"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Saturday, 12 April 2014

What I would have said

Norman Lamb was on BBC Radio 4 Any Questions last night. The things he said about the NHS made me decide to call Any Answers today to refute his assertions. I called their number and spoke to a researcher who noted my response and said she would pass it on to a producer. I was then called back by a producer who checked my details but warned me that there was unlikely to be the time to discuss the NHS on this edition. She was right, the public apparently are more interested in a fiddling minister, an English Parliament or the middle class habit of taking kids on holiday in term time than the NHS.

This is what I told the researcher, and I would have said on air.
I am calling to refute the statement from Norman Lamb that the NHS is "horribly fragmented" and that his government is moving to a "joined up system". The effect of Norman Lamb's government's policies are that we are going in the opposite direction, the system getting more fragmented, not more integrated as Lamb claimed.
I have had diabetes for 40 years and for the last 20 years I have had diabetic eye disease - retinopathy. I use diabetic services in my local hospital, I use services at their eye clinic and I use GP diabetic services. Before the election all three services were commissioned by one commissioner, the local Primary Care Trust. The commissioner plans a service and ensures that patients are able to access the service, and since there was one commissioner this meant that they could decide which services were carried out in hospital and which were provided by GPs.
Since the Health and Social Care Act was enacted last April my care is commissioned by three different commissioners. The local Clinical Commissioning Group commission diabetic hospital services, the NHS England Area Team commission GP services and Public Health England commission the monitoring of my diabetic eye disease. Three different commissioners instead of one. Norman Lamb talked about "treating the whole person" but his policies have made that more difficult because there are three commissioners instead of one. I know where the CCG is located because the CCG are high profile, the other two organisations are not. I have only just found out that the NHS England Area Team who commission GP services are based 40 miles away from where I live and they commission GP services for 1.6 million people. GP are a thoroughly local service but are now commissioned by a remote and aloof organisation. I still do not know where Public Health England are based, they keep themselves to themselves.
These three commissioners do not work together. I know this because my local CCG have announced that they intend to cut the number of hospital diabetic outpatients appointments by a third, but when I asked at their public board meeting if they will ensure that local GPs have the skills to care for these diabetics denied access to the hospital clinic, I was told: "we do not commission primary care". So the CCG are allowed to decommission services at the local hospital without first ensuring that local GPs will be able to care for the patients from the cut service. If the PCT had decided they wanted to move services out of the hospital they would have been able to do this because they commissioned both hospital services and primary care.
The result of the mess of my care being commissioned by three different organisations who do not talk to each other is that NHS services are becoming far more fragmented.

Sunday, 23 March 2014

Sweet Tea and Diabetic Wee

Thirty eight years ago, aged eleven, I was discharged after a week in hospital. I was sent home with a glass syringe, a plastic tub and a bottle of surgical spirit to store the syringe, five reusable needles (a year's supply), a couple of bottles of insulin and a chemistry set.

I had been diagnosed with juvenile onset diabetes, later called insulin dependent diabetes and now known as type 1 diabetes. Simply put, my body had ceased to make any insulin and so I could no longer control my blood sugar. The treatment was to inject insulin refined from the pancreases of cows. The chemistry set was so that I could determine whether I was injecting the right amount of insulin. It contained a test tube, an eye dropper and a bottle of tablets containing caustic soda and copper sulphate. Five drops of urine, ten drops of water, then drop a tablet in the tube and wait 30 seconds while it fizzed and turned the liquid a colour between blue (no sugar: good) and bright orange (2% sugar: bad). The value was recorded in a notebook to show the consultant at the six monthly appointments. Although it is almost forty years ago, I remember my book was littered with 1% and 2% readings.

Just think about this: regularly, 2% of my urine was sugar. If a teaspoon holds about 4g of sugar, and a mug of tea is about 200ml, a mug of tea with a teaspoon of sugar is about 2% sugar. On a regular basis, my urine was as sweet as your tea*. (Diabetes mellitus comes from the Greek word diabetes meaning siphon - to pass through - and the Latin word mellitus meaning honeyed or sweet, in other words sweet urine.)

To get that sweet, empirical measurements show that on average my blood sugar would have to be about 12 mmol/l and this is about double the recommended level for a diabetic. The urine tests gave results up to 2%, so when I got the bright orange result it mean that the concentration of sugar in my urine was 2% or more. Since the test didn't show a value higher than 2% I have no way of knowing how high my urine sugar really got. (In fact, I now know that I could have repeated the test with two drops of urine rather than five, and this could have measured up to 5% of sugar.) I was also prescribed urine dipsticks to test for ketones. Ketonuria occurs when the body breaks down amino acids to get energy rather than glucose, and in a diabetic this can occur when blood sugar is over 15 mmol/l (due to too little insulin). From memory, I occasionally detected ketones, so my blood sugar was likely to be three times or more the recommended level.

The problem with urine testing is that it is hours after the fact. My bladder could have several hours of urine (eight, for the early morning pee) and hence my blood sugar could be high for all of this time. Worse, four decades ago, there was not the concept of taking an adjustment dose of insulin to correct a bad result. Re-usable needles meant that injecting was an unbearable pain, and blunt needles (and the impure animal insulin) affected the injection sites (scarring and fat loss) so it was always best to have as few injections as possible. For the first ten years I had two injections a day: one before breakfast and another before dinner. Consequently, without an adjustment dose, a high urine test could mean a high blood sugar for at least half a day. Controlling blood sugar in the 70s and 80s was not easy.

