Health Secretary Jeremy Hunt delivers a speech during his visit to the Evelina London Children's Hospital on July 5, 2013. Photograph: Getty Images.
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NHS privatisation isn't working, it’s time for a more mutual solution

Mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner.

As much as many of us would like to ignore the fact, our National Health Service is at the most critical juncture in its long history. An ever-ageing population, together with the stark rise in prevalence of those suffering from lifestyle diseases, both place our healthcare system on a financially unsustainable footing. Indeed, long-term conditions, such as obesity and diabetes, will alone bankrupt the NHS within a decade, with a £19bn funding gap expected if these conditions are not managed properly.

Yet from government there seems to be a lack of good ideas on how to ensure that NHS remains viable as an institution free at the point of use. Many of the arguments surrounding health reform suggest that the solution to this financial crisis is a laughably simple one – more liberalisation. The trend towards NHS liberalisation, which started with Margaret Thatcher and continued with the Health and Social Care Bill, has been at the heart of health reform over recent decades. This trend is based upon the proposition that is all that is needed to improve NHS services is to open up the system to private sector providers. Then competitive forces will, as if by magic, improve patient quality whilst making the necessary savings.

But although competition in certain cases is to be welcomed, it is alone insufficient to tackle the health systems incoming problems. The complex conditions of the future will require a different type of healthcare, delivered by a different healthcare system. The NHS of the past, which was designed to combat acute diseases like polio and tuberculosis, is simply not configured to treat the chronic diseases associated with ageing and flawed lifestyle choices. These conditions require more integrated forms of service delivery that provide holistic, whole-person care.

It has long been known that integrated care is the holy grail of NHS reform. Yet the coalition government has failed to make this a top priority, and the cancellation of the £3.8bn Better Care Fund is clear evidence of this. In fact, instead of choosing the harder path towards better healthcare integration, the government has opted for and prioritised yet more liberalisation in the form of the Any Qualified Provider programme.

This initiative is intended to open up services and improve patient choice. Under this scheme, private providers are allowed to deliver basic NHS services. At a first glance, by the government’s standards the programme seems to have been a success, with 105 firms singed up to the scheme. But instead of opening up the service to smaller providers, as was first intended, the process has been criticised for prioritising the larger providers. A study of AQP found that 24 of the 105 firms were large companies with at least 250 members of full-time staff.

AQP is not the answer to integrated care, as it merely atomises and fragments care by multiplying the number of bodies delivering healthcare. In this way, it simply destabilises existing services and damages care pathways. It cannot, therefore, deliver the whole-person care we need. Because of this, we at ResPublica ask that the government seriously consider scrapping the Any Qualified Provider scheme. Competition and choice are to be welcomed, but they should not come at the price of collaboration and holistic care. We would instead argue for a different approach.

In our latest report, Power to the People: The mutual future of our National Health Service, we argue that mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner. Mutual organisations are, by their very nature, democratic and benevolent institutions. As such, they are perfectly placed to integrate the needs of patients with the capabilities of clinicians in an inclusive fashion.

Such a proposal is not an odd suggestion. Mutuals already have a firm foothold in the NHS. Foundation Trusts, which operate on a mutual model, are now the standard composition for hospitals, and mutual NHS spin-outs are raising standards across the sector. One type of mutual organisation that has often been ignored, but could perhaps perform such a vital role, is the friendly society.

Before the advent of the NHS, most healthcare was provided through friendly societies. Just before the onset of the Great War, there were 26,877 friendly societies operating in England and six million members. The democratic and inclusive characteristics of these organisations would make them ideal candidates for performing an integrator role that would connect disparate elements of the NHS to deliver the holistic care our older people need.

As the report makes clear, the financial benefits of this model could be vast. By integrating care, we estimate that the NHS could save £4.5bn by 2020. Embracing mutualism would not only integrate care and deliver better outcomes, it would have significant financial benefits as well. Clearly, if we are to have the integrated care that so many of us need, then policy makers will have to ditch their fixation with ever increasing liberalisation and assess the benefits more mutualism could bring to the NHS.

Adam Wildman is research manager at ResPublica 

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Inside Big Ben: why the world’s most famous clock will soon lose its bong

Every now and then, even the most famous of clocks need a bit of care.

London is soon going to lose one of its most familiar sounds when the world-famous Big Ben falls silent for repairs. The “bonging” chimes that have marked the passing of time for Londoners since 1859 will fall silent for months beginning in 2017 as part of a three-year £29m conservation project.

