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Heath policy debate

14 to 20 June 2004

After the dismal performance of Labour in the local and European elections, many Labour MPs and members are worrying about how the party can best recover. But the Conservatives suffered at the elections too and this week health was the focus for both parties to shift the debate onto domestic issues.

Both leaders focused on choice – employing very similar language – but before looking at this in more detail, contrast the backbench views of Frank Dobson and Boris Johnson on the way health policy should develop.

The Labour view
Writing in The Guardian, the former Labour health secretary asked: ‘How has a government that has achieved virtual full employment and record increases in the take-home pay of the worst-off not got the credit it deserves? How come that new and better buildings, more teachers, more doctors and nurses, improved standards of teaching and better and quicker treatment by the NHS aren't reaping an electoral reward?’

‘Its not just Iraq. Many more people have been put off by domestic policies which run counter to their basic beliefs. ‘Those interested in healthcare have been angered by the divisive introduction of foundation hospitals, the endless reorganisation and the franchising out of the simpler and more profitable services to private firms.’ ‘Ministers must recognise that another round of initiatives based on competition, diversity, choice and extending private sector involvement in the public services will do more harm than good’

‘The fundamental basis of Labour's philosophy and our electoral appeal is our commitment to equality. This includes making the best public services available to all by working together to provide them and clubbing together to pay for them. Cooperation is at the heart of that approach: hospitals or schools can strive for improvement, but they don't have to compete with one another to achieve it. Nor should we turn education and healthcare into management systems which reward some institutions and punish others… If we want to help those who are getting the worst deal, we must concentrate attention and resources on improving the least successful schools and hospitals’ [1].

The Tory view
Boris Johnson does not agree. For him, the NHS is “unimprovable” and there is no point in chucking money at flawed institutions. He is vexed by the ‘the classic posh-liberal routine’, about ‘why only the Labour Party can really be trusted with the NHS’ and the argument that it ‘It unites the nation’.

In a column for The Telegraph he recounted a story of a recent encounter with a woman he met at a dinner party expressing this view. The NHS is ‘a wonderful system, she said, and to prove her point she revealed her own recent miracle experience’. ‘She had been sitting at another dinner party, she said, and there had been this brilliant consultant dermatologist there. She told him of her affliction. She disclosed that she was troubled by a Rice Krispie on her back. The dermatologist could not have been more attentive. "Don't you worry," he told her, and to cut a long story short this noble physician somehow wangled matters so that she was able to go and see him the following morning. She had barely arrived in his consulting rooms when he whipped out his scalpel, and the Rice Krispie was gone before you could say snap, crackle and pop. "I mean," said my friend triumphantly, "wasn't that just fantastic? And it was all free! That's what you Tories don't understand about the NHS. That's why people in this country love it as it is”.’

Johnson considers this course of events as “fundamentally soviet corruption”. There are hundreds of thousands of people waiting for life-saving operations, who are never going to meet their consultant radiologists or cardiologists at dinner parties, and who have no choice but to take whatever the NHS provides, whenever it gets round to providing it. These are the people who are paying more and more in their taxes for this "unimprovable" universal service, and who find that their operations are cancelled at the last minute, because the surgeon is too busy; and all the while the affluent liberal middle classes use their clout and their contacts to get the best from the system, and then feel all gooey and warm inside because they have participated in the socialising marvel of free healthcare’.

‘Labour believe they have a monopoly on virtue and on caring and that they somehow have an ideological freehold upon the NHS. On the contrary: they are so deeply wedded to their union-based model that there is no realistic hope of reform under this government’. ‘Instead of treating patients like serfs and dolts, why not give them the same prerogatives, the same influence, as my friend who goes to dinner parties? Why not let people choose when and where they will be seen, rather than being mucked around by the bureaucrats? [2]’

Choice is marked out as the battleground in the forthcoming election
On the same day, both Tony Blair (in his monthly press conference) and Michael Howard (in a speech at the Institution of Civil Engineers) spoke about choice in public services.

Comment in The Times noted that ‘the next general election could be a lot more interesting than 2001 and more interesting than many of us had feared. Tony Blair and Michael Howard both set out where they want to fight the campaign, and it is on the same ground. The two leaders have parallel reasons for highlighting public services, to demonstrate that they share voters’ concerns. Mr Howard wants to show that he has a positive programme for voters to back, rather than just a negative list of reasons to reject Labour. Mr Blair wants to convince voters that he is not spending all his time on Iraq’ [3].