These days diabetics have finger prick blood testing monitors, so we can instantaneously test blood sugar, we also have insulin pens that can accurately deliver small adjustment doses of insulin and (the most significant innovation) we have sharp needles. Controlling blood sugar, though easier, is still not easy because injected insulin does not act immediately, and (depending on the type of insulin) it may continue to affect blood sugar for a couple of hours. Further, some foods are digested quicker than others and hence affect blood sugar in different ways. Managing diabetes is always a case of finding out what works and then sticking with it. Change is the worst word in a diabetic's life.

In my next blog I will describe the issues with the controlling diabetes using finger-prick blood glucose tests, and what could be done to improve the situation.

[*] This is all very approximate, but figure 1 in this paper suggests that 2% Clinitest represents between 2.5g and 4.5g (say about 3g) in 100ml of urine, which means my urine was as sweet as one and a half teaspoons of sugar in a mug of tea.

Saturday, 22 February 2014

Are You Involved?

Whose Patient Are You?

There really is just one type of patient: a patient. A patient is a person who is ill and needs care, simple as that. It could be elective or emergency care, but it is still care. It could be a single episode, or a lifetime of treatment for a long term condition, but it is still care. The patient is the receiver of care.

When pushed, I would set up a dividing line between NHS and private patients for the simple reason that private patients have made a conscious decision that they want to opt out, and are choosing not to be the same as everyone else. People who choose to have private care have the same rights to NHS care as the rest of us, but they choose - for a variety of reasons - not to exercise those rights. It is their choice, but they can opt back in any time they like. However, for the rest of us, private care is not an option, which is why it is so important to defend our access to the NHS and to get involved in the improvement of NHS care.

Thus, there are just two types of patients: private patients and NHS patients. This is pertinent to this blog because this is about public and patient involvement which is a concept unique to the NHS. The relationship private patients have with their healthcare provider is a simple customer-provider relationship, if you do not like the service you take your money to another provider. The relationship an NHS patient has with their healthcare provider is far more complicated than this. NHS patients do not have control of the money spent with providers and I would argue it is incredibly important that they don't. The reason is that providing good care is very different to providing a profitable service. Many NHS services cost more than the money provided, so "taking your money elsewhere" is often a case of "taking the deficit elsewhere".

Which Parts of the NHS Do You Use?

The NHS is often viewed by managers and politicians as primary, secondary and tertiary care, but from the patients perspective this is either GPs (primary care) or hospitals (secondary and tertiary care). There is also a dividing line between acute (or physical health) and mental health; and typically, if you have a mental health issue which results in hospitalising that will be in a mental health hospital even if you have a physical health condition that would otherwise mean that you should be in an acute hospital. In addition, there is a grey area within the NHS: community health services. As the name suggests these are services delivered in the community, in small clinics or in the patient's home. Community services are largely a historical relic of local authority involvement in healthcare before the establishment of the NHS. You could argue that community services are primary care that should be delivered by GPs, or alternatively, you could argue that they are step-down services of hospitals, and in some cases (like Continuing Healthcare) hospital services delivered in the patient's home. In some areas community services are delivered by acute hospital trusts, in others they are delivery by mental health trusts, and in others they are delivered by private companies.

To us patients, we need care from the NHS as a whole. We may have physical or mental issues, we may need episodic care or have a long term condition needing long term care. We may need the care in our homes, in a GP surgery, a community clinic or in a hospital. In all cases we are simply a patient. Treating us as a patient rather than a consumer of multiple services is the philosophy behind whole person care.

Getting Involved

Public and Patient Involvement (PPI) is a legal responsibility of NHS organisations. The Health and Social Care Act 2012 (HSCA) created two new commissioners, NHS England and Clinical Commissioning Groups (CCGs) and the Act created a responsibility for PPI for both (as outlined in this document by National Voices). Section 23 and section 26 of the Act, add section 13H and two sections 14U and 14Z2 to the NHS Act 2006 to place a duty of PPI on, respectively, NHS England (called "The Board" in the Act) and CCGs.

PPI is a legal requirement of NHS commissioners and there are requirements for NHS providers to have patient involvement too; private providers of NHS care do not have to have PPI and consequently do not.

An NHS England Patient?

NHS England commissions primary care (GPs, opticians, dentists, pharmacies), care for prisoners and military personnel. They also commission tertiary care and care for rare conditions. The HSCA places a duty for NHS England to "promote the involvement of patients, and their carers and representatives (if any)" in the decision making of "the prevention or diagnosis of illness in the patients" and "their care or treatment". NHS England has put some effort into the PPI for rare conditions but have been largely quiet about the much bigger issue of PPI in the commissioning of primary care. Primary care is commissioned on a regional basis by the so-called Area Teams. These rather shadowy groups do not hold meetings in public and their board papers are not published, so the public do not know what these groups are doing, nor able to challenge their decisions.

Logically, the Area Team should be recruiting patients through GPs, opticians, dentists and pharmacies because they commission the services patients use from these providers, but there is little evidence that Area Teams are doing this. If you want to be involved in the commissioning carried out by your Area Team there is little information about who to contact.

Shadowy is perhaps being too kind to them, the Area Teams seem to want to avoid the public entirely.

A Clinical Commissioning Group Patient?

