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

Sunday, 8 November 2015

Unbiased Journalism

It doesn't happen. It cannot. Journalism always contains some bias. I have written for a living since 1996 (books, journal columns, features, and more recently, training courses and presentations) and I can confidently say that, from my experience, journalism is never unbiased.

We know that the national newspapers have their own overt biases. When we pick up a newspaper we know their political leanings (they all tell us who to vote for at the General Election, so of course they all have a political bias). We also know, in general, how a newspaper will react to a news story and we make allowances when we read the article and subconsciously strip out the opinion and bias to extract the news. (However, to be frank, the Daily Express support for Junior Doctors surprised me).

Journalism always has a bias. Journalists on the Nationals usually excuse themselves by giving a quote from someone who is known to have an opinion contrary to the main opinion they are reporting. I find that lazy and inadequate. A formulaic quote from a Press Officer at a government department, or a public body, can never be regarded as a balanced response. For a start, a Press Officer is, by definition, detached from the issue, they are not responsible, nor are they necessarily knowledgeable of the subject. A Press Officer is simply another journalist, poacher-turned-gamekeeper: a journalist giving a quote to another journalist. Worse, a Press Officer is merely parroting the statements from the person who the article's journalist should have interviewed, so why haven't they?

Some journalists have suggested that any subconscious bias in their copy is removed by editing. I find this hard to believe, particularly if an article is written by a "specialist journalist". As their title suggests, specialist journalists are unique at the publication. Other journalists editing the piece will not have adequate knowledge of the subject to be able to determine if there is "bias" in the article. At most publications, the editing that occurs is more about the publication's style guide, grammar, spelling and legal liabilities, than about the subject of the article.

Most of my career has been writing for technical journals. I have never used the term "reporter" to describe what I do, and I rarely use "journalist". The reason is because I wrote columns and features and refused to report on the carefully created press releases, or press conferences, from the vendors of the products I wrote about. More recently, I have worked for those vendors and have written such press releases (or "white papers" as the vendor insists on calling them) and feel justified that I ignored them when I wrote for the journals. I always called myself a "writer" because I knew that everything I wrote was my - well researched - opinions, and I was employed because the journals' editors trusted my opinions.

These journals always had a rather unhealthy relationship with the dominant vendor because although they were subscription publications, and had some income from their readers, a significant proportion of their advertising came from the dominant vendor. Thus, the articles were about the products of the provider of the journal's main income. That is a difficult situation to manage and can lead to a form of hagiography, or worse, simple churnalism where press releases are regurgitated. This is not how I worked.

I always made sure that whenever I wrote an article I always went back to first principles: try the product myself and write about what I experienced, and not what the vendor said I should experience. Further, if I was critical - which I usually was - I would say why there was a problem with the product, but more importantly, how the reader could work around the issue. The vendor was generally happy because I was helping them to improve their product and provide ways to keep their customers using their product. I could not do this by merely reporting what the vendor said because the vendor rarely wanted to publicise flaws in their product.

Sometimes (but not often) I would be contacted by people who worked for the vendor and they would indicate issues they were concerned about. Whistleblowing is an overused phrase, but I guess it's possible to say that such people were "whistleblowing" on the product. A journalist on a national newspaper would have reported such issues as "concerns from an unnamed source". I never did this, because I could see that there was nothing to be gained by reporting second hand concerns. If an issue was reported to me, I would replicate the issue, sometimes spending a large amount of time writing code to illustrate the issue and its cause. I would then publish my findings and how to replicate the issue. I would never jeopodise a source by quoting them as "an unnamed source" and I would never write an article based solely on the opinion of someone unwilling to be named: I would always do the research myself first,

My opinion is that all written words are biased to some extent, and that it is impossible to remove all bias. Worse, any attempt to "remove" bias by so-called balancing opinions with bland statements from Press Officers is amateur and lazy. It is far more important that a journalist clearly states their biases so the reader can take them into account when reading the article, than to attempt to remove (in their opinion) any traces of bias from the report.


You may have detected the use of the past tense when I talk about writing for journals. The reason is that a few years back I wrote a critical piece about the most significant product of the dominant vendor. As always, I provided the results of my research and the tools for readers to replicate my findings. After the article was published, I was contacted by a senior manager at the company who asked me to retract my findings, and gave me an incentive, he offered contract work to help them improve the product. It turned out that the manager was not authorised to make the offer of work (and so it was a hollow promise), and anyway, I later learned that a manager several levels up in the company had declared that I was not welcome at any of the company's sites and my name was removed from the list of writers would got preview copies of their products. In effect, my career writing for journals was shut down.

Ironically, after that I worked for a publishing company where I wrote conference presentations and "white papers", for the vendor who had "banished" me. My name never appeared on these items, so the manager who had declared me persona non grata was none the wiser, and was likely to have given one of my presentations.