Similar language employed on the need for NHS reform
In speaking about choice, both leaders used remarkably similar language. ‘Michael Howard said, “We must let parents and patients choose what they believe is best for them and their children . . . I want to give everyone the kind of choice in health and education that today only people with money can buy.” Tony Blair said, “The challenge now is to shape services better around the needs of those who use them . . . To make sure that choice is available to the many and not just the few.

Howard presented “right to choose” as an updated version of the Tories’ 1980s theme of the “right to buy”. According to The Times, ‘this is potentially fruitful territory for the Tories, given the suspicions of many Labour MPs and advisers with the whole idea of choice and personalised services’.

Howard attacked Labour's record on schools and hospitals, arguing that Germany, Sweden and the Netherlands produced "much better results than we get here in Britain". In France, he said, there were no waiting lists and patients had "routine access to quality of health care we don't think is possible in Britain". "Choice is not a leap in the dark. It is about learning from what works best in other countries and intelligently applying it in Britain. The right to choose is the way to raise standards for all."

‘But Labour accused Mr Howard of stealing its colours over choice. Tony Blair committed the Government to expanding choice for parents over schools for their children, while an aide of John Reid, the Health Secretary, said choice in hospital care had been in operation in the NHS for more than a year and was being extended’ [4].

How much difference is there between Labour and Conservative visions of choice?
Michael Howard said Britain's health and education systems were "trapped in a time warp" and said that in the NHS, only greater choice for patients would improve standards’. He said that by 2009-10, the end of the next parliament, the Tories would have spent £49bn more in these two electorally sensitive areas than the amount earmarked for next year [5].

Attacking Tony Blair's record, he said: "The reality is that Labour have spent without real reform. That is also Labour's tragedy. It is also the country's tragedy" [6].

Yet that evening, John Hutton offered the same analysis in a speech to the British Association of Medical Managers, the failure of its traditional structures and the need for reform. The problem with the NHS was that its “centralised, top down system has frequently acted as a brake on innovation, our monolithic structures have resulted in patients receiving very little real choice over where as well as when they get their treatment [7].

Defining choice?
The day after the two leaders’ speeches, they clashed at Prime Ministers questions. A Conservative member asked, “When the prime minister uses the word choice, what does he mean?” Blair’s answer was unusually clear – to paraphrase – “it means patients can choose to go to hospitals where there are shorter waits”.

Mr Howard said his "right to choose" policy would help patients such as one of his constituents, who had to wait 369 days for a knee operation that they could have had in 33 days at another hospital. Blair countered that Labour would deliver choice within the NHS, whereas the Tory goal was to send people outside it. Rather like a football fan, baying at a supporter of a rival team, Blair said ‘"If you want the debate to be between now and election day, who cares for Britain's national health service ... come on and have it" [8]’.

How do the parties’ differ on choice?
According to BBC on-line, the debate ‘actually represented the beginnings of a proper debate about what they really mean [by choice] and where they differ from each other’ [9].

They appear to differ in two ways. First, Labour are offering a limited choice whereby patients will be offered four choices within their Strategic Health Authority boundaries with a fifth “wildcard” option that will allow the patient to be referred outside these boundaries if they are eligible. The Conservatives say choice of provider should be unlimited and open to any provider in the country. Secondly, Labour will offer patients treatment in the private sector if they provide at the cost of the NHS tariff. The Conservatives will offer provision in any private hospital and if the cost is above the NHS tariff, will pay (somewhere around) 50% of the additional cost. (The full details of both parties’ plans will be outlined on Thursday 24th June).

According to The Independent, ‘Downing Street has ordered Dr Reid to bring forward the five-year plan to next week to give the impression that the Government is regaining its momentum…It had been planned to announce new commitments to improve the NHS in July’ [4]. The fiercely Labour, Sunday Mirror predicts the five-year plan to ‘draft Michael Howard’s political obituary’ [10].

And according to The Times, the Conservatives will counter these proposals with proposals for individual care plans. ‘The announcement will go head-to-head with the Government’s five-year NHS plan…‘Doctors and nurses will be told that they can choose freely from across the NHS the best care plan to suit the individual, rather than be hamstrung by local facilities. The detail of the new policy will be published next week’ [11].