Of course, “Big Ben” is the nickname of the Great Bell and the bell itself is not in bad shape – even though it does have a huge crack in it.

The bell weighs nearly 14 tonnes and it cracked in 1859 when it was first bonged with a hammer that was way too heavy.

The crack was never repaired. Instead the bell was rotated one eighth of a turn and a lighter (200kg) hammer was installed. The cracked bell has a characteristic sound which we have all grown to love.

Big Ben strikes. UK Parliament.

Instead, it is the Elizabeth Tower (1859) and the clock mechanism (1854), designed by Denison and Airy, that need attention.

Any building or machine needs regular maintenance – we paint our doors and windows when they need it and we repair or replace our cars quite routinely. It is convenient to choose a day when we’re out of the house to paint the doors, or when we don’t need the car to repair the brakes. But a clock just doesn’t stop – especially not a clock as iconic as the Great Clock at the Palace of Westminster.

Repairs to the tower are long overdue. There is corrosion damage to the cast iron roof and to the belfry structure which keeps the bells in place. There is water damage to the masonry and condensation problems will be addressed, too. There are plumbing and electrical works to be done for a lift to be installed in one of the ventilation shafts, toilet facilities and the fitting of low-energy lighting.

Marvel of engineering

The clock mechanism itself is remarkable. In its 162-year history it has only had one major breakdown. In 1976 the speed regulator for the chimes broke and the mechanism sped up to destruction. The resulting damage took months to repair.

The weights that drive the clock are, like the bells and hammers, unimaginably huge. The “drive train” that keeps the pendulum swinging and that turns the hands is driven by a weight of about 100kg. Two other weights that ring the bells are each over a tonne. If any of these weights falls out of control (as in the 1976 incident), they could do a lot of damage.

The pendulum suspension spring is especially critical because it holds up the huge pendulum bob which weighs 321kg. The swinging pendulum releases the “escapement” every two seconds which then turns the hands on the clock’s four faces. If you look very closely, you will see that the minute hand doesn’t move smoothly but it sits still most of the time, only moving on each tick by 1.5cm.

The pendulum swings back and forth 21,600 times a day. That’s nearly 8m times a year, bending the pendulum spring. Like any metal, it has the potential to suffer from fatigue. The pendulum needs to be lifted out of the clock so that the spring can be closely inspected.

The clock derives its remarkable accuracy in part from the temperature compensation which is built into the construction of the pendulum. This was yet another of John Harrison’s genius ideas (you probably know him from longitude fame). He came up with the solution of using metals of differing temperature expansion coefficient so that the pendulum doesn’t change in length as the temperature changes with the seasons.

In the Westminster clock, the pendulum shaft is made of concentric tubes of steel and zinc. A similar construction is described for the clock in Trinity College Cambridge and near perfect temperature compensation can be achieved. But zinc is a ductile metal and the tube deforms with time under the heavy load of the 321kg pendulum bob. This “creeping” will cause the temperature compensation to jam up and become less effective.

So stopping the clock will also be a good opportunity to dismantle the pendulum completely and to check that the zinc tube is sliding freely. This in itself is a few days' work.

What makes it tick

But the truly clever bit of this clock is the escapement. All clocks have one - it’s what makes the clock tick, quite literally. Denison developed his new gravity escapement especially for the Westminster clock. It decouples the driving force of the falling weight from the periodic force that maintains the motion of the pendulum. To this day, the best tower clocks in England use the gravity escapement leading to remarkable accuracy – better even than that of your quartz crystal wrist watch.

In Denison’s gravity escapement, the “tick” is the impact of the “legs” of the escapement colliding with hardened steel seats. Each collision causes microscopic damage which, accumulated over millions of collisions per year, causes wear and tear affecting the accuracy of the clock. It is impossible to inspect the escapement without stopping the clock. Part of the maintenance proposed during this stoppage is a thorough overhaul of the escapement and the other workings of the clock.

The Westminster clock is a remarkable icon for London and for England. For more than 150 years it has reminded us of each hour, tirelessly. That’s what I love about clocks – they seem to carry on without a fuss. But every now and then even the most famous of clocks need a bit of care. After this period of pampering, “Big Ben” ought to be set for another 100 or so years of trouble-free running.

The Conversation

Hugh Hunt is a Reader in Engineering Dynamics and Vibration at the University of Cambridge.

This article was originally published on The Conversation. Read the original article.