Saturday, 25 July 2015


It is worth listening to Peter Hennessy's Reflections interview with Nigel Lawson, the Listen Again link is here. What is immediately apparent is how arrogant Lawson is. Here is a man who's policies caused the so-called Lawson Boom that pushed up inflation and hence interest rates (to 15%! a level that seems incredulous now) and which lead to a catastrophic bust, and yet he never had a single regret and blamed everything on everyone else because in his mind he could do no wrong. In the interview Lawson said:
the idea that you go from state ownership to private ownership that had had never been tried anywhere in the world and we were the pioneers in this country and it was subsequently followed all over the world, first in the western world and subsequently in the countries that had escaped from the Soviet Union - the Soviet empire rather - and they went in for privatisation and indeed it was not only this country that gave the policy to the rest of the world but gave the word privatisation which is used in every language under the sun 
Well, thank you Nigel, we now know that not only have you screwed up this country, but the entire world! Such arrogance.

Monday, 13 July 2015

NHS Funding Inquiry

Lord Patel, a Crossbench peer and Obstetrician, on the 9th of July moved a debate in the House of Lords over the "sustainability" of the NHS. In effect, this was the House of Lords debating whether taxpayer funding of the NHS was a good idea. Predictably, the debate was mostly filled with anecdotes from people who appear not to realise that their one anecdote is just one treatment out of the 18 million that are performed every year and is thus not representative. Also predictable was that the Tory peers who spoke acknowledged the need for taxpayer funding but expressed their favour of having an inquiry to bring in insurance or user charges.

At no point during the General Election was there any suggestion that any political party would change how the NHS was funded, the "sustainability" of NHS funding was not, and still isn't in doubt. The service is funded by general taxation and if it needs more money, more money is found from taxation. At the budget the Chancellor promised an extra £8bn - not enough, but it shows that taxpayers can afford to pay more if there is the political will. So why the debate?

I suspect it is more to do with the Junior Minister who represented the Government in the debate than with Lord Patel. The minister, Lord David Prior, is a former Tory MP and deputy Chair of the party, and was the previous chair of the Care Quality Commission. Prior is a loose cannon, who is well known for wanting to extend private provision in the NHS:
"We need more competition to drive up standards of care; more entrants into the market from private-sector companies, the voluntary sector and other care providers"
This makes him useful to the Government because he can be expected to initiate the sort of debates that no one has voted for, and where better than in the House of Lords, which no one has voted for? Lord Patel is a Crossbencher and so is not restrained by party political strictures. This meant that he was able to ask a question that party politicians cannot ask - can we fund the NHS in ways other than taxation? The right-wing Prior saw Lord Patel's debate as an opportunity.

The NHS principles that have (mostly) stood firm since 1946 are summed up in clauses 4 of Command Paper 6761:

That is, the NHS is available to everyone, whether or not they can afford to pay user charges, or whether they are insurable. This says quite clearly, that the NHS cannot be funded by co-pay or health insurance. The question about whether the NHS could be funded through user charges or insurance is answered here: No it shouldn't.

The Conservatives, as can be expected, were far more in favour of moving away from tax funding. For example, Lord Cormack, while acknowledging that the NHS would need more money, would not even countenance a tax rise:
"All forms of funding must be looked at. We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come—we have to have a quality service that does not lurch from crisis to crisis, from one application of sticking plaster to the next. It is crucial that we attain that."
Matters not!? As a true Tory, he says that the funding should not come from taxing the rich, but instead from taxing the sick.

More disappointing were the contributions from Labour peers. Lord Warner is well known for being in favour of the private sector and even suggested in his speech that "failing" providers should be privatised. On the issue of NHS funding he said:
"Our tax-funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment. The voices of dissent and outrage will no doubt be deafening but a wise Government should begin now the process of helping the public engage in a discourse about future funding of the NHS."
This is hardly an endorsement of the tax-funded system, indeed, he appears to suggest that the government should "help" the public to think of other ways to pay for healthcare. Another Labour peer, Lord Desai, even made the bizarre suggestion that people should be issued with an "Oyster card" which is deducted whenever a patient uses healthcare, and patients should receive a "bill" at the end of the year:
"Another suggestion that I have made before in your Lordships’ House is that, although we do not want anyone to feel that they are being charged for using the health service, we ought to make clear to people the cost of providing it. People think that because it is free, it is costless—but it is not. We often worry about people missing GP appointments, so I propose a sort of health Oyster card for every citizen. Every time they used the National Health Service, they would have to swipe their Oyster card and a certain number of points would be deducted. The Oyster cards could be recharged. At the end of the year, people would get a bill showing how many points had been used and on which health service facilities. If people missed a GP appointment, 15 points would be deducted rather than two—things like that. Perhaps something like that could be done to make it clear to people that a free National Health Service is not a costless one. If we can somehow get people involved as patients and potential patients so that they modify their behaviour in demanding healthcare, it may solve some of the problems of the National Health Service."
This is another version of  Jeremy Hunt's daft suggestion to put the price on prescription medicines, a policy expertly dismissed by Roy Lilley recently. The problem with the NHS is not unnecessary demands, it is the sheer magnitude of people who need healthcare. An "NHS Oyster card" will not reduce the number of elderly people with acute co-morbidities. And if "consumer demand" is a problem, the solution is to turn patients back into patients rather than healthcare consumers, and remove the market.

