Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health

I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH,  to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.

I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)

Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:

i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.

One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.

iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.

Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.

 

An unholy alliance: religion, neo-liberal economics and good old fashioned patriarchy – restricting women’s abortion rights in Eastern Europe

11/05/2012 Comments Off on An unholy alliance: religion, neo-liberal economics and good old fashioned patriarchy – restricting women’s abortion rights in Eastern Europe

A report from guest blogger Charlotte Gage on ‘How much does abortion cost?’ a session organised by ASTRA Central and Eastern European Women’s Network for Sexual and Reproductive Health and Rights at the AWID Forum in Istanbul.

I attended this session where speakers from Poland, Romania, Hungary and Slovakia outlined the economic dimension of sexual and reproductive rights in their countries, and the increasing restrictions on access to abortion.

Provision of abortion and other reproductive health services are under threat from neo-liberal economics which is increasingly restricting state-funded services throughout the region. This is being fuelled, by ideological opposition to abortion from both the Catholic and Orthodox Churches, sometimes with funding and support from US anti-choice organisations which is thought may include the US-based Human Life International and Opus Dei.

Most countries in the region have experienced reforms to health systems following democratic transition from Communism, but the results of these vary. The restrictive abortion laws in countries such as Romania and Albania under Communism were seen as a social experiment to increase the population and provide new generations of workers, and have since been relaxed. More recently however, Ukraine and Russia have tried to implement restrictive laws, to reverse a decline in population.

The influence of religion varies throughout the region. In Poland the Catholic Church still has a strong influence, and as its access to public resources increases, through provision of adoption services, it has a vested financial interest – as well as ideological one to opposing reproductive rights. In other countries it is the influence of, and funding from, the US anti-choice movement that is driving forward an anti-choice agenda.

The increasing reluctance by governments to pay for contraception and abortion services is also having an impact.

In Hungary, an advertising campaign in which images of fetuses asked not to be murdered was funded by PROGRESS EU funding – a fund aimed at supporting equality. The Government was forced to stop the campaign after feminist organisations complained to the European Parliament.

In tandem with ideological tactics aimed at creating attitudinal change, the budget for reproductive health in Hungary, which supported women who could not afford to pay for an abortion, has been significantly reduced with no explanation. Women seeking home birth are subject to unaffordable insurance premiums and in one case a midwife has been imprisoned for supporting a woman to give birth at home. For PATENT – People Opposing Patriarchy these were all cited as examples of the continued repression of women’s reproductive rights in Hungary, patriarchy in action, and the denial of women’s autonomy.

Freedom of Choice, Slovakia,  has campaigned against the lack of unbiased and accurate information on family planning. It also takes on the  influence of the Catholic Church hierarchy which is opposing progressive policies such as inclusion of more information in school textbooks and making contraception more affordable.

The Polish Federation for Women and Family Planning described how in 1993 Poland became the first country in Eastern Europe radically to restrict abortion and is now, regrettably, serving as a model for other  Governments in the region. Official figures show just 600 abortions were performed in Poland in 2010 (compared to 8,000 in 1989), but this figure hides the large number of privately performed abortions and those provided to Polish women abroad.

In many of the countries it is the actual cost of abortion for women that creates the main barrier to accessing services. Women on low wages sometimes pay the equivalent to the average monthly wage for an abortion. In Slovakia, where there are no state controls on the maximum price of contraception, prices are rising and contraception is becoming unobtainable for many women. Moreover, across the region professional resistance to medical abortion combined with high costs means women are denied the option of choosing this extremely safe method of abortion.

An interesting response to the economic and ideological squeeze on abortion access came from a speaker from the Romanian organization European Centre for Public Initiatives (ECPI) which said that Romania has not yet fully learned the lessons from its past. Though the liberalisation of abortion in Romania has led to significant reductions in maternal mortality there have been recent attempts to restrict and limit abortion in Romania, including proposing mandatory (biased) counselling and a three day waiting period before a woman is able to have an abortion.

ECPI believes that calculating the financial benefits of providing reproductive health care may be a powerful tool in opposing further restrictions. To this end, it is attempting to estimate the full cost of unsafe abortion including:  the health care costs following unsafe procedures; social costs including sick leave and disability benefits if the woman is injured; the costs of childcare if the woman dies;  and violence against women services for those who experience violence following abortion.