The morning after the Commons clash between Howard and Blair (Thursday 17 June) the Today programme invited Professor Allyson Pollock and Reform’s Nick Herbert to talk about what choice means [12].

Nick Herbert said the NHS was conceived 60 years ago in a far less consumerist society and people’s expectations have changed. People expect a level of service, which they don’t get from the NHS, where services are still rationed and made to queue. He believes the role of the NHS should be changed – rather than provide care, it should only guarantee access to it. The government should give spending power to patients. He cited the “liberalisation of optical services” as a good example of what he meant. “We have seen a huge polarisation of services and poor people can still access free glasses”

Allyson Pollock said this example exactly illustrated her problems with the policy. Poorer people cannot get nice frames – they are limited to “Eric Morcambe” style-frames and cannot access the same quality. The problem with choice is that “people never really have enough information to properly employ it”. Patients rely on “good professional judgement”. Current debates about choice hide the reality of what is really happening: the slow privatisation of the NHS. The problem with markets is they lead to providers selecting people rather than the other way around.

Is extending choice politically feasible – can the Conservatives extend it beyond Labour proposals?
Alice Miles, writing in The Times said, ‘In reality the current NHS reforms take it about as far as it can go without introducing different funding to finance real patient choice. That, arguably, really would be the “end” of the NHS, for the only thing that “is” the NHS any more is care free at the point of use for all. Unless a degree of co-payment, or top-up, is to be introduced to the consumer-driven NHS (and Mr Blair used to talk about that, but seems to have stopped), Labour would be better calming the rhetoric and conceding Mr Brown’s more limited concept of choice. A distinction needs to be drawn between consumer demand in healthcare and in education. There is everything to be gained from the pressure of parental choice in driving up school standards and both main parties are quite rightly moving in that direction.

But ‘in healthcare, however, they are dancing on pinheads. Given both parties’ acceptance of Mr Brown’s centralised funding formula for the health service, and their common embrace of the private sector, there is little real room for manoeuvre. Despite all the overheated rhetoric, there really is nothing much to choose between them [13].

She believes there is little scope for the Conservatives to take choice further than Labour have already. ‘Mr Howard ditched the terms "patients' passport" and "pupils' passport", and hinted at changes to the policy framed under Iain Duncan Smith’. As ‘The private sector has been forced to sharply reduce the cost of operations it performs on NHS patients; the cost to a private patient is falling too because of this downward pressure. [So] If the Tories offered to pay only 60 per cent of the cost [as was the plan in the patient passport], it would seem a bit stingy’ [13].

The Wall Street Journal (Europe edition) was also a little critical of Howard. While praising the speech, saying that if implemented properly, the policy could present a genuine alternative to the “the government’s failed strategy for the public services, it noted the inconsistency of pledging to outspend the government whilst at the same time criticising its tax and spend approach. “We’d like to think the British taxpayer is smarter than Mr Howard imagines, and would spot the inconsistency of promising greater choice while spending more of their money without asking them. And if this extra £49bn is really needed, it would make the “right to choose” more expensive than the existing set-up, a decided drawback” [14].

The chimera of choice
Steve Richards in The Independent was typical of columnists who found the debate on choice unreal. ‘Suddenly we are leaping from a long drawn out era of public squalor to a sunny land where patients and parents will be spoilt for choice’.

‘I can think of no other issue that will convey a sense that they live on a different planet than their claims about choice’. They ‘are seeking to deceive the voters by claiming that with a click of their fingers, Britain will move from a land of waiting lists and elusive GPs to one where a surplus of sparkling hospitals and eager doctors compete for our custom’.

‘In the end there is no getting away from it. Voters cannot have European-style public services and aspire to US levels of taxation’ [15].

Where will choice take us?
The NHS Confederation hosted a seminar to explore where choice will take the NHS and what it will mean for people.

Nigel Edwards was concerned about how choice will lead to implicit rationing. The implications of choice are that clinicians will have to be much more specific about the care they give to people; it will have to be codified. This is also means that what is NOT available will also have to be stipulated. We will also get into difficult debates about how choices are established – will it be determined by committee, by managers, by doctors, by democratic forums, on a practice-by-practice basis (under new proposals for practice commissioning), across PCTs, at StHA level, or will it be a national and political discussion? Edwards believes discussion will not take place at national level and here will be local variation in how these “choices” (about rationing) are made. If we are to see a return to some kind of fundholding (under practice commissioning) we will have to be aware that the sum of individual “choices” may not produce socially optimal distributions of healthcare.