Clinical Commissioning Groups commission secondary care (ie hospital care), mental health, GP out of hours services, urgent care services like ambulance and 111, and community services. CCGs are membership organisations in that every GP practice has to be a member of a CCG. (These GP members of CCGs are involved in their decision making, but unfortunately the so-called members councils emulate NHS England by meeting in secret and refusing to publish their minutes.)

The new section 14U that the HSCA adds to the 2006 NHS Act a duty to promote PPI on CCGs, and in addition it says that NHS England should publish guidance on how CCGs should do this. This statement appears to be the case of the tail wagging the dog: CCGs can tell NHS England a lot more about PPI than the other way around. The new section 14Z2 goes into more detail about the responsibilities of CCGs. This says that patients should be involved "in the planning of the commissioning arrangements" and in the "changes in the commissioning arrangements" of the CCG.

As part of their authorisation CCGs had to provide their PPI strategies to, and these be approved by the largely PPI-free NHS England. Consequently every CCG has some form of Patient Participation Group (PPG), and most of these are based upon the PPGs of their member GP practices.

A GP Practice Patient?

General Practices have had PPGs for many years. PPGs are paid for through Directed Enhanced Services (DES) (until the end of this financial year) so GPs are actually paid to provide them. Most practices take this money because they recognise the benefit that patient feedback from a PPG can provide. One requirement of the DES payments is the annual patient survey which practices can use, through locally determined questions, what patients want and how the practice can improve their facilities and services.

There is another distinct advantage that practices gain from having a PPG that GPs are only now starting to realise: CQC. If a practice is CQC inspected the first thing the inspector will ask is "can I talk with your PPG?". A negative response is not going to allow the rest of the inspection to go well, and, as practices are starting to learn, a friendly PPG can do wonders for their CQC rating.

Or A Foundation Trust Patient?

Foundation Trusts (FTs) are a special case because they are the only part of the NHS where there is elected patient representation. Foundation Trusts have a membership (usually opt-in for public and patient membership, but opt-out for staff membership). The membership elects governors to the FT's Council of Governors. More than half of the Council must be public or patient elected governors and the remainder of the Council are elected staff governors and stakeholder appointed governors. The public and patient elected governors represent the constituencies that elect them but the HSCA (section 151(4)) says that in general governors "represent the interests of the members of the corporation as a whole and the interests of the public" (the "corporation" here refers to Public Benefit Corporation which is the legal term for a Foundation Trust).

In general governors have a responsibility "to hold the non-executive directors individually and collectively to account for the performance of the board of directors". Foundation Trust Board of Directors meetings must be held in public (section 152(5)) however, as a public body it means that the Foundation Trust can use the Public Bodies (Admission to Meetings) Act 1960 to exclude the public (which includes governors) from parts of the Board meeting where it "would be prejudicial to the public interest by reason of the confidential nature". In spite of this, Foundation Trust governors have a right (section 152(4)) to have access to all Board minutes including the minutes of the confidential section of the Board from which they are excluded, so although governors cannot attend the confidential section, they can see what was said.

Other than the general responsibility to hold non-executive directors "to account for the performance of the board of directors", there are specific responsibilities. For example, if a Foundation Trust intends to increase its income from private patients by more than 5% of the total income of the trust (an event that is as a rare as finding a hen's tooth) more than half of the Council of Governors must approve. In addition, governors must inform the Board of Directors whether it is satisfied that treating private patients "will not to any significant extent interfere" with the treatment of NHS patients (section 164(3)). This last responsibility is fairly toothless because governors do not have any power to stop an FT from treating private patients.

The two most powerful powers of governors are to appoint and remove non-executive directors, and to determine whether significant transactions should go ahead. Governors appoint the non-executive directors (NEDs, including the Chair of the trust) and can remove them, governors also determine the pay of these directors. NEDs are members of of the Board of Directors, and board decisions are made collectively by all directors. NEDs do not have an operational role, they do not manage the trust, instead their role is to challenge the executive directors. NEDs also form the appointments committee that appoint, and determine the pay of the executive directors. Although the NEDs appoint and remove the chief executive, governors have to approve such decisions. Possibly the most powerful responsibility of governors is covered by the term significant transaction (section 167). The Foundation Trust can only enter into a significant transaction if more than half of governors approve. The Act does not define what a significant transaction is other than saying that they must be specified in the trust's constitution. Any changes to the constitution must be approved by Governors and the trust Board of Directors.

What About Private Providers?

The government says that there is a "fair playing field" when it comes to commissioning services, however, the one area where the playing field is not "fair" is where it comes to patient involvement and patient representation. There is no legislation that requires private providers to involve patients in the provision of the care they provide. There is no legislation that requires private providers to have public board meetings or publish their board minutes. If the provider is a charity or a social enterprise, they will have their own rules about patient involvement, however, usually such third sector providers behave as if they are private businesses when providing NHS commissioned services.

If you are offered an NHS service from a private provider bear in mind that no patient was involved in designing the service. No patient is involved in the continuing improvement of the service nor in holding the senior management to account for the service. As a patient you will not have an opportunity to be consulted about the provision of the service. All of this is worth bearing in mind before you consider using a private provider for your NHS care.

So What Sort Of Patient Are You?

If you want to get involved in the planning and delivery of NHS services, you have lots of opportunities. The problem is that the different parts of the NHS do PPI in different ways and some parts (particularly commissioners) define involvement as "help us performance manage those other people". When you combine this with the total lack of PPI in the private sector, it all adds up to a mess.