It may ‘leave a bad taste in the mouth’ to try to put a monetary value on women’s lives, but in the face of ideological opposition to women’s reproductive autonomy, and governments’ focus on cutting budgets, it might be the most powerful argument we can make.

Charlotte Gage

With thanks to Katarzyna Pabijanek – ASTRA Network Coordinator

Does midwifery have to be privatised to provide continuity of care for women?

30/03/2012 Comments Off on Does midwifery have to be privatised to provide continuity of care for women?

Published on the British Medical Journal Guest Blog, 29 March 2012

Earlier this year we received news of a social enterprise, Neighbourhood Midwives, providing midwifery services in the community in London, and a private company providing midwifery services for NHS Wirral Primary Care Trust. One to One, in the Wirral, promotes itself as offering the kind of continuity of care in pregnancy and maternity that midwives have wanted to provide but have often been unable to, for decades. It heralds its high rates of home births—part of which it, bizarrely, appears to attribute to the launch of the BBC drama Call the Midwife set in the East End of London in the 1950s. Of course women would prefer a single familiar and friendly midwife to see them through pregnancy and labour, instead of a roll call of harassed and overworked ones who they may only meet once, or one who barks commands as she flits between different women on the labour ward (a la real life in One Born Every Minute, Channel Four). Of course what women most want is a safe delivery and a healthy baby.

It is hardly necessary to revisit all the ways in which midwifery is failing women and midwives are being failed in turn by the health system. The Royal College of Midwives has long been calling for the urgent recruitment of 5,000 more midwives to deal with a spiralling birth rate amid great uncertainty about future resourcing in the wake of cuts and NHS reforms. In this context it is certainly worth considering the opportunities and pitfalls presented by independent organisations of midwives providing services to exploit the new liberalised health commissioning environment.

Different questions arise:

Will midwives be attracted to leave the NHS and join groups of independent providers? Which ones? Will they be those who are highly motivated to provide a good quality of service for women, continuity of care, and women-centred midwifery; or those who are unhappy or ill equipped for providing the spectrum of care women need including support through complex or high risk pregnancies and obstetric emergencies (which happen in some 15% of all pregnancies); or those who seek better or easier working conditions. This is strongly related to the question about why there is such a shortfall of midwives in the NHS, where independent organisations will find the midwives to staff their services, and—if they can find them—why the NHS can’t recruit and retain them instead?

How will these services be linked in, and relate to, services in NHS settings? It is clear that such services will be set up to support women only through low-risk pregnancies, but inevitably a proportion of those women will end up in NHS maternity units through choice or necessity. What will the impact be on NHS service planning for emergency and unplanned admissions from independent providers?

How will the comparative effectiveness and efficiency of these services be assessed when they, by their nature, will cream off the low-risk cases and have greater capacity to provide home-births which are less costly? It is not hard to see how attractive this kind of low-risk provision might be to the private sector and how essential it would be for them to return women back to the NHS as soon as it might cost them a penny more than expected.

Will the NHS—as in so many areas of care—be expected to treat only the complex and expensive cases, or handle the mistakes of the private sector? If so, what are the implications for NHS midwives who also need to look after low risk cases as part of the spectrum of care they offer, and enjoy doing so? If private provision leads to even more medicalisation of NHS services could it result in a further haemorrhaging of good midwives from the NHS?

If NHS maternity services are at risk of becoming a dumping ground for complex cases and obstetric emergency, how will this impact on options for those women who may want a more low-intervention approach, but with the safety net of doing so in a hospital setting?

Will the independent, community-based service be open to and promoted to all women, or will we end up with two tiers of provision? Will women who are well-versed in what they want get shiny new community services, while everyone else—including teenagers, those with language or learning difficulties, the poor, and those simply lacking in knowledge and confidence—is expected to “like it or lump it” in the local hospital?

How have these new groups managed to organise NHS support to arrange professional insurance when this is something independent midwives have often struggled or failed to do?

Finally, the question we are asking about all NHS services: is it just a matter of time before we are expected to pay fees for some services, and could privately provided midwifery be one of these?

