meant that for the first time since the sixties unelected anonymous people were given the power of life- or death over British subjects.

So opaque were the “rules” governing nice’s remit that drug companies had to go to court to find out how they actually evaluate and approve new drugs.

Then in parallel whilst labour were messing around with “mainstream” drugs they flip flopped with recreational drugs. One memont downgrading cannabis then upgrading it, as well as ignoring the scientific evidence of ecstacy.

On Wednesday, August 02, 2006 Health Direct posted: Risks of taking drugs compared- Scientific review of dangers of drugtaking– Drugs, the real deal when Health Direct reproduced the first ranking based upon scientific evidence of harm to both individuals and society. It was devised by government advisers – then ignored by ministers because of its controversial findings.

The analysis was carried out by David Nutt, a senior member of the Advisory Council on the Misuse of Drugs, and Colin Blakemore, the chief executive of the Medical Research Council. Copies of the report have been submitted to the Home Office, which has failed to act on the conclusions.

Since then labour’s stance on recreational drugs has not improved, below and tomorrow Health Direct posts a review by the Financial Times:

The Slow Road To A Ban

The emergence of the rave party scene in the 1980s and the circulation in the early 1990s of the Californian pharmacologist Alexander Shulgin’s “cookbook” on how to make more than 200 psychoactive substances created the conditions for a new generation of potent products.

When the resulting “designer drugs” began to proliferate in Europe, national authorities saw the need to introduce new mechanisms to speed up cross-border regulation and control.

Currently, the European Monitoring Centre for Drugs and Drug Addiction and Europol, which liaises between police across the EU, consider whether a new drug merits more detailed study. They look at the substance’s biological, psychological and behavioural effect on the user; the effect on families, neighbourhoods and communities, and on society at large.

They then may recommend to the European Commission and the European Medicines Agency that a “risk assessment” be launched. If a qualified majority of the European Council agrees, the drug may then be banned and brought within criminal laws in EU member states. The process can take many months from identification to ban.

The UK Drugs Market

Despite the tough criminal penalties for dealers, illegal drugs are available relatively cheaply. The Home Office says cannabis in resin or herbal form typically sells for £10 for an eighth of an ounce – enough for half-a-dozen joints – and the more potent skunk for twice that. Ecstasy sells for £2-£5 per pill, amphetamines for £10 per gramme and cocaine and heroin for £30-£50 for a gramme – enough for four or five lines. Crack cocaine sells at about £65 per gramme.

By contrast, “herbal highs” such as Spice are more expensive, typically selling for £20-£30 in shops and over the internet. One reason may be precisely because they are not banned, so purchasers will pay a premium to stay within the law. Plus, for large manufacturers, there are overheads to cover such as tax that are not borne by criminal dealers.

Legal drugs’ slick marketing and packaging may persuade customers that they are less dangerous for their health. But Les King, a Home Office adviser, warns against glib comparisons with their illegal counterparts. “Perhaps Spice is seen as safer,” he says, “if only because it comes in a nice package rather than, like cannabis, in a dirty piece of clingfilm.”


Transplant row over organs for drinkers

Heavy drinkers are receiving nearly one in four of the UK’s liver transplants, it was revealed last night, igniting a furious row about the ethics of allocating organs to people with alcohol problems.

Figures show that transplants for heavy drinkers have risen by more than 60% in the past decade, while waiting lists have lengthened. In December 1997, 180 people in the UK were awaiting a liver transplant, compared with 325 in the same month last year.

Dr Tony Calland, chairman of the British Medical Association’s medical ethics committee, said surgeons are within their rights to refuse transplants to anyone with alcohol-related liver disease if they do not demonstrate a genuine desire to stop drinking.

And the mother of a young woman whose organs helped to keep five people alive after she died said it was “offensive, terrible and unfair” that an increasing proportion of livers were going to people with serious alcohol problems.

Eunice Booker, whose 26-year-old daughter, Kirstie, died in a car crash in 2006, said: “I find it offensive that one in four of the livers donated go to alcoholics. If there are two people side by side wanting a liver, and both have the right tissue match, and one is an alcoholic and one isn’t, there’s no contest – you take the one who’s not an alcoholic, they are more entitled.”