Patient involvement in improving services come from two perspectives: the provider and the commissioner. The commissioner designs the service and monitors delivery, patients can be involved in the designing of a service, and as the recipient of the service, they can be involved in feeding back how well the service is performing. Commissioners monitor services to enforce the contracts they have with the providers, most contracts have some kind of penalty or incentive and often patient feedback is involved in these. Contractually, providers clearly want to avoid the penalties and gain the incentives, so patient participation is important to them.

For example, patients join a GP practice PPG to help improve the services at the GP practice from a provider's perspective. GPs are mostly commissioned by NHS England Area Teams (there are a few GP services that CCGs commission) but the lack of PPI in Area Teams means that there is little commissioner patient involvement in improving GP services. It is very clear that patients join GP PPGs to improve GP services, if they want to improve hospital services the obvious route is to join a hospital PPG (or equivalent PPI). However, most CCGs draw from GP PPGs to form their own patient groups. CCGs do not provide services, and they do not commission GPs, so a patient who joined a PPG to be involved in the improvement of their GP services will find that they are asked by the CCG to improve services they originally did not volunteer to be involved with.

CCG patient participation groups are involved in the commissioning, and improving, of hospital services, mental health services, community services, urgent care services and out of hours through the commissioner-provider relationship. In other words, very few services that involve GPs.

Conflicts of Interest

Commissioners are quite open about that they will use the contract with the provider as a lever to improve services: threats of commissioning another provider, or moving the service to the free-for-all that is Any Qualified Provider. Collaboration has largely disappeared due to the recently introduced procurement regulations.

Gone are the days when the patient group of a provider could collaborate with commissioners to improve the service. The patients of a provider's PPG will have direct experience of the service and are a valuable resource: a patient involved with a public sector provider will have more experience about the service being commissioned than a patient who is not involved with the provider. Thus, it makes a lot of sense for a CCG to involve those patients in redesign of those services. Similarly, if a CCG wants to improve a service, the best course of action would be to consult the existing service provider, since that provider will be more of an expert about the delivery of the service than the commissioner. However, CCGs wary of litigation under the new procurement regulations are reluctant to seek advice from those providers and their patient groups because they may appear to be giving unfair competitive advantage to those providers. From a PPI perspective, if a CCG involves a patient in commissioning and that patient is a member of a PPI group at a provider, that could be regarded as being anti-competitive.

It works the other way around too: there is no incentive for an existing provider to help design services if those services will be put out to competitive tender with the possibility that the provider may not win the tender. The new procurement regulations are a barrier to the improvement of services.

CCGs are rather inconsistent in applying the strictures of the procurement regulations. CCGs can commission Locally Enhanced Services from GPs, and these may replace services formerly delivered in secondary care (so-called "move services to the community"). Since CCGs are membership organisations where the members are GP practices, CCGs have to take steps to prevent "conflict of interest" when awarding LES to member GPs. However, these steps are usually just for show. For example, the GP members of a governance board declining to take part in a vote that awards services to GPs when the decision has already been made out of the boardroom. This, we are told, is acceptable. Furthermore, if a CCG involves its patient group in commissioning LES there is a high chance that it will involve patients who are members of the PPGs of the GP practices who would benefit.

I Am Just A Patient!

Patients are patients, they are not your patient or our patient, they are NHS patients. It is quite clear that public and patient involvement is getting fragmented because of the new competition-based procurement regulations. Patients are excluded to prevent perceived "conflict of interests", while real conflicts are not being addressed. Patient involvement is vital to the NHS, not only does it give a legitimacy to the commissioning by a public organisation, but it has the potential to make significant improvements to the services being commissioned. No patient is restricted to one provider or one service, no patient pathway is limited like that, so why should patient involvement be limited?

Before the fragmentation of services and PPI gets much further we need to stop and rethink. Ultimately we need to remove competition from healthcare planning because it is resulting in competition lawyers determining which providers are commissioned. While we wait for that to happen, the next best thing would be a declaration from the Secretary of State that patients are far more important than competition laws and to tell commissioners that they cannot exclude patients from commissioning on the grounds of "conflict of interest". To ensure that such a declaration is followed, a neutral third party should have not only the responsibility to ensure that patient involvement occurs, but also to enforce it. Such a neutral third party should have the same power over all commissioners and providers: NHS England, NHS England Area Teams, CCGs, Local Authority social care commissioners, NHS providers, GPs and private providers.

At the moment there is no such patient organisation, but there is a possibility that local Healthwatch could be given new powers, responsibilities and resources to do this. Such a revitalised Healthwatch would be able to support patient groups so that they are independent of providers and commissioners, being able to discuss the issues that concern the patients. Healthwatch could be given the power to delay the commissioning of a service on the groups of inadequate patient involvement. It could also have the responsibility to ensure that all providers (NHS and private) have patient engagement and involvement in the delivery of services. Such power would give meaning to Healthwatch.

(Richard Blogger is an elected Foundation Trust governor and a patient representative at his local CCG PPG. He has been excluded from patient involvement in commissioning by the CCG on the grounds of "conflict of interests".)

Saturday, 26 October 2013


Just got back from 2 hour circular walk. We walked along the footpath on the left of the map, above, going along the railway and intending to join the footpath (the diamonds) at Castle Meadow Bridge along the Grand Union Canal. It clearly looks like the two footpaths cross, but unfortunately the footpath does not just cross the towpath, it crosses over the towpath.