We would all like to see services providing continuity of care for pregnant women in the community. If this is to be provided by independent organisations it must be freely available, and must not be provided at the expense of good quality, comprehensive NHS maternity provision by midwife-led units, whether within or attached to NHS hospitals.

A guest blog by Lisa Hallgarten: social media manager at Reproductive Health Matters; sexual health trainer, educator, and blogger at Education For Choice; and advocate for better sex education for all young people.

An open letter to Shirley Williams

17/02/2012 Comments Off on An open letter to Shirley Williams

Dear Baroness Williams,

I have greatly appreciated your continuing efforts during the debate on the NHS Bill in the House of Lords until recently and that you took the time to send out the group emails that have kept those of us on the outside informed.

I am writing now, however, to say how disheartened I was to learn earlier this week that you have called for the Bill to be amended and passed, as if the entire Bill were not about competition, intended to open the door wide to privatisation and atomisation of the NHS, which is the Government’s strategy not only with the Health Service but with home and social care, with education and indeed almost everything else.

Your Party, as part of the Coalition, is certainly in an untenable position, as you are the ones who will make the passage of the Bill possible. I would not want to be in your shoes with the public when the true nature of the betrayal of the Health Service emerges if the Bill goes forward. Simon Hughes misguidedly believes that removing Andrew Lansley after you pass the Bill will save the situation, but it will not, though indeed Andrew Lansley should go precisely because he tried to sign away responsibility for his own position. But he must go along with the Bill, not after it or instead of it.

No one, from David Cameron on down, can ignore the increasingly articulated views of most health professionals as well as the public, which have grown in strength over the past few months as more and more people come to understand what is at stake. If democracy still means anything, then both Houses of Parliament must bow to the strength of public opinion and withdraw this Bill before it can do any further damage.

If all the Conservatives could find to say in defence of the Bill, e.g. on Question Time, is that the BMA didn’t support the NHS in 1948 either (a misreading of history), and that because it is already being implemented it is too late to turn back, then they (and you) have well and truly lost the argument.

Indeed, I would ask you whether the extent of implementation of the Bill – even before it has been debated fully, let alone voted upon – is unconstitutional. If it isn’t, then it should be.

I urge you from your position of leadership to convince both parties in the Coalition that this Bill is unsalvageable and should be withdrawn – as the only honourable thing left to do.

 

With kind regards,

Marge Berer

Editor, Reproductive Health Matters

The breast implant fiasco: a scandal of private medicine

18/01/2012 Comments Off on The breast implant fiasco: a scandal of private medicine

First published 17 Jan 2012 on the BMJ Group Blog

So, the silicone’s hit the fan.

The use of industrial-grade silicone intended for mattresses, the possible fraud in hiding information from inspectors at production stage, and the failure in quality control in the regulatory phase, are particularly outrageous. However, the rapidly expanding private sector provision of breast implants for cosmetic reasons, by an “industry” that has been permitted to remain self-regulating in spite of evidence of its shortcomings and the risks involved, was a public health problem waiting to happen.

According to a 2010 review by Melanie Latham, [1] after the Labour government came to power in 1997, Labour MP Ann Clywd raised debates in the House of Commons about the possible risks of silicone from breast implants leaking into the patient’s body. Some efforts to regulate the private cosmetic surgery sector took place: in the Standards Care Act 2000, the Health and Social Care (Community Health and Standards) Act 2003, the National Health Service Act 2006, and the Health and Social Care Act 2008. These acts provided for a system of registration and inspection of private facilities and providers, but left the supervision of these regulations within a system of self-regulation, largely in the hands of private surgeons and clinics themselves. [1] Powers of entry and inspection of premises were handed over to the Care Quality Commission in 2008, a body that has experienced more criticism than one could reasonably expect it to survive. [2]

In the meantime, criticisms arose which have dogged the industry for over a decade: [1] that clinics were not adhering to minimum standards set in 2000, not monitoring quality of care and not recording adverse events. Accusations were levelled that they lacked written guidance on clinic procedures, published misleading advertisements about the potential success of treatments and had informal and undocumented complaints procedures and inadequate registration of surgeons.