Official figures that show in the year to 31 March 2008, 151 liver transplants, out of a total of 623 carried out across the UK, went to people with alcohol-related liver disease – 23% of the total. By contrast, in the year to March 2007, there were 94 liver transplants for people with alcohol-related liver disease, just 14% of the overall total.

Calland acknowledged that the trend was raising new questions for surgeons, who are within their rights to insist that anyone with alcohol-related liver disease demonstrates a genuine intention to address their problem before the operation is approved.

“Organs are precious resources and should be used where the clinical outcome – the patient’s health – justifies the use of something so scarce,” Calland said. “You have to have very definite evidence that the person is going to stop drinking. If someone won’t promise, you could refuse them the transplant on clinical rather than ethical grounds.”

Concerns about alcohol-related health problems in Britain are increasing. A report by the London School of Hygiene and Tropical Medicine two years ago suggested that deaths from cirrhosis of the liver were rising faster in Britain than anywhere else in Europe. The rise was especially sharp in men and women aged under 45, where death rates now exceed the European average.

Last month, Alison Rogers, chief executive of the British Liver Trust, warned that “the death toll from alcohol remains unacceptably high” and that twice as many people are dying from alcohol as 15 years ago.

Some have questioned whether livers are being allocated fairly. Professor Nigel Heaton, the surgeon who performed a liver transplant on alcoholic footballer George Best, said at the time that new measures were needed to identify patients likely to abuse alcohol after their operations so that medical staff could make an assessment as to whether there were more suitable candidates.

“If you knew someone was going to be recidivist, you wouldn’t take them on for a transplant,” he said.

A spokesman for NHS Blood and Transplant, the special health authority that oversees transplants, said the decision to allocate each organ was made on a case by case basis: “The patient’s surgeon assesses whether that person is fit physically and is able to cope with the rigours of living after a transplant.”

Liberal Democrat shadow culture, media and sport secretary Don Foster, who obtained the new transplant figures, said only by increasing the cost of alcohol could the nation’s health be saved from Britain’s binge-drinking culture.

“These figures are a stark warning about the impact alcohol is having on health services in this country,” he said. “Recent studies have proven that the cheaper alcohol is, the more we all drink. None of us wants to pay more for our alcohol, but with an alcohol crisis on our hands we have to look again at raising the price of the cheapest alcohol.”


Sir George Godber- pioneer who marched the NHS forward

It has been the misfortune of every chief medical officer for the past 30 years to have had to follow in the footsteps of Sir George Godber who has died at the age of 100. With his death has gone one of the last living links to the foundation of the National Health Service.

A monocled, barrel-chested, buccaneer of a man, he was the son of a successful market gardener in Bedfordshire who put all seven of his children through university long before the days of state-funded higher education.

Godber qualified as a doctor at the London Hospital and New College, Oxford, in 1933. For much of his early career he worked amid the poverty of London’s East End.

That experience shaped him just as it had shaped Sir William Beveridge and Labour prime minister Clement Attlee, the architects of the welfare state. Godber saw the way poverty created ill-health and the indignity that both doctors and patients faced.

In 1939 he joined the Ministry of Health and in 1942 was charged with helping prepare a “Doomsday Book” on the state of British hospitals. He saw the appalling physical state of the hospital stock.

Nye Bevan’s arrival as Minister of Health in 1945 was in many ways Godber’s moment also. By then he was personal assistant to Sir Wilson Jameson, the chief medical officer, and was intimately involved in the negotiations that led up to the founding of the NHS in 1948. Like many in the department he was entranced by the silky way Bevan handled power.

He helped organise the scheme to get hospital specialists spread around the country and by 1950 was deputy chief medical officer. In that role, and as chief medical officer for a mighty 13 years from 1960 to 1973, he was the last CMO with the sheer stature to tell both the medical profession and ministers when they were wrong.

During fraught negotiations over a new GPs’ contract in the mid-1960s that could have seen them quit the NHS, it was late night phone calls between Godber and the then BMA secretary, Dr Derek Stevenson, that helped keep the show on the road.

Godber became CMO just as Enoch Powell arrived as minister for health and Sir Bruce Fraser became the department’s permanent secretary – a triumvirate that between them shook the NHS out of its postwar -torpor.