When we got to the bridge, there was clearly a path to the canal but there was a locked gate and fence preventing us from getting down from the footpath to the towpath. So we retraced our steps a bit and then walked on to Tythe Barn Bridge to try and get down there.

The following is a photo taken after we had got down from the public footpath to the canal, looking up at the bridge which has the public footpath. As you can see, there are steps, but the route is blocked with a fence and a locked gate.

And just for the record, this photo shows the bridge from the top of the steps, showing the post indicating that it is a public footpath:

The likelihood is that the land owner blocked the access, although why they would do that is unclear.

There are two rights of way here, and two authorities involved. The footpath, the green dashed line, is a public right of way. In England many such footpaths have been rights of way for centuries. The footpath goes across private land (in this case a plantation of poplars and firs). The law gives walkers right of access across the land, but the footpath is owned by the land owner. The local county council have a responsibility to maintain a list of the footpath routes and usually local walking groups ensure that the signs and items like stiles and gates are maintained.

The canal towpath, the green diamonds on the map, is a recreational route with the agreement of the land owner, in this case, the Canal and River Trust. Canals were formerly state-owned by British Waterways, but in part of its privatisation plan (which can be subtitled "we don't own or do anything") the Coalition government first tried to turn British Waterways into a mutual, and then decided it should be a charity. There is nothing in either the Conservative, or the Lib Dem 2010 election manifestos about taking the canals out of public ownership to mutalise them or give them to a charity, but that is typical of this undemocratic government.

Two types of footpaths, yet no integration of the two because the land owner of the footpath (as is their right, it is their land) has blocked access. Of course, we found a way down, climbing over a fence a little further along the canal. We were halfway round the circular walk, so if we hadn't had access to the canal we would have had to retrace our steps along the footpath, and since the canal looked like a pleasant (and less muddy) walk we decided it was worth climbing over a fence. Anyway, I had planned the walk from the map, making sure we were walking along rights of way, and I was annoyed that my plan was wrong because of the inflexibility of a land owner.

The problem with integration is that you have to get everyone involved to work together, if one party refuses to cooperate, integration does not happen. In the case of the access between the towpath and the footpath what was needed was a little bit of leeway from the land owner of the plantation, but the land owner clearly didn't want to cooperate, and hence the fence and gate were installed to prevent integration between the two footpaths..

NHS and social care integration will be far more complicated. Not only are there two public sector organisations commissioning the work (CCGs and local authority social services), there are a myriad of provider organisations, some public sector (hospitals) and some private sector (nursing homes). The possibility of one or more of these organisations deciding not to be flexible is high, and the result will be poor care for patients.

Personal Health Budgets

I did feel sorry for the young man from the CCG, I have an absolute objection to Personal Health Budgets and yet I was a member of a CCG patients' group to which he was giving a presentation about PHBs. I was polite and allowed him to say his piece, and then went through the slides one by one pointing out the flaws. I prefixed my criticisms with "I know this is government policy and you have to implement them, but...". I got the impression that he had never had such robust objections before, so I was doing him a favour by giving him a taste of what he should expect in the future. I will relate one part of the conversation here.

CCG Guy: ... and with your personal budget you will be able to purchase whatever you think will help your condition, so if you think you will benefit from an acupuncture session, you'll be able to buy one with your personal budget.

Richard: This CCG regards acupuncture as a treatment of low clinical value and will not pay for it. Before the last PCT adopted the Croydon List, [the local hospital] used to offer acupuncture to people with chronic pain. After the Croydon List was adopted (and the CCG formally adopted it at their July board meeting) acupuncture is no longer available as an NHS treatment, and now it is the only private treatment that [the local hospital] offers, since chronic pain sufferers still request it.

CCG Guy: ... and this is a way that people with a personal health budget will be able to use their budget to get the treatment they want.

Richard: ... but you will create two tiers of patients. There will be those who have personal health budgets who will be allowed to use NHS money to have low clinical value treatments; and there will be the rest of us who will be denied those treatments by the CCG. Two tiers of patients.

CCG Manager to CCG Guy: Richard is right, how do we prevent there from having two tier patients?

CCG Guy: The CCG is developing a list of treatments that patients will be restricted to.

Richard: But isn't that the case already? The Croydon List. Where is the personalisation when we are told that we can only buy from a restricted list?

And the conversation went on. Basically Personal Health Budgets in a time of austerity has nothing to do with personalising care. They are a way to get patients to get used to paying for healthcare so that eventually we can be moved to a European social insurance system, just like Nick Clegg said he wanted in 2005.

Tuesday, 8 October 2013

BBC Reporting of Hunt's Tweet

You would think that a tweet is pretty easy to report - there are less than 140 characters, so the easiest way to report it is to give the tweet and allow readers to make up their own mind. The BBC apparently found this a bit hard to do. For the record, here is that tweet:

This is pretty unequivocal - Hunt is accusing Burnham of attempting a cover up. This is how the BBC reported it on the 6 October:

Although this article did not provide a copy of the tweet, it did report it accurately: Hunt suggested that Burnham attempted a "cover up". However, the following day, the BBC changes its tune. On the 7 October, the BBC changes "suggested" (which is assertive) to "appeared" (which suggests doubt):

There is no doubt: Hunt was suggesting that Burnham had "attempted a cover-up".

The BBC's poor reporting does not end there. At the end of the article on the 6 October, and the article on 7 October, the concluding paragraph says:

Here, they are "reporting" what the Tory MP Steve Barclay is claiming, but the BBC have not looked at the evidence themselves, otherwise they would have dismissed Barclay's claims as being fabricated.