Prior, summed up the debate by saying that he was personally in favour of a taxpayer funded system:
"However, I have listened to the debate and the strength of feeling about whether we should take a longer-term view that goes way beyond this Parliament. The sustainability of the health service is an issue that extends out 20 years, probably, but it is one that every developed country faces. I would like to meet the noble Lord, Lord Patel, and maybe two or three others, to discuss this in more detail to see whether we can frame some kind of independent inquiry—I do not think that it needs to be a royal commission. We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund. The issue is: what will the long-term demand for healthcare be in this country in 10 or 20 years’ time? Will we have the economic growth to fund it? 
At heart, our ability to have a world-class health system will depend on our ability to create the wealth in this country to fund it. I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned."

The statement at the end is a curious one, suggesting that he is not wholly convinced because he would support other funding mechanisms if the state of the economy demanded it. (An odd statement to make because it implies that if the country goes into recession, and people lose their jobs and have to spend less, he would be in favour of taxing the sick through health insurance and user charges.)

However, Prior goes way above his station by declaring an inquiry on an issue as fundamental as how the NHS should be funded. If Jeremy Hunt, George Osborne or David Cameron had suggested such an inquiry I would express my opposition, but at least those politicians hold significant positions in the government and have the power to order such inquiries.

But why is a junior minister, the "Under Secretary of State for NHS Productivity", announcing an inquiry in an area that is outside of his remit? I suggest the reaction of the Press is the reason: this inquiry has not been reported in the mainstream media. If the Health Secretary, the Chancellor, or the Prime Minister had announced such an inquiry it would have been on the 10 o'clock News, the front pages of the national newspapers and there would have been a whole Newsnight devoted to what the inquiry will be looking at. Because a little known minister announces such an inquiry, the media are not interested, and so something as fundamental as the funding of the NHS will go ahead without any public scrutiny.

There is one final point to be made. Prior says:
"We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund."
Indeed. The Kings Fund has already carried out such an inquiry, it was called the Barker Review. Barker says:
"We looked hard at the question of introducing new charges into the NHS. However, most options for charges seem likely to raise administrative problems and the risk of adverse impacts, which make them unattractive."
Barker rejects any idea of user charges, did any of the Lords in Lord Patel's debate mention this? Further, Barker suggests that the gap in health funding should be met by more taxes, not fewer:
"We make two suggestions to close this gap, although clearly there are others. The first is a review of wealth taxation, including inheritance tax, which is too frequently avoided. The second is a package of increases in National Insurance, affecting those over 40 (who will be considerable beneficiaries from the new settlement) and the higher paid."
It is interesting that the Chancellor has removed the ability to raise taxes through inheritance tax by raising the tax threshold in the Budget, and he has cut some National Insurance contributions. In other words the very things that Barker says should happen, Osborne does the opposite. On can conclude Osborne is likely react similarly to Barker's opinion on user charges.

The government already has a detailed report into NHS and social care funding, one which recommends raising taxes. Rather than acting on this report, Prior (taking an action which few people would regard him as authorised to do) orders another inquiry, this time using people he has chosen and presumably people who will produce the desired result.

Sunday, 7 June 2015

Prisoner debt

If I were ever to become a Special Advisor to the Conservative Party not only would I lose all credibility and respect of all of my friends and family, but I would also lose any credibility and respect I have for myself. So take this as a declaration that the following is not what I think should happen, but, considering that we have one of the most right wing governments ever elected to this country, this is what may happen.

Comfort Allowance

In March 1943 my grandfather, grandmother and father (then 10) were interned in the Civilian Internment camp at Lunghua in Shanghai. (Yes, the same camp as JG Ballard, and no, Empire of the Sun is not autobiographical; the camp was not like that and Ballard has even written saying that the book was a novel and the event did not happen.)

In August 1945 the camp was liberated and in September 1945 my grandmother and father (who was seriously ill) were repatriated (first via plane to Hong Kong, and then a three month journey via a military hospital ship back to Liverpool). My grandfather stayed on in Shanghai and returned to the job he had before the war. I have the letters that my grandfather wrote back to England (he returned back to the UK in July 1946, it was not his intention to return, but that is another story...).

