The NHS in the UK at 75: On life support or death watch?: It's the politics, stupid (to misquote Bill Clinton).

This Perspective argues that the NHS in the UK is facing a critical 'tipping point' which means that its very survival is at stake. The article considers the political responses to this crisis-(briefly) from the Conservative government; (briefly) from the 'anti-NHS' Right in politics; (briefly) from the 'centre' in politics in the form of the Tony Blair Institute for Global Change; and (in depth) from the left-of-centre, the Labour Party. Labour is likely to form the next government, which is why its approach (in terms of both political strategy and the substance of health policy) is considered in depth. It is argued that Labour's approach, derived from an understandable desire by leader Sir Keir Starmer to disown its 'unelectable' recent past, is currently inadequate for the task of putting the NHS on a secure footing for the future.

'We did everything we could': An account of toxic leadership.

BACKGROUND: The UK government's reckless and incompetent response to Covid-19 has produced an outcome which is amongst the worst in the world, and arguably the worst in terms of deaths per 100,000 population of major countries (especially when one measures mortality from Covid in terms of cause of death on the death certificate, rather than the UK government's own measure-death of a tested individual within 28 days of testing). This article updates my initial analysis in this journal over a year ago, and traces the negligent and shambolic policy-making, and supine official scientific advice, which has led to such a dismal outcome. METHODS: It does so by examining the policies and approach of the UK government from the begining of the pandemic (in UK terms, January 2020) up to June 2021. All relevant declarations, speeches, decisions, public interviews and policies were noted on a daily basis, examined and critically assessed-along with daily data and information over the whole period on Covid's threat to, and spread across, the UK. CONCLUSIONS: On three successive occasions, Boris Johnson and his compliant Ministers acted too late and too weakly to prevent avoidable death and illness. At the time of writing the vaccination programme in the UK has been destabilised by the government-yet again-having failed to secure its borders, this time against the Delta variant (Indian mutation) of the virus. Overall, in terms of border control, quarantine, testing, tracing, isolation and timely and enforced lockdown, the government put short-term, superficial considerations above coherent strategy. It dressed up its incompetence as a superficial libertarianism and defence of the economy, but thereby managed to achieve the worst of all worlds in terms of three egregious failures-appalling health outcomes; (ironically) worse economic damage than countries which took draconian action; and (also ironically) continually recurring restrictions as a result of earlier failure to take strong action to suppress Covid and keep it at bay. Public reaction in England (unlike in Scotland and Wales) to the Johnson government's shenanigans has not been commensurate with that government's level of failure, which sadly reflects a debasement of the political culture in England.

'There's the end of an auld sang': Farewell to the NHS market.

The new White Paper, Integration and Innovation, prefiguring a Health and Social Care Bill for England, means that the NHS structure in England will have come full circle in the last 32 years, since the Thatcher government began in 1989 to implement the reforms announced that year in the White Paper, Working for Patients (incidentally without waiting for parliamentary approval, which came in 1990). This will be denied by some, who will depict the 'new' integration as only being possible as a result of learning during the various phases of reform over the last 30 years. This is a fallacious teleology. It is argued here that, while the 'old' NHS of the 1980s (of course) required improvement, the persistent 'reforms' of the last 30 years or so have been based on political fads which have been both hugely expensive and, in the end, transitory and self-defeating.

Insouciance and inexperience: A deadly combination when dealing with COVID-19.

This article gives key reasons for the UK's tardy and confused attempts to react to the COVID-19 pandemic. It explains very poor outcomes in the UK (in terms of the spread of the virus and high mortality, already striking at the time of writing), in terms of an initial lack of political will to prioritise public health, itself a product of a strong Prime Minister who made the "wrong call". It also highlights a failure to "follow the science", except in so far as the "science" had already accepted some dubious political judgements and the lack of capacity to test as the starting-point.

Undergraduate teaching in geriatric medicine: mapping the British Geriatrics Society undergraduate curriculum to Tomorrow's Doctors 2009.

INTRODUCTION: in 2008, the British Geriatrics Society (BGS) developed the Recommended Undergraduate Curriculum in Geriatric Medicine. This was subsequently mapped to the second edition of Tomorrows' Doctors (TD2, 2003). Following the publication of the third edition of Tomorrow's Doctors in 2009 (TD3), the mapping exercise was repeated to verify the extent to which the updated General Medical Council recommendations supported teaching in ageing and geriatric medicine. METHOD: we analysed TD3 and identified 48 aspects of its general guidance that were relevant to the teaching of medicine for older people. We then mapped these to the 2009 BGS curriculum. RESULTS: the BGS curriculum was supported in full by TD3. However, learning outcomes relating to the interpretation and conduct of research in TD3 had no corresponding outcomes in the BGS curriculum. CONCLUSION: the BGS curriculum for medical undergraduates continues to provide a specific and complete list of learning objectives, all of which could help to operationalise the general statements made in TD3 with relation to ageing and geriatric medicine. Learning outcomes in research in frail older patients have been added following this mapping exercise.

UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine.

INTRODUCTION: in 2008, a UK national survey of undergraduate teaching about ageing and geriatric medicine identified deficiencies, including failure to adequately teach about elder abuse, pressure ulcers and bio- and social gerontology. We repeated the survey in 2013 to consider whether the situation had improved. METHOD: the deans of all 31 UK medical schools were invited to nominate a respondent with an overview of their undergraduate curriculum. Nominees were invited by email and letter to complete an online questionnaire quantifying topics taught, type of teaching and assessment undertaken, and the amount of time spent on teaching. RESULTS: one school only taught pre-clinical medicine and declined to participate. Of the 30 remaining schools, 20 responded and 19 provided analysable data. The majority of the schools (95-100%) provided teaching in delirium, dementia, stroke, falls, osteoporosis, extra-pyramidal disorders, polypharmacy, incontinence, ethics and mental capacity. Only 68% of the schools taught about elder abuse. Thirty-seven per cent taught a recognised classification of the domains of health used in Comprehensive Geriatric Assessment (CGA). The median (range) total time spent on teaching in ageing and geriatric medicine was 55.5 (26-192) h. There was less reliance on informal teaching and improved assessment:teaching ratios compared with the 2008 survey. CONCLUSIONS: there was an improvement in teaching and assessment of learning outcomes in ageing and geriatric medicine for UK undergraduates between 2008 and 2013. However, further work is needed to increase the amount of teaching time devoted to ageing and to improve teaching around elder abuse and the domains of health used in CGA.

Hyper-stasis as opposed to hyper-activism: the politics of health policy in the USA set against England.

This paper considers health policy-making in the USA with England as comparator. It contrasts policy inertia in US healthcare despite crisis with hyper-activity in perpetual 'reform' in England despite absence of crisis in the NHS. It does so from the standpoint of political science and political economy. I suggest that 'path-dependency', the view that past policy constrains future policy, lacks explanatory power and that wider and deeper explanations must be sought. The USA's apparent path dependency is in fact a story of political economy and power, buttressed by institutions. England's apparent lack of path-dependency in promulgating NHS reform is in fact a story of executive hyper-activism which is oblivious to how implementation will obviate its prescriptions. This failure of 'reform' in the NHS is not a symptom of concealed path-dependency but a sign of pragmatism by those charged with implementation. In the USA, the durability of its various systems of healthcare is by contrast a sign of pragmatism not being adequate to achieve health sector reform. In the USA, a weak state is unable to manage healthcare reform which would actually benefit US capitalism as a whole. In the UK, a strong state has created and developed the NHS to the benefit of capital through the economical provision of healthcare to the workforce. Such an 'investment state' is a testimony to the continuing validity of the neo-Marxist argument that social investment and social expenses are an important and functional component of the capitalist state.

Learning lessons about lesson-learning: Covid complexity.

In the article, 'Learning Lessons from the Covid-19 Pandemic', Powell (2022) rightly implies that there is a profusion of confusion in the 'industry' which has grown up around lesson-learning from the pandemic. His contribution sets out a helpful framework for classifying or making attempts at lesson-learning. He combines the tripartite classification of inadequate approaches to policy-learning and policy transfer developed 30 years ago by Dolowitz and Marsh ('uninformed-incomplete-inappropriate'), which he inverts to produce a classification of approaches which are informed, complete and appropriate, with the framework of 'outcome-mechanism-context' from realistic evaluation. (I use the term realistic rather than realist, as the latter implies an epistemological stance as opposed to what was intended, which is that evaluation takes account of complexity in a realistic manner.) This produces a classification, and possibly an 'ideal type', of informed outcomes, complete mechanisms and appropriate context. Powell rightly implies that no overall conclusion is available from the literature reviewed. He does however imply that different approaches may work in different settings. This is true in one sense but misleading in another. This commentary argues that such 'relativism' is not only dangerous in practice but mistaken in theory.

A systematic mapping review of randomized controlled trials (RCTs) in care homes.

BACKGROUND: A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes. METHODS: A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for "Nursing Home", "Residential Facilities" and "Homes for the Aged"; CINAHL for "nursing homes", "residential facilities" and "skilled nursing facilities"; AMED for "Nursing homes", "Long term care", "Residential facilities" and "Randomized controlled trial"; and BNI for "Nursing Homes", "Residential Care" and "Long-term care". Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results. RESULTS: 3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health. CONCLUSIONS: This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis - are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.