Burnham, provided the emails himself in a blog on Labour List. I urge you to read the email yourselves, but the most relevant part is paragraphs 10 and 11:

This email was from Jill Finney to Jamie Rentoul. In it Ms Finney says Burnham was "furious" that the CQC press office had not released the information about Basildon & Thurrock according to accepted rules, and rather than "putting pressure" on CQC to "water down its concerns" Burnham ordered a joint press release between the two regulators CQC and Monitor. Clearly the accusation by Barclay is fabricated, yet the BBC report it as if it is true.


Now the Department of Health says that Burnham should have been consulted before the emails were released to Barclay:
the Permanent Secretary at the Department of Health, Una O'Brien, has written to him saying they should have consulted him before releasing the emails. "I am sorry that on this occasion, the protocol was not properly observed and I apologise both on behalf of the Department and the CQC for this lapse." She goes on to say: "My investigations have revealed that this was a genuine oversight on the part of officials but nonetheless unacceptable."

Thursday, 3 October 2013

Labour's Plans for Private Patients

Labour has said relatively little about what they plan to do about private patients in NHS hospitals should they win the next election. HSJ reports:
"The repeal bill would also cut the cap on the amount foundation trusts can earn on private work from 49 per cent of their total turnover to 'single figures', [Burnham] said"
This statement is factually wrong repeating misinformation that has emanated since the Health and Social Care Act was passed. The inaccurate figures are political and are used to spur the faithful. But worse, the promise simply says that Burnham will preserve the status quo.

What the Act Really Says

First, the misinformation. Section 164(1) of the Health and Social Care Act (HSCA) 2012 says:
"An NHS foundation trust does not fulfil its principal purpose unless, in each financial year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes."
The "health service in England" is the government's new name for the English NHS. (You can see why Andy Burnham is so keen on "restoring the N in the NHS".) The issue is the other statement "services for any other purposes" because this does not specifically mention private patients.

This section says quite clearly that the NHS income of an FT must be greater than its non-NHS income. So the "49%" figure often quoted is too low, the amount of non-NHS income can be 50% minus £1. Secondly, nowhere does it mention private patients or "private work", it says "for any other purposes". The HSCA repeals section 44 of the NHS Act 2006 which specifically restricted "private charges" which were defined as:
"charges imposed in respect of goods and services provided to patients other than patients being provided with goods and services for the purposes of the health service."
The problem with the less restrictive definition in the 2012 Act is that it widens the income that are included in the so-called "49%", so parking charges, charges for public health work that the trust does (public health is now a local authority, not an NHS, responsibility), income from things like rent from nurses in hospital residential blocks, or services provided for the third sector (like, say, palliative care consultants seconded to a hospice) are all included.

The 2006 Act definition also had its problems. People often took it to mean private patient charges, but that is  not what the Act says. Section 44 declarations included things like income from patents the trust holds or rent on buildings they own but don't have an immediate need for. This is not the spirit of the law, which was to restrict private patients, and one could argue that rent on surplus property is a beneficial thing.

Further, some trusts used this ambiguity in the definition of "private charges" to their advantage, for example, The Christie rather than listing their private patient income in their Section 44 declaration they listed the profit they made from private patients (or more accurately, their share of the profit since their private patients were treated by a joint venture with HCA). Again, this does not follow the spirit of the law.

The Christie listing the profit from treating private patients indicates that the patients bring in more money than the hospital spends on them. Most trusts give the private patient income in their Section 44 declaration and no indication of the expenditure on those patients, so there is no indication whether the hospital makes a profit on private patients. Indeed, the hospital could easily make a loss because many hospitals have private patient units not to generate income, but because their consultants demand the ability to have their private practice in the hospital and trusts grant this privilege as a workforce concession.

Single Figures

The following table lists the trusts with the largest private patient income (2011/12) and the proportion of total income that came from private patients.

Foundation TrustPrivate Patient Income (£000)% income
The Royal Marsden NHS Foundation Trust51,14422%
Royal Brompton & Harefield NHS Foundation Trust29,11714.4%
Great Ormond Street Hospital for Children NHS Foundation Trust28,1579.8%
Guys and St Thomas NHS Foundation Trust23,0813%
Royal Free London NHS Foundation Trust19,2246.4%
Moorfields Eye Hospital NHS Foundation Trust18,68214.5%
University College London Hospitals NHS Foundation Trust18,0062.6%
Kings College Hospital NHS Foundation Trust16,8822.6%
Chelsea and Westminster Hospital NHS Foundation Trust11,2643.7%
The Christie NHS Foundation Trust10,7089.1%

In fact, only three trusts generate more than "single figures" in private patient income: Royal Marsden, Royal Brompton & Harefield and Moorfields. So every other trust will be unaffected by Burnham's "single figures" approach to private patient income. That is, for all but three trusts he intends on preserving the status quo.

According to Monitor, in financial year 2012/13 the aggregated figure for private patient income for all Foundation Trusts was £358m out of a total income of £38.9bn (or £34.7bn if you include only patient activity). This means that on average FTs had private patient income of 1%. So Burnham's "single figures" seems to indicate that Foundation Trusts are currently well below his limit and hence most FTs could significantly increase the number of private patients.