The letters are mostly about his failing health, and about money: he expresses great regret that he could not provide more money for my grandmother. Bear in mind that my father needed many operations and this was before the NHS, so my grandmother would have to pay the medical bills.

In one of the letters is a passage that says:
"Our firm promised to pay for comfort allowance but whether they will pay for our wives + families remains to be seen."
This needs a bit of explanation.

The camp provided little food to the internees. Part of the reason was that there was little food in Shanghai during the war. The camp had a small farm with chickens, and my grandfather had to pay for eggs and milk (I have records of how much he paid, and even in the camp there was rampant inflation). My father was a young boy so it was important that he had milk and eggs. (By "eggs" I mean not only the gooey stuff inside that could be boiled, poached or fried, but also the shell. Egg shell was ground up and children had to eat this as a source of calcium.)

In addition, the internees could receive Red Cross Parcels. These were not charity, the name comes from the fact that the Red Cross delivered the parcels and ensured that they were checked and did not contain forbidden items. Before they were interned, people gave some money to a trusted friend who would not be interned, and this friend would purchase allowed items and package up for the Red Cross to deliver. My grandfather worked with a Rumanian Jew, Bernard, who had escaped Nazi East Europe. In some of his letters Bernard gave his nationality as "Rumanian" in others he described himself as "stateless", but since he was not from an Allied country, he was not interned by the Japanese. My grandfather gave Bernard money to provide Red Cross parcels, but since no one knew how long internment would last, and the money soon ran out.

Internees could borrow "comfort allowance". Since this money would be used to pay for essentials, the word "comfort" was certainly a euphemism. The money came through the Swiss Consulate who handled British affairs in occupied Shanghai. The British government reimbursed the Swiss government for this money. At the end of the war, the civilian internees were expected to reimburse the UK government for this debt.

That's right, people were interned for two and a half years in appalling conditions, with inadequate food, and the UK government treated it as if they were staying in a holiday camp, running up a bill that had to be paid.

The comment in my grandfather's letter referred to an offer from the company he worked for to pay for the cost of his internment "comfort allowance", although he was unsure as to whether they would also pay for my grandmother and father. I have no other references to these payments, so as far as I know my grandfather paid for the food my grandmother and father had while interned. Since my father was seriously ill during the last 6 months of internment, there were also his hospital bills and medical for that time. (On two occasions my father was allowed out of the camp to go to a hospital in Shanghai for x-rays.)

Ludicrous and Unbelievable Election Pledges

The Cameron government were elected with an unexpected majority. It surprised Conservatives as much as it surprised everyone else. They did not expect to get a majority, and so, in the last few weeks of the election campaign, to give them some chance of forming a minority government, or be the biggest party in a coalition, the Tories went on a rampage of throwing money around in a series of election pledges they did not intend to honour. The problem is that they did get a majority and they do have to deliver the election pledges.

Such pledges include: cuts in inheritance tax, rise in the tax threshold, an extra £8bn for the NHS and (the expensive pledge of) seven day working, right to buy of Housing Association houses underwritten by the public purse and increases in the state pension. Big expensive pledges. All of these come at the same time as a ludicrous law that says that income tax, VAT and National Insurance will not be raised during the Parliament, and an unbelievable pledge that the government will generate a surplus in 2018-19. These expensive pledges have to be paid for and the government have said they will do this with cuts including £12bn to welfare.

Cutting their way to a surplus will be very difficult, so I reckon the government will find ways of raising revenue, and this means they will look towards user charges.

"Prisoner Debt"

The Ministry of Justice estimates that the cost per prisoner is £34k per year (2013-14 pdf). Compare this to higher education students who leave university with (on average) a £44k debt. Assuming that the student debt was generated over a 3 year period, this means an average debt of £14,600 per year per student. Basically - using these contrived figures - prisoners are twice as expensive as students.

The cost of higher education has been "solved", or at least the Conservative government thinks so since they do not intend any significant reforms in the student loan system, except, perhaps, the sale of the Student Loan Company as a asset to pay for their reckless election pledges.

The government has squeezed the provision of prisons, with many prisons privatised, and services like probation moved to privately provided "payment by results". However, these reforms have been more ideological than a sure way to make sustainable savings. It could be argued that there is little scope to make prison provision cheaper, so the only way to reduce the government's contribution will be to find another source of income.

This is why I said above that I think the government will look to user charges. Prisoners cost the state £34k a year, the government could regard this as an "obligation" of the prisoner, just as they regard the cost of higher education tuition to be an "obligation" of the student. Every year the prisoner remains in prison, their "debt" will go up. If the prisoner shows good behaviour and receives a cut in their sentence, their "prisoner debt" will be curtailed. Right wingers like financial incentives and this will fit into their ideology: the prospect of curtailing their "prisoner debt" will make prisoners reform! Of course, giving a prisoner a bill when they are released could be counter productive since most prisoners will not want to be released, so steps will have to be taken to avoid this.