He ended by posing the question: “If you don't like the commissioning patterns of your local authority then what do you do about it? [16]”

Patient’s won’t travel for GP appointments
It is important not to carried away with talk of choice and to recognise its practical limits. The Times reported that an initiative to offer “choice” has not done as well as expected

‘A network of surgeries that was set up to ensure that the Government’s [48-hour] access target for GPs was met has closed after just five months’. The idea was to make extra appointments available at other surgeries, where there was no spare capacity, so patients could travel for a consultation. But only 4 per cent of the available appointment times were taken up so the scheme has been scrapped.

‘The “virtual surgeries” scheme involved five practices in North Staffordshire being paid £500 a month to take on nine extra consultations a week at the end of their normal surgery hours. In this time GPs could see overflow patients from nearby practices who otherwise would not be seen within the government target time of 48 hours after asking for an appointment’.

‘The idea was set up to tackle a local staffing crisis among GPs, but local doctors have opposed it since its inception. Dr Keith Tattum, a Stoke GP, says: “Virtual surgeries had little to do with improving patient access to services and everything to do with the manipulation of figures to give the impression that government targets on access were being met. “They have failed because they did not address the very serious situation, which is that there are too few GPs trying to meet the demands of too many patients.”

Dr Stephen Fawcett, the clinical chairman of North Stoke primary care trust, laments: “It was an innovative idea but patients voted with their feet. They would rather see their own GP than go across town” [17]

Choice doesn’t extend to choosing to know the sex of their baby in pregnancy
‘In spite of the government's drive to give more choice to users of the health service, ministers have decided not to intervene against trusts that prefer to keep pregnant woman in the dark’.

‘The problem came to light after a north London couple were denied information about the sex of their baby after a foetal scan at Chase Farm hospital in Enfield. When they complained, they were told by Averil Dongworth, the chief executive, that it was often not easy to determine gender and a 20-minute scanning session would have to be extended to provide such information. This would be costly’.

‘When pressed on why the department's policy of choice did not extend to this area, a spokeswoman said: "There are no national guidelines. Decisions about the provision of maternity services is the responsibility of local NHS trusts. It is up to the trust to decide whether to let parents know the sex of their baby" [18].’

Plurality
The Sunday Times’ business section carried a feature on the implications of NHS plurality for the future of private medical insurance. It said, ‘the huge changes taking place in the NHS are forcing the private sector to change its business models. The companies that don’t react are unlikely to survive’.

‘The big problem facing them is that, if the state service starts to run well, there will be less demand for private medical cover’. Demand for private medical insurance grew during the 70s and 80s when the NHS was perceived to be crumbling. But it has now ‘peaked at about 12% of the population, and for the last 10 years organisations such as Bupa and PPP have struggled to grow.

Payment for one-off operations have grown and it is this area of business that private providers are now focusing on. Adrian Norris of Mellon’s human resources and investor solutions group, believes that while the changes pose a challenge for medical insurers, they will also create opportunities. He said, “We may see the beginning of a third tier in the health-insurance market. You have the NHS free at the point of service, the top-level gold-plated service and potential for a middle range service with perhaps a narrower choice. “This may involve being looked after by a salaried surgeon rather than a Harley street surgeon. It could become a stack ‘em high, sell ‘em cheap private environment and priced accordingly”.

The article concludes, ‘there is little doubt, however, that the long-term trend is for huge changes to take place in the health service. The market will become more open and competitive, which will lead to lower costs. It will need strong leadership fro the private sector to steer a profitable course through the health revolution’ [19].

How can we be sure that the NHS is getting better?
The Government has spent a lot of time trying to convince the public that the NHS is improving. It faces accusations that it does not have a lot to show for its investment. An opinion piece in The Times’ Public Agenda - written by Camilla Cavendish, the same journalist who chaired the NHS Confederation seminar on choice, cited earlier - questioned official statistics and in particular the political pressure that can change their presentation.

‘Confronted on a recent Today programme on Radio 4 with the same old figures that suggest that NHS productivity is plummeting, John Reid, the Health Secretary, suddenly announced that NHS productivity was in fact rising, at 1.5 per cent a year. Good news! But where did he get the figure?’