If Burnham imposes a "single figures" restriction that raises the question of what the three trusts mentioned above will do. Most likely they will fudge the issue (like The Christie and GOSH have done) by restructuring and treating their private patient units as separate businesses and then listing the profit of these separate companies as their private patient income. The profit will be considerably less than the income, and so they could easily meet the "single figures" criteria.

As I said, Burnham intends to preserve the status quo.

What is the Question?

The problem with Burnham's statement is that he's not telling us what he is trying to solve. There have been a lot of ignorant noise about "half of patients in NHS hospitals can be private patients" which ignores completely that there could never be enough private patients to fill half of all English NHS hospitals. Burnham was simply responding to the ignorant noise, which is no help at all. So let's try to determine the problem he's trying to solve.

Privatisation of Services in NHS Hospitals

This is a legitimate issue. NHS hospitals are crap at providing private healthcare. Private healthcare is essentially performing elective treatment in a plush five star setting. The NHS does not do plush five star settings. Further, the NHS does the difficult healthcare - emergency care - very well, and it usually prioritises the difficult cases over the easy cases because its ethos is to give care according to clinical need. Combined, this means that the NHS really is not geared up to deliver healthcare for those with money to throw away. Consequently, many NHS hospitals hand over their private patient units (PPU) to private healthcare companies. (They are often described as "joint ventures" but in actuality they are just handing the service to a private company.) If an NHS hospital wants its private patient unit to be run well and generate a profit, it is usually a good idea to hand the PPU over to a private company so that the NHS hospital can do what it does well: treating NHS patients.

The problem is that this is privatising a service: the service is being run by a non-NHS provider, and since PPUs are often within an NHS hospital (the best ones are - if your treatment goes wrong you'll want to be a trolley ride to ITU) this means private providers are within an NHS hospital.

Private Health Services

Some people are ideologically opposed to anyone paying for healthcare. The problem with this approach is that about 20% of healthcare spend in this country is on "private healthcare" and has been for a couple of decades, so taking this ideological approach is a bit futile. (To be fair, that 20% is mostly services, and over-the-counter medicines, from pharmacies, but it also includes opticians who are almost completely private, and dentists where a large proportion of their care is private.)

We have a mixed market economy and getting the right balance between the private and public sector is important. Currently there is no need for people to pay for private care, the NHS provides care that is needed clinically, and does so to a high quality. People who pay for private care are spending money unnecessarily. Should we stop people from wasting their money like this, if it does them no harm? It really seems to be at the more dimwitted end of class warfare to deny people the opportunity to waste their money on things that neither give themselves an advantage nor harms anyone else.

Private Patients Using NHS Facilities

The Government's argument for NHS hospitals taking on private patients is that they are considered another income stream. The government claims (often excessively) that private patients are subsidising NHS treatments. In fact, there is more evidence that the opposite is the case. NHS hospitals can, and do afford expensive equipment: there are accepted, and cost effective ways to fund such equipment and if there is a clinical need, the NHS will provide the service (for example, MRI machines were introduced into NHS hospitals years before they appeared in private hospitals).

The two most expensive medical machines that will be installed in this country are the two Proton Beam Therapy Units being installed at UCL Hospital and The Christie. These machines cost £125m each and a Department of Health study showed that the private sector had no interest whatsoever in providing these services. There was a need for these facilities and a cost effective solution (Public Dividend Capital, essentially a government capital investment on which the trusts pay an annual 3% "dividend").

The problem when a private patient is treated in an NHS hospital is that they will be treated with the expensive equipment that the NHS paid for. The fee from those private patients are relatively tiny compared to the cost of the equipment and are insignificant contributions to funding them. However, such high cost pieces of equipment are usually scarce resources, so a private patient will take the place that a NHS patient could have used. Further, since private patients are healthcare consumers they will demand (quite rightly, they are paying) more time than an NHS patient, and will usually be pushed to the front of the queue. This is the two tier NHS.

It is frankly throwing in the towel when it comes to the NHS being a public service, to argue that the only way that a trust can get capital investment is by accepting that a private company builds a private patient unit. Further, it is accepting that the NHS is, and should be, a second rate service.

Two Tier NHS

The most important issue is that private patient units could lead to a two tier NHS: one version for those who can pay, another version for those who don't. This goes against the founding principle of the NHS which is that care is according to clinical need and not ability to pay. The command paper (Cnd 6761) that introduced the NHS, started with this paragraph:
The Bill provides for the establishment of a comprehensive health service in England and Wales. A further Bill to provide for Scotland will be introduced later. All the service, or any part of it, is to be available to everyone in England and Wales. The Bill imposes no limitation on availability – eg,. limitations on financial means, age, sex, employment or vocation, area of residence or insurance qualification.
Since NHS care is free at the point of delivery, it means that when people pay for care in an NHS hospital, they are paying for something more than the NHS patient will get (otherwise, why would they pay?). Often private patients think they will get care quicker than NHS patients (and jump the queue), and sometimes they think they will get more choice (for example women who demand Caesarian Sections for non-medical reasons). Usually all that private patients get is a single room and restaurant quality food; in other words they are paying for five star hotel services.

Illness is a great leveller: we are all vulnerable and dependent when we are ill. How can we justify that some people are able to get better care just because they are wealthy? Do they have posh illnesses?

What is the Answer?

Burnham's answer is to bring private patient incomes "down to single figures" but, as mentioned above, over all, private patient income is just 1% with just three trusts having more than "single figures" private patient income. So Burnham's "solution" is to maintain the status quo. There are other solutions, some more effective than others.