There is a model in student loans that can be used. When students leave higher education they are not presented with a bill and told to pay it immediately. Students do pay off their loans, but not in a lump sum. They pay off their loans gradually via automatic deductions from their pay packet. The infrastructure is there. It works, so why not use it as a mechanism for ex-cons to pay off their "prisoner debt"?

Government Charging Prisoners

Of course, there will be objections to charging prisoners for their spell in prison, but as I have already shown above, the British government already have a precedent for doing this: they charged people who had committed no crime and were imprisoned by a foreign government! If they can charge citizens they know to be innocent, what moral objection will they have to charging people who have been convicted of committing a crime?

You may balk at the idea of charging prisoners for their board and lodging while incarcerated, but bear in mind that many people are already being charged for services that the state should provide and it is likely that other user charges will appear in the next few years ("hotel charges" for staying in an NHS hospital is a likely charge). We have a right wing government, committed to reducing the state, so don't be surprised of the extremity of the schemes they will create to pay for the reckless pledges they made to get elected.

Friday, 27 February 2015

DevoManc: Huge Centralisation of NHS Commissioning

One Health and Wellbeing Board to Rule Them All

The proposals, that are known as DevoManc, are huge, they promise lots and yet there are very little detail about how they will work. Labour should be very cautious about them.

The normal way to make huge changes to how we are governed is for a political party to put the proposals in their manifesto and ask the public to vote on it. Osborne has not done this, so it is legitimate to say it is not democratic and probably not constitutional. At the very least, since it will involve a lot of legislation, there should be a white paper on the DevoManc proposals so that there is a consultation process involving experts. This has not happened, which means that we have a huge change that has not been properly consulted upon. Worse, the negotiations about this policy has involved months of secret negotiations between the (mostly Labour) leaders of the ten Greater Manchester councils and the (Conservative) Chancellor. How can this be a proper way to decide the future of a region, policy by secret meetings?

To any Labour politician who is thinking about DevoManc, I suggest you get yourself a barge pole and keep it far away from this policy.

The DevoManc Memorandum of Understanding (pdf) says under the agreement NHS commissioning will be devolved to the Joint Commissioning Board (GM JCB) this will include:
  • Acute care (including specialised services);
  • Primary care (including management of GP contracts);
  • Community services;
  • Mental health services;
These services are either commissioned currently by the twelve Clinical Commissioning Groups, or will be soon, under NHS England's new plans for co-commissioning. (The only exception is "specialised services" which only makes up 10% of the NHS budget.)

The other services that the GM JCB will commission are:
  • Social care;
  • Public Health;
  • Health Education
  • Research and Development
The first two are currently commissioned by the ten local authorities and, along with the commissioning carried out by the NHS CCGs, are overseen by the local authorities' Health and Wellbeing Boards (HWB). (The last two services in the list will involve further consultations because neither CCGs nor Local Authorities are responsible for them, however, taking the responsibility for training and research out of national bodies is very worrying.)

Think about this. This is not devolution this is centralisation! The only part of the NHS budget that is being devolved is the specialised services which is about 10% of all NHS money spent. That means that 90% of NHS money in the twelve CCGs and the ten local authorities that make up the Greater Manchester Combined Authority will be centralised, not localised.

Also, note that CCGs are membership groups. Were the GPs, who are members of the CCGs, consulted about this, and did they approve it? (For the curious, the answer is no, the discussions were secret, remember.) Primary Care Trusts were criticised for being big and remote, the GM JCB will be the granddaddy of big and remote.

Greater Manchester have already created the GM Health and Wellbeing Board. This is "one board to rule them all!" The very existence of this board means that it will override the subservient boards of the ten councils, localism of NHS and social care in the region will undoubtedly be controlled by Manchester City Hall.

This is in no way like the careful plans that Andy Burnham created. Burnham said that under Labour existing NHS structures would be retained (in particular, CCGs and HWBs). He did this specifically because the very last thing the NHS needs right now is yet another re-organisation. Burnham's plans would be for local HWB to have more control over local CCGs, in particular, to ensure that the "NHS Preferred provider" policy is followed. Burnham is not suggesting a radical re-organisation.

DevoManc is a huge, disruptive change and it cannot go ahead without a lot of legislation (not least, changing the behemoth that is the Health and Social Care Act 2012). It cannot be done before the election. Labour's approach should be to calm this down, point out how reckless it is to make policy by secret agreements and promise after the election to have a proper commission on devolution, and before any legislation is changed, have a white paper with proper public consultation.