Powell, who described Godber as the minister’s “bodyguard and lightning conductor”, told the story of a scandal breaking in the papers over an incompetent surgeon and asking what he, as minister of health, could do about it. “Leave it to me, minister,” Godber said before returning a week later to assure Powell that the man “will never operate again”. (Fat chance of that happening again under labour’s politically correct nanny state nowadays.)

He saw the NHS not as an achievement but as a permanent march forward, although by 1972 in his final report as chief medical officer, he felt confident enough to declare that “in time of need for myself or my family I would rather take my chance at random in the British National Health Service than in any other service I know”.

Way into his eighties, Godber was never afraid of new ways of delivering NHS ideals. Even journalists who voiced opinions about the NHS would find neat handwritten letters in the post, praising, or gently chiding for some error.

While at the London Hospital he had met and married Norma who for 55 years provided the support for an inspirational but driven man.

The couple had seven children, four of whom died in childhood or adolescence from a genetic blood -disorder.

It is perhaps not surprising that the three survivors have spent most of their careers in healthcare.


NHS managers voice worries over ‘Stalinist’ SHA tactics

The zero tolerance culture for failure has made some chief executives fear for their jobs as a “Stalinist” culture is draining the NHS of experienced chief executives and making trusts insular and risk averse, senior leaders have told the Health Service Journal.

The concerns were prompted by the departure of two London hospital chief executives from trusts facing serious performance challenges. The sudden resignations of Tara Donnelly, from West Middlesex University Hospital trust, and Julian Nettel, from Barts and the London trust, have left managers across the capital fearing for their jobs.

“If someone asked me for views as to whether they should apply for a chief executive’s post, I’d say I wouldn’t touch it with a barge pole”.

Many also feel the shake-up will discourage people from applying for top jobs at a time when vacant posts often attract just one candidate.

Making mistakes

University College London Hospitals foundation trust chair Sir Peter Dixon told HSJ: “It raises all sorts of questions about the way we treat our senior managers. I think there’s a Stalinist culture among SHAs that isn’t helpful. You need to be able to make a mistake.”

He added: “There’s not a mass of people waiting on the sidelines who want to take these jobs on.”

Barts and West Middlesex face deep rooted problems and have been named as trusts that will fail to secure foundation status.

But many trusts in London are performing badly against targets – and the region has the highest number of trusts that will fail to become foundation trusts. Managers fear NHS London is looking for scalps in response to Department of Health pressure.

Performance anxiety

A London acute trust chief executive said: “It feels as though there’s a new intolerance in London and that some excellent, talented leaders are being forced out or put under so much pressure they leave.

“A lot of chief execs are thinking ‘there but for the grace of God’.”

A London insider said: “If someone asked me for views as to whether they should apply for a chief executive’s post, I’d say I wouldn’t touch it with a barge pole.”

The insider added: “These are difficult jobs and this makes people adopt risk averse behaviours.”

Ms Donnelly stood down after her trust failed to alert NHS London that eight patients had waited more than 12 hours in accident and emergency. The SHA said this meant nearby trusts were unable to help.

But a chief executive at a neighbouring hospital said: “We wouldn’t have been in a position to help out, however much we’d have wanted to.

“I think [the resignation] is very hard on a first offence and whether that’s really in the best interests of the organisation is very debatable.”

Official protocol

HSJ understands West Middlesex had established informally that other hospitals were unable to help but did not follow official protocol.

NHS London has taken a hard line on trusts it feels should be able to deliver on key targets. HSJ understands this was not the first time there had been a difference of opinion between the trust and the SHA.

One London hospital chief executive said the departure of Malcolm Stamp, NHS London’s provider agency chief executive, last December had deprived leaders of someone at the SHA with whom to have informal discussions.

The “high level of anxiety” resulting from recent resignations made trusts potentially reluctant to help other organisations if it meant they would miss targets, the chief said.

Performance management

Managers in Partnership has seen an increase in casework involving senior managers in London in recent months, mainly disciplinaries, grievances and capability procedures related to performance management. Chief executive Jon Restell said it was understandable that SHAs wanted to hold top managers accountable but said putting people under “unreasonable amounts of pressure” would not help.

However, King’s College Hospital foundation trust chief executive Tim Smart was unsympathetic. He said: “Personally I don’t subscribe to the view that there is a climate of fear. I think targets are targets and you have to deal with them.”