Mr Reid’s throwaway remark was a curious pre-emption of the Atkinson review, which is developing new measures for public sector productivity but has not yet reported. Its basis seems to be the preliminary work done by the Department of Health, which led Sir Nigel Crisp, the NHS chief executive, to say in December: “we estimate that (NHS) productivity is increasing at the rate of around 1 per cent a year”. Hey, what’s 0.5 per cent between friends? Or an estimate versus a certainty?

The current measure of NHS productivity is not perfect. Measuring consultant episodes does not reflect, for example, the Government’s success in keeping heart patients out of hospital by prescribing statins. A better measure is needed: but “better” should mean more accurate, not more helpful politically.

In an age of managerial politics, the numbers take on enormous, almost unhealthy, importance. The Government is furious at the bean-counters’ insistence that public sector productivity has slumped since 1997, despite massive injections of cash. A leaked memo to the Cabinet Committee in March implied that £20 billion a year was being wasted on bureaucracy and soaring wage claims, at the expense of frontline services. It was perhaps hardly surprising that the committee asked the ONS to review the way it compiled the figures. But it was shocking that the Committee asked the ONS to do so urgently, in order to develop a more “credible story ” in the run-up to the next election.

‘Surely it is time to set up a genuinely independent statistical office which serves the interests of the citizens who finance it — which helps the politicians restore credibility — and which is prepared to admit to the odd statistical error’ [20].

Service and organisational development
Have general hospitals ‘had their day’?
The NHS Confederation this week initiated a debate on the future of hospitals, which will be explored further at its annual conference (23rd to 25th June). Nigel Edwards, its director of policy, wrote a think piece for The Guardian’s Society section.

It began, ‘though most public contact with the NHS takes place in primary care, hospitals dominate the debate and take pride of place in many local communities.
But public affection and political reticence are conspiring to prevent a vital debate about hospital services that now needs to be aired. It is time for the public to ask whether the district general hospital has had its day’.

‘There are a number of other pressures on hospitals, which means that, in the future, not all will be able to deliver the full range of services that the public has come to expect. Developments in medicine mean there is a long-term shift towards much greater specialisation, with individual clinicians covering a smaller number of conditions. This points to the development of centres of excellence, where hospitals serve much larger populations than in the past. At the same time, smaller hospitals are also hit hardest by the European Working Time Directive, which cuts doctors' hours and makes staffing rotas much more difficult’.

‘However, this centralisation of hospital services is not without its problems. Super-hospitals are capital intensive and take time to build. They are difficult to run, and it often proves awkward to discharge patients because of the distance from their homes. But perhaps the most significant objection is that many of the arguments for centralisation make the assumption that, in the future, hospitals will work in exactly the same way as they do now’.

‘To achieve this, we must challenge the belief that specialists need to be tied to an institution. Instead, we should see specialists as part of networks that span hospitals. The specialists can visit or, in some cases, provide advice through electronic links to support generalist physicians and nurses who are expert in the management and rehabilitation of patients with acute illness. Local hospitals need to take on a bigger role in caring for the large number of patients they see with long-term conditions [21].

Electronic prescribing
In the context of reports of wide variations around the country for the take-up of newer cancer drugs, Lord Warner announced that ‘the national plan to allow hospitals and family doctors to handle all prescriptions electronically is to be brought forward to 2006, rather than being introduced over two years from 2008’.

Lord Warner said electronic prescribing would provide far better data for auditing the quality of care, and for establishing why some doctors were not following guidelines from the National Institute for Clinical Excellence on which treatments they should be prescribing.

Cancer tsar, Mike Richards said that the "unacceptably high variations" in access to cancer drugs appeared to be caused less by lack of money than lack of capacity - for example the absence of a suitable space to prepare or administer what were often highly toxic drugs, or shortages of specialist pharmacists, nurses, or doctors. Variations in doctors' views of how useful the new products were remained, despite the institute's guidance [22].

John Reid said, "If we can tell doctors in one area that they seem to be using a particular drug much less than colleagues elsewhere, that provides a trigger for them to reassess their own practices and often leads to improved levels of use” [23].

Doctors to text patients?
Researchers in Italy have conducted a successful pilot scheme monitoring the health of cancer patients through mobile phone text messages. They have reported the results in the journal, ‘Medical Informatics and Decision Making’.

‘The researchers, from Italian communications company Reply and the Istituto Nazionale Tumori in Milan, have developed and tested a wireless patient monitoring system using short questionnaires sent to patients' phones’, which are answered without having to leave their homes. ‘The researchers hope it will help doctors to discover a patient's suffering or any change in their symptoms from a distance’.