Monday, 19 January 2015

Fill in the gaps

This is my response to Bill Morgan in a blog on the Spectator. Bear in mind that Morgan was a Special Advisor to Lansley so there is a whiff of the Mandy Rice-Davies about his post.
You rightly start by saying that the 2010 winter was affected by a flu outbreak. However, you then go on to say that 2011, 2012 and 2013 were uneventful. This is not true. There was more flu and norovirus at this point last year compared with now. Last year the NHS could cope (just) with the flu, this year the NHS cannot cope even without flu. It is this problem we have to address. The run up to Xmas was mild - just like it was the year before - so why wasn't 2014 like 2013?
It isn't a small dip in A&E performance. Every winter you will find that *some* trusts will fail to meet targets (the usual suspects), but what is characteristic about this winter is that *every* trust has been effected, even the best performers. Since the dip (you claim "small", well on the front line it isn't seen that way) is universal, so there must be a universal reason for it. You're right to say that Labour have jumped upon the Lansley "reforms" (well, fragmentation of the NHS) without explaining why it has affected A&E performance. The problem is that most trusts will say that they really don't know - the problem started in the summer when we had winter activity all year with no lull. As you rightly say, no trust, nor NHS England can explain why, but the facts are clear - there are large numbers of frail elderly people, who are sick with multiple conditions and these are the reason for the drop in performance. 
People from different parts of the health service and different political persuasions, will have their theories, but it is rather silly to blame it on the GP contract because the performance problems is not due to the people who would have otherwise gone to a GP. You dispute the cuts in social care, which I think is brave since many social services are close to collapse. (My theory, is that it is community health services, that has failed. I think we have got to the limit of treating people "in the community", at home or in nursing homes, certainly at the level of funding there is now. Nursing homes are a particular problem, there isn't enough NHS medical care in those homes (which is their right), so people are deteriorating unseen. You *can* blame GPs for that. Consequently people are being admitted from care homes in a poorly state. But I can be wrong, just like anyone else.)
You say "the reforms – largely focussed on making doctors responsible for long-term NHS planning", which is a statement from a politician, not from someone with any experience in how CCGs run. Most GPs will tell you that they have no more control or say in how local services are planned. GPs are inherently independent and most of them want to remain so. A few GPs have got involved in CCGs, but this happened with PCTs too. GPs joined the PCT and became managers and those few GPs who have joined CCGs have now become managers too. Analysis I have carried out on CCGs show that less than a third of CCG boards have a GP majority (and mostly, that is the limit of GP involvement). Plus ca change, plus c'est la meme chose.
In fact the fragmentation of commissioning has been a disaster, which is why things are changing now and with co-commissioning CCGs are starting to look just like PCTs. For my condition - type 1 diabetes - there was one commissioner of all the NHS services I use in 2010. Now there are three different commissioners, one for the GP services, one for the hospital services and (bizarrely) another one for the monitoring of my diabetic eyes. None of these commissioners talk to each other. Whenever I ask them why such-and-such service is not integrated with the other services (like it was in 2010) I am told "we don't commission that". It's a mess, and the mess was predicted when Lansley came up with his plans in 2010.
You talk of the timing "why would a set of reforms cause short-term problems in our A&Es two-and-a-half years after most of them were in place". This is a valid question (except your calendar is wrong, the reforms came into place in April 2013, 20 months ago, not 30 months ago). However, I think you are saying "look over there". We know that social care has been viciously cut in the last four years (NAO says a 7% cut in spite of a £1bn from the so-called ringfenced NHS budget every year), and four years of cuts are enough to put that service to the edge. Four years of a deteriorating service is more likely to have an effect than a 20 month old policy, however cracked-pot that police was.
Your Wales argument is a red herring. Wales is mostly rural, it has higher levels of deprivation than England and is arguably too small and too dispersed to be an effective health system. The problem in Wales is not Labour, it is Wales, and maybe we should accept that devolution of the NHS to Wales was a mistake.
Bear in mind that Morgan works for a public relations company and its a fair bet that they have a contract with someone or other connected to the Conservative party, so the piece is more PR than anything else. I thought I would fill in the gaps in the PR piece.

Wednesday, 12 November 2014

Private patients and the Efford Bill

The Efford Bill is a good start into reversing the damage that is the Health and Social Care Act (the Act that "senior Tories" who couldn't be bothered to listen to experts now describe as gobbledegook). However, as you would expect with such a short bill there are few details. In this post I will cover one issue: NHS trust providing private services.