The SHA denies any suggestion that it bullies managers. Deputy chief executive Anne Rainsberry said the SHA simply wanted to improve performance and there would always be a turnover of chief executives.


Health Direct has seen this increasing trend in intolerant centralist health bosses for a while.

On Wed, Feb 11, 2009 we posted London acute trusts face shake up as bosses resign
London’s hospital trusts face a massive management shake up after the resignations of five chief executives over failures in their trusts.

Labour closing maternity increasing, say Conservatives

Labour closes maternity services increasing, say Conservatives with nearly 50 per cent of hospital trusts having to close to maternity admissions at least once in 2008.

The Conservatives, who collated the figures from freedom of information requests, said they demonstrated Labour’s “terrible record on maternity”.

Fifty of 104 trusts that replied to the requests said they had closed to admissions or diverted women elsewhere at least once during the year.

In a similar survey of 83 trusts for 2007, 42 per cent said they had to close at least once.

In total, there were 553 closures in England in 2008, up 38 per cent from 402 in 2007, the Conservatives said.

Labour’s record

Shadow health secretary Andrew Lansley said: “These figures are a telling reminder of Labour’s terrible record on maternity.

“Every one of these figures tells an awful story of mothers being turned away from hospital at a hugely emotional time – when they are due to give birth. Labour seem to be deliberately running down maternity services in some hospitals as a precursor to shutting down maternity units altogether.

“The labour government must increase midwife numbers as they promised, make sure local maternity units get their fair share of NHS funding, and sort out their disastrous negotiation of EU rules on doctors’ working hours.”

In 2007, the government committed to improving the safety of maternity services, including by appointing 1,000 midwives by September and “up to 4,000” by 2012. Last January it said an additional £330m funding would go to primary care trusts for maternity over three years.

However, a large proportion of primary care trusts are not earmarking the money for maternity, meaning it may not reach services.


Royal College of Midwives director for England Jacque Gerrard said: “Capacity within maternity units is being stretched to the limit and beyond, resulting in closures.

“The Department of Health, however, has set a target to recruit the equivalent of another 3,400 full time midwives by 2012, and it has started to increase the money going into maternity care.

“Some of this money, however, is not finding its way into the hands of the people at the front line to employ more midwives and improve maternity services.

“The Royal College of Midwives is urging people who run health services locally to be more proactive and use money earmarked for maternity services actually for maternity services, so that women are not being left worried and deeply disappointed.”

Patient safety

A spokesman for the Department of Health said: “Sometimes units do have to temporarily shut their doors, usually for very short periods of time.

“We appreciate that it is distressing to be told that your care is going to be provided elsewhere but this is always undertaken in the interests of safety for the mother and baby.


NHS boss angry at transplant organs for foreigners

A leading National Health Service hospital has come under attack from the government’s transplant authority for giving livers from dead Britons to overseas European Union patients in private operations.

More than 40 procedures using organs from British donors have been carried out on foreigners at King’s College hospital, London, over two years.

According to NHS Blood and Transplant (NHSBT), the trade undermines Gordon Brown’s £4.5m attempt to increase organ donations and creates an “obvious potential conflict of interest”. It accused King’s of “a persistent lack of clarity” over the trade.

The criticisms appear in correspondence released to The Sunday Times under the Freedom of Information Act.

Lynda Hamlyn, chief executive of NHSBT, wrote in one letter to the hospital: “This is the third specific issue of concern raised by UK Transplant [part of NHSBT] over the past four years about the transplantation of livers from deceased UK donors into nonUK residents undertaken on a private basis at King’s.

“People joining the organ donor register and families giving consent for organ donation need to be completely confident that UK residents . . . are treated fairly.”

In one week following publication in The Sunday Times last month of figures on private transplants given to foreigners at King’s, 22 people withdrew their names from the organ donor register in protest.

Tim Smart, chief executive, denied King’s College Hospital NHS Foundation Trust had failed to give clarity. He said EU patients had the same legal entitlement as British patients to receive donated organs.


Last month Health Direct posted Outrage over NHS organ donations sold to foreigners
when the organs of 50 British National Health Service donors have been given to foreign patients who have paid about £75,000 each for private transplant operations in the past two years, freedom of information documents show.