The questions ask patients to rate symptoms such as weight loss, shortness of breath and having trouble sleeping. The results are gathered and presented on a secure web page which gives the doctors a quick overview of how their symptoms are evolving. ‘Any serious changes in symptoms causes a flashing light to appear next to a patient's name, which can help doctors prioritise those in most serious need of intervention’. However, 42% of those patients asked to take part in the trial refused to participate, mostly because they were not experienced in the use of mobile phones.

The researchers, write, "The wide and growing use of mobile phones and the internet by the general population provides important new methods for communication between doctor and patient." ‘The researchers said the next step was to show that the system was useful to patients and doctors so that it would be accepted by clinicians’ [24].

References
1. Dobson, F., Change course or face defeat, in The Guardian. 15 June 2004. p. www.guardian.co.uk/comment/story/0,3604,1238851,00.html accessed same day.
2. Johnson, B., I snap, crackle and pop at this view of the NHS. The Telegraph, 17 June 2004: p. accessed same day.
3. Riddell, P., Leaders agree on one thing: the battlefield, in The Times. 16 June 2004. p. http://www.timesonline.co.uk/newspaper/0,,172-1147172,00.html accessed same day.
4. Woolf, M. and C. Brown, Howard promises consumer choice in schools and health. The Independent, 16 June 2004: p. http://news.independent.co.uk/uk/politics/story.jsp?story=531962 accessed same day.
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6. BBC-online, Howard stresses 'right to choose'. BBC News, 16 June 2004: p. http://news.bbc.co.uk/1/hi/uk_politics/3808065.stm accessed same day.
7. Hutton, J., Speech to the British Association of Medical Managers. 15 June 2004.
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9. Assinder, N., Prime ministers questions. BBC News on line, 16 June 2004: p. http://news.bbc.co.uk/1/hi/uk_politics/3812061.stm accessed same day.
10. Leader, Saving the NHS will kill off Howard. Sunday Mirror, 20 June 2004: p. 14.
11. Charter, D., Parties fight on common ground of the NHS. The Times, 17 June 2004: p. www.timesonline.co.uk accessed same day.
12. Today, Nick Herbert and Allyson Pollock debate the meaning of choice. BBC Radio 4, 17 June 2004.
13. Miles, A., The choice of NHS choices is a passport to confusion. The Times, 16 June 2004: p. www.timesonline.co.uk/newspaper/0,,172-1147093,00.html accessed same day.
14. Leader, Howard must decide if he is a supply sider or a Keynesian. Wall Street Journal (Europe), 17 June 2004: p. 8.
15. Richards, S., The chimera of hoice: how both Labour and the Tories are deluding the public. The Independent, 17 June 2004: p. 35.
16. Kelsey, T. and N. Edwards, Where will choice take us. 16 June 2004, NHS Confederation seminar.
17. Health, Patient's shun 'virtual clinic', in The Times. 15 June 2004. p. Public Agenda: 4.
18. Carvel, J., Health chiefs defend right to withhold baby's gender, in The Guardian. 15 June 2004. p. http://society.guardian.co.uk/health/story/0,7890,1238972,00.html accessed same day.
19. Waples, J., Private medicine needs surgery. The Sunday Times, 20 June 2004: p. www.timesonline.co.uk/printFriendly/0,,1-421-1153057,00.html.
20. Cavendish, C., Public Opinion, in The Times. 15 June 2004. p. Public Agenda: 3.
21. Edwards, N., Our beloved general hospitsl will soon be a thing of the past. Society Guardian, 16 June 2004: p. http://society.guardian.co.uk/nhsplan/story/0,7991,1239408,00.html accessed same day.
22. Timmins, N., Electronic scheme to handle medicines advanced, in Financial Times. 15 June 2004. p. http://search.ft.com/s03/search/article.html?id=040615001161 accessed same day.
23. Stephenson, P., 'Unacceptable' variation in access to cancer drugs, in The Guardian. 15 June 2004. p. http://society.guardian.co.uk/cancer/story/0,8150,1238569,00.html accessed same day.
24. Stephenson, P., GPz 2 txt 4 health. The Guardian, 15 June 2004: p. http://society.guardian.co.uk/primarycare/story/0,8150,1239280,00.html accessed 17/6/04.