Private Patients and Foundation Trusts

The 2006 NHS Act has a section to restrict the income from private patients that a Foundation Trust (FT) can generate s44:
(1) An authorisation may restrict the provision, for purposes other than those of the health service in England, of goods and services by an NHS foundation trust.
(2) The power must be exercised, in particular, with a view to securing that the proportion of the total income of an NHS foundation trust which was an NHS trust in any financial year derived from private charges is not greater than the proportion of the total income of the NHS trust derived from such charges in the base financial year.
(3) "Base financial year" means the first financial year throughout which the body corporate was an NHS trust or, if it was an NHS trust throughout the financial year ending with 31st March 2003, that year.
This says that the income from private patients as a proportion of the total income of a Foundation Trust must not be higher than the proportion in the financial year 2002/03. If an FT generates a higher proportion it will be in breach of its "terms of authorisation" and this may result in regulatory action (most likely a look of stern disapproval from Monitor).

The section also implies that an NHS Trust which intends to apply to become a Foundation Trust must make sure that its private income generation was proportionally the same as it was in 2002/03 financial year. Since the then government said that every NHS Trust had to become a Foundation Trust this section was more influential on aspirant NHS Trusts than on authorised FTs (GOSH authorisation as an FT was delayed by several years because of its rampant private business). However, the rule was easily circumvented since the section involves income and not numbers of patients, and trusts came up with clever dodges like joint ventures (The Christie) or moving the private work to a charity (GOSH) so that the income to the NHS Trust was the profit of the joint venture company (or the surplus of the charity, donated to the trust) rather than the revenue for private patient treatment. Although the regulator, Monitor, took action against such dodges, the action was closer to a stern look of disapproval than to actual action that would reduce private patient activity.

Although every NHS Trust "had" to become a Foundation Trust, there was no rigid timetable and no sanctions against NHS trusts that failed to become an FT, and so, in practice, NHS Trusts with large incomes from private patients just generated more private business. There were lots of criticism of section 44, particularly in the case of patents. If a trust creates a new device, drug or treatment and decided to create a worldwide patent, the income from licencing under this patient (even if it does not involve UK patients) was still considered part of the private patient income. Furthermore, the omission of the numbers of private patients in the law meant that a trust could treat lots of private patients but charge them small amounts and still meet the s44 criteria.

Health and Social Care Act

The Health and Social Care Act (HSCA) repealed section 44 and replaced it with a more lax restriction. The Tories hoped that repealing this section would result in Foundation Trusts creating private businesses, but this has not happened, certainly not at the rate that the Tories hoped for.

Section 164 of the HSCA replaced the old s44 with this section:
(2A) 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.
This says that NHS income of a Foundation Trust (again, omitting NHS Trusts) must be more than the income from its non-NHS services. It is erroneously quoted as "49% private patients" for two reasons. First the non-NHS income can be more than 49%: it can be 50% less £1. (Does this matter? Yes it does. A small NHS trust will have an income of £200m so the 1% difference between 49% and 50% is £2m, and £2m is not a small amount of money.) The second reason this is not a "49% private patient income" rule is that the section does not mention private patients, it says "total income from the provision of goods and services for any other purposes". That is, any income other than income from Clinical Commissioning Groups (CCGs) or from NHS England. This "any other purposes" includes local authorities, charities and even car parking charges (paid by NHS patients). So a trust that has no private patients will have a non-NHS income under this section, potentially an income of many millions. Yet again, our law makers have made a bad law.

Neither s44 of the NHS Act, nor the new section created by s164 of the HSCA covered NHS Trusts. It is clear that about a third of NHS trusts will never become Foundation Trusts, which means that those third will know that the private patient income restriction does not apply to them in practice. Further, both sections have downsides, covering services other than private patients.

Efford Bill

The Efford Bill has two clauses that cover private patient income: clause 7 covers private patients in Foundation Trusts and clause 8 covers NHS Trusts. In effect, they say the same thing (and hence finally applies private patient income restrictions on NHS Trusts): The following is from clause 7:
(3) An NHS foundation trust shall ensure that its total income from the provision of goods and services for provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness otherwise than for the health services or for which charges are made by the trust is not greater than either—
(a) such percentage of its total income from the provision of goods and services in connection with the prevention, diagnosis or treatment of illness as the Secretary of State shall direct; or
(b) such higher percentage as shall be determined by the Secretary of State for an individual NHS foundation trust.
This says that there will be a private patient income cap, and it will either be a universal cap or it will be set on an individual trust basis. This does not say what that proportion will be, so a Tory Secretary of State can set the cap to 50% to get the same effect as the HSCA. Allowing the Secretary of State to set individual caps is a sop to the rampant privatisers in trusts like Royal Marsden or GOSH who have built up their private businesses to be significant proportions of the trusts' income.

The phrasing of the clauses "for which charges are made by the trust" implies private patients, however, it still covers income, not the actual services or numbers of private patients.

Two Tier NHS

The main reason for restricting private patients is to prevent the creation of a two tier NHS, where NHS patients in an NHS hospital will get second rate services compared to private patients. The Efford Bill clauses do not address this issue.