Ann Clywd’s calls for an independent umbrella body to govern the cosmetic surgery profession, the most recent in 2008, [3] went unheeded. In 2009, the president of the British Association of Aesthetic Plastic Surgeons said: “In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ‘2-for-1′ advert for general surgery? That way lies madness!” [4]

Little did he know that Health Secretary Andrew Lansley, by opening the door to privatisation of health care on a wide scale, would make it even more likely that such problems might occur. The Health and Social Care bill is scheduled for report stage—where MPs discuss possible amendments—on 6 February. Lansley’s own response to the current implant fiasco has changed practically by the day and has included a mix of moral outrage on behalf of patients and threats to pursue, through the courts, the cosmetic industry companies that are refusing free removal of the sub-standard implants. [5] Why? Because, as he told the House of Commons, he didn’t think the NHS should foot the bill except for women whose implants were provided on the NHS (almost all of them women who have had breast cancer).

Some of the companies, for their part, are refusing to remove or replace the implants, or refusing to do it free of charge, for fear of bankruptcy. They hold the government responsible for failing to stop the implants coming into the country in the first place. The Medicines and Healthcare Products Regulatory Agency say there is no evidence of cancer risk and that women need not have the devices removed. [6] The bottom line is that in a fiasco, no one wants to take responsibility because of the cost, which reduces women’s health to a political football. Madness? No, these are the consequences of failure to control private medicine.

Is there a risk of cancer if you have mattress material in your tits for the next 5, 10, or 25 years? Who knows! Who wants to wait to find out the hard way? Women who fear the further risks of more surgery in order to have them removed, for a start. How are breasts repaired after they’ve had implants in place, particularly in women who have had breast cancer and may have tissue damage from surgery, radiotherapy, and chemotherapy? This is a serious dilemma, not the sort of “choice” Andrew Lansley goes on about.

Is there a greater risk of rupture with mattress material than with approved silicone gel? How can we know when private clinics are not obliged to keep such records and, even if they do, cite “commercial confidentiality” [7] to get out of reporting what data they may have? The so-called Independent Healthcare Advisory Service, which actually represents the major cosmetic surgery companies, claims to have audited all its members about the risk of rupture, and says data showed a rupture rate “within the industry standard of 1-2%.” Who set that “standard?” The industry, of course. Is it acceptable that implants have been found to rupture on average in one to two of every 100 women who have them? Let alone in the 7% reported in a small sample of 100 patients conducted by Transform, one of the biggest cosmetic surgery companies? [8] Acceptable—absolutely not!

Silicone gel removal

Silicone gel being removed from a ruptured implant RHM 2010;18(35):96

But that’s not all. Breast implants cause a lot of problems that we rarely hear about. Last month, for example, the New England Journal of Medicine reported the case of a woman, who had had a mastectomy and later heart surgery, whose breast implant was dislodged during a Pilates breathing exercise. It migrated through the space between her ribs to sit next to a lung and had to be surgically removed and replaced. [9]

The National Research Center for Women and Families, a USA-based, non-profit research and information centre that provides information about breast implants to about 1,000 women annually, reports that all breast implants carry a risk of the following: tightening or hardening of the scar tissue around the implant (which can be painful and disfiguring); rupture of the shell holding the silicone; leaking of silicone following rupture (requiring an MRI to detect accurately and surgery to remove it); autoimmune symptoms in women whose implants have leaked; risks related to removal (this “explanting” is a rare skill even in the USA, the breast implant capital of the world); negative effects on breastfeeding; reduced accuracy of mammograms (serious especially for women who have had cancer); breaking of implants due to pressure during mammography; and the need for subsequent surgery for many of these problems. [10] And let’s not forget the absence of any requirement to provide adequate information to women considering implants in the first place.

Lastly, what does it cost? Breast enlargement at a Transform clinic, according to their website last week, costs £1000 deposit and £224.58 per month payable over one year (a total of £3694.96), or £250 deposit and £88 per month over five years (a total of £5580). This is before we begin to talk about the financial implications for women of having to pay for additional procedures to check for and repair the consequences of a rupture, leaking silicone etc, on top of the implant surgery itself. What caused this fiasco? In the UK, breast implants for purely cosmetic reasons are a highly profitable part of our burgeoning private medicine industry. Welcome to Andrew Lansley’s “new” NHS, American-style.

And now solicitors can get their share too!