Leave it up to FT Governors

This is the "cop-out" solution, just as the current Coalition government hides behind "localism" as a way of shirking its responsibilities, leaving a decision about private patient income to governors is simply passing the buck. Let's be clear about this, governors are voluntary. They are not paid. Although they are supposed to represent the community, memberships of Foundation Trusts are a fraction of the community the FT serves and only a fraction of the membership actually votes for governors. They are also low profile and have little interaction with the community. (Ask yourself when was the last time you saw an FT governor quoted in a local newspaper, and compare that to local councillors.)

The suggestion is that an FT Board, with high paid and experienced managers, will present a proposal to treat private patients to the governors, a council of inexperienced, unpaid volunteers. This is not a fair contest. At the moment, the purpose of governors is to ensure good governance, that is, to ensure that decisions made by the board were carried out in a fully informed and exemplary way. The governors are not (with a few exceptions*) supposed to challenge the actual decision, only how the decision was made. this is an important point because governors are about governance, they do not have any management role and do not run the hospital.

There is another issue with this suggestion: it is essentially one-way. While it may be possible for a Council of Governors to change their constitution to remove existing private patients, it is very unlikely that this will ever happen since management will argue that they have invested in private patient facilities and governors are making a decision that could have a financial effect on the trust. Such an action will also be a managerial decision and governors do not, and should not, be involved in the management of the trust. For this reason, giving governors the responsibility of putting their policy on private patients in their constitution is a one-way process towards the trust treat private patients.

A suggestion of allowing governors to decide is passing the buck to inexperienced volunteers, and it is a de facto approval that all trusts should always have private patients. This is sanctioning a two tier NHS.

[* The main exception to this statement is that governors can define "significant transactions" which will require a majority vote of governors. Such transactions could be a merger with another trust, or an expenditure, or seeking a loan, over a certain limit. The main point is that governors determine what these transactions are.]

Ban all Private Patients in NHS Hospitals

Andy Burnham could simply say that NHS hospitals should only treat NHS patients. There are several issues to this. The main one is that NHS hospitals have often invested money into private patient units and switching from higher income generating private patients to tariff NHS patients would make it more difficult for those trusts to realise their investment. While it would be a huge publicity coup to show NHS patients using plush private patient units, to enable such a policy the government would have to provide some kind of subsidy. This will never happen.

The other main issue is the effect on consultants. Consultants are used to being allowed to have a private practice, and some trusts have a private patient unit as a way of ensuring that their consultants are on site. This is good employee relations and it ensures that NHS patients can be seen quickly even when a consultant is treating a private patient. If a private patient unit was closed in an NHS hospital consultants would run their private practices elsewhere, with the possibility of making them less accessible to the NHS hospital. While the NHS consultant contract continues to allow consultants to moonlight, this problem will persist.

Change Consultant Contracts

We have had 65 years of the NHS allowing its most highly trained employees to moonlight for their competition. And it is their competition because these days private hospitals are encouraged to do NHS work and the government are overseeing rationing that is pushing patients towards private hospitals and self-pay. In most industries, workers are employed on exclusive contracts, with dismissal (and litigation) if they work for the competition. Even zero-hour contracts have exclusivity rules. NHS consultants have a very outdated privilege that no other employee enjoys.

While it would be too difficult to change all consultants' contracts to make them work exclusively for the NHS, it could be done for new consultants. Consultants could be given the choice: the opportunity to work with demanding caseloads, inspired teams, to do research and help shape the country's health service; or to do private work. The NHS will attract the best doctors, those with a vocation.

Inversely Link Private Patient Activity to NHS Waiting Times

Banning private patients, or changing consultant contracts are controversial solutions, a more innovative solution is to link private patient activity to NHS waiting times.

The current 18 week Referral To Treatment waiting time target (against which all trusts are performance managed) is a political one. In 1997 the average waiting time for elective treatment was 18 months, so the incoming Labour government pledged to lower that to 18 weeks. There was a lot of politics in changing months to weeks, but there is nothing special about 18 weeks (four and half months). In Denmark, for example, the waiting time target is 4 weeks. The RTT target should be inversely related to the relative number of private patients with the 18 week RTT target applying only to hospitals with no private patients. If a trust wishes to raise the number of private patients its RTT target will be reduced.

It is intolerable that an NHS hospital can make an NHS patient wait while allowing private patients to pay to jump the queue: if there is capacity to treat private patients then NHS patients should not wait. If private patients are such a gold mine (and I am not convinced that private patient income actually covers the cost of the care they receive) then an FT would have an incentive to reduce NHS waiting times to give them the privilege of treating private patients (or conversely, if their waiting times rises, a trust will be restricted in how many private patients they can treat and this will provide the extra capacity to treat more NHS patients and an incentive to reduce waiting times).

Concluding Remarks

The problem that Andy Burnham should solve is move towards a two tier system, where patients can jump the queue, or receive better care by paying for it. It is the numbers of private patients, not the size of private income that is the problem.

The ultimate solution to this problem is to ban all private patients in NHS hospitals, but this may be too much to achieve. At the very least an incoming Labour government should change consultant contracts so that newly appointed consultants will have to work exclusively for the NHS. Over a long period of time this will reduce the numbers of private patients as demand from consultants for private patients will fall. In the meantime, a new Labour government could use private patients as a lever to improve NHS care by linking the number of private patients the trust can treat to the Referral To Treatment target: if the trust treats more private patients, its RTT target is reduced.