There are two basic principles that need to be met to prevent the creation of a two tier system:

  1. The treatment of private patients do not adversely affect the treatment of NHS patients
  2. Private services must not be subsidised by the trust from NHS income.

The first principle says that NHS patients should not see the quality of their treatment deteriorates when the trust treats private patients. "Quality" is a broad term, and it could cover things like private patients not having to wait their turn at an outpatients clinic, so the NHS patients have to wait longer, or the re-scheduling of NHS patients treatment because a private patient has chosen to be treated at that time. However, I think the best metric is waiting times, indeed, I think that waiting times are so important that this is effectively a subclause to principle 1:
  1. a) A trust will not be allowed to treat private patients in a speciality where it is not meeting the 18 week referral to treatment target for NHS patients.
The 18 week referral to treatment target (RTT) is a guarantee to NHS patients. A common cause for patients to pay for private treatment is that they are waiting too long. A trust that wants to have private patients (and there are many reasons why they will want this, other than income) there is an incentive to have long waiting lists, so NHS patients have to suffer so that the trust can increase the numbers of private patients.

The second principle says that a trust's private income must be calculated in a business like way, and that there should be no overt or covert subsidies. An example of overt subsidies are diagnostics. If a private patient has a MRI scan that patient should be charged a commercial rate for the scan, they should not be charged the NHS tariff rate which is typically lower than commercial rates.

Covert subsidies are more nuanced. For example, every NHS trust treats emergency patients and so have intensive care units (ICU) able to treat the most ill of patients. Private hospitals typically do not have ICUs, or if they have a unit it is a low level unit. This means that if something untoward happens the private hospital calls 999 and the patient suddenly becomes an NHS patient. Private patients in an NHS hospital have the reassurance that the skills and equipment to handle emergency patients are on site, and indeed, this is often a marketing point for the trust's private patient unit. However an ICU is not cost free, the unit is paid by emergency tariffs and capital charges are paid from the trust's general income. The unit exists for every patient treated by the trust since potentially every patient may need it, and hence the payment for every patient will include a contribution to pay for the ICU. Similarly, private patients should contribute to the funding of the facility, if they don't then that is a covert subsidy.

Amending the Efford Bill

The Efford Bill should have sections to address the principles given above. On an annual basis, an NHS Trust or Foundation Trust must meet the two principles. In the case of NHS Trusts there should be an annual declaration from the trust board that the two principles have been met. In the case of a Foundation Trust the trust's Council of Governors should provide this declaration. In both cases, the declaration will typically come from the trust's auditors who will have a duty to inspect the trust's private patient business.

Meeting the RTT target is so important that on a quarterly basis achievement the RTT target should be evaluated and if the target is not met the trust should only be allowed to treat private patients in the failing speciality following quarter if the trust can give credible assurances that it will meet the target in that quarter.

There are two more changes that should be made to the Efford Bill as described in the next section.

Reasons for Private Income

The usual reason given by trusts for treating private patients is that it provides extra income for the trust (hence why principle 2, above, is important). However, the income from private patients is rarely large (not every trust has a thriving private patient business like GOSH). Using private patients to subsidise NHS treatments has several issues, not least because few private patients like to be treated like a cash cow to subsidise NHS treatments. If NHS tariff is too small to cover the cost of the treatment the solution is to increase tariff, not to subsidise NHS treatments by other activity.

To address this issue the Efford Bill should have a section that says that NHS patients must be taxpayers funded. At the beginning of the bill is a section that says that NHS treatment should be free at the point of use (a version of this section has appeared in NHS Acts since the 1946 Act):
(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.
The mention of charges here refers to the co-pay that exists in the NHS: dental charges, prescription charges, charges for devices like wigs etc. While such charges are abhorrent it is unlikely that they will be removed. There should be an additional clause that says that notwithstanding the income from the charges mentioned in section 1(4) NHS treatments should be funded wholly by the taxpayer. This will remove the excuse that many trust's give that they have to have a private business to subsidise NHS patients. It also puts an onus on Monitor and NHS England, who set the NHS tariff, to ensure that tariff covers the costs of treatment.

The main reason for private patients is HR. Consultants are currently able to do private work even though they are contracted to an NHS organisation. Private patient units in NHS hospitals mean that the consultants do not have to go offsite to run their private business. In all other sectors of the economy this would be called moonlighting and would be disallowed. So to remove this incentive there is a need to change the consultant contract so that they can only work for the NHS organisation that they are contracted to. I doubt if such a change will ever happen, so an alternative would be to say that all income from private patients treated in an NHS organisation should be treated as income of the trust. This will ensure that the consultant is still an NHS consultant regardless of whether the patient is private or NHS. The intention of this rule will be to persuade consultants to treat their private patients in a private hospital, and hence prevent the creation of a two tier NHS.