PIP support ad

Advertisement appearing on a website following the PIP scandal



References
1. Latham M. A poor prognosis for autonomy: self-regulated cosmetic surgery in the UK. Reproductive Health Matters 2010;18(35):47-55.
2. Hawkes N. The Care Quality Commission: unfit for purpose? BMJ 2011;343:d8034.
3. Hansard 6 March 2008, column 1957. Reported in Latham [1].
4. Mercer N. Clinical Risk 2009;15:215-217. Quoted in [1].
5. Boseley S. Breast implant scandal: comestic surgery companies face court action. The Guardian. 11 January 2012.
6. Reported in: Keeley B MP. Breast implants: why a review is welcome [Letter]. The Guardian 3 January 2012.
7. Campbell D. Plastic surgeons facing “significant” rise in legal action. The Guardian. 9 January 2011.
8. Boseley S, Meikle J, Willsher K. Implant firms say rupture rate is within the norm. The Guardian 4 January 2012.
9. Fong TC, Hoffmann B. Disappearance of a breast prosthesis during pilates. N Engl J Med 2011;365:2305.
10. Zuckerman DM. Reasonably safe? Breast implants and informed consent [Commentary]. Reproductive Health Matters 2010;18(35):94-102.
11. At: http://www.transforminglives.co.uk/procedure-prices.html. Accessed 13-1-12.

Fighting the English Health and Social Care Bill

03/10/2011 Comments Off on Fighting the English Health and Social Care Bill

I have just written a letter to 16 members of the House of Lords, asking them to intervene and make sure the Health & Social Care Bill is thoroughly examined and if possible rejected to prevent it passing into law as it is.

The letter was designed to support the efforts of those among the Lords already working actively to subject the Health & Social Care bill to the in-depth scrutiny it did not receive in the House of Commons via a special committee, and to urge them at the minimum to find ways to substantively amend it so as to reduce the damage from its worst clauses. Even more, what I really wanted was to convince the House of Lords to reject it altogether. The bill is fatally flawed. If it is passed, even with amendments, it will turn the “NHS” in England into a mere logo.

I believe one of the reasons why the Bill did not fall in the Commons was that the opposition did not attempt to defeat it per se, but rather put forward many amendments without consensus or unity among all those who were seeking to oppose/amend the bill. Cross-party opposition was totally absent on a subject that cries out to be treated in a cross-party manner because it affects us all (though not equally). Moreover, the time for debate was so limited that it made a farce of any serious examination of the bill itself, let alone the many amendments that had been tabled.

Many people who oppose the bill called on both Labour and the LibDems in the Commons to hold a consultation with expert key parties – in the NHS, in health professional associations, civil society health advocacy groups and patients’ groups. We wanted them to draft an alternative bill for which to campaign, as well as table a united set of amendments to this bill. This did not happen, to our great disappointment.

Many people are therefore looking to the Lords to play the role it is justly famous for – stepping into the breach in a crisis and putting things right.

Here are some compelling arguments against the Bill:

My blog, 17 reasons to oppose the bill, which outlines all the forms of privatisation envisaged in the bill, none of which have been ameliorated or cancelled out by amendments in the Commons, why they are a mistake and what to support instead.

 “It’s already happened” by James Meek writing in the London Review of Books is the best description I have seen to date of the negative consequences for hospitals of privatisation of the NHS. It uses the example of what has happened over recent years to the Wrightington Hospital near Wigan and its orthopaedic centre of excellence for hip and other joint replacements.

“An unsuitable case for treatment” by Hackney GP Jonathon Tomlinson describes the serious problems that privatisation and “choice” (highly restricted in reality) have already placed in the way of his treating one of his most vulnerable and ill patients and why he believes he can no longer do what is best for his patient in the face of NHS changes.

A diary by Andrew O’Hagan, also from the London Review of Books, is about Nye Bevan and the history of the NHS, how much the proposed reforms go against the ethos of Bevan to ensure universal access to health care, and a report of his conversations with a GP at the Kentish Town Health Centre in London, who explains what a disaster it will be if GPs have to hold the purse strings locally.

These contain incredibly strong arguments and examples for any debate, and the basis for alternatives to the clauses in this Bill, and to the Bill as a whole.

There are two campaigns being run to try and influence the House of Lords: one by 38 Degrees and the other by the TUC.

Join the fight against the privatisation of the NHS!

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