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

Saturday, 17 July 2010

NHS White Paper Part 4

Autonomy, accountability and democratic legitimacy

This is where the white paper starts to get really worrying. The title should be "De-nationalisation of the NHS". The fact that they even think that they need to reinforce some new idea about the "democratic legitimacy" of the NHS shows what little regard this new ultra right-wing Conservative government have for the NHS. On the subject of legitimacy, what mandate has Lansley got to do this? None. His party could not squeeze a majority at the last election.

Autonomy, accountability and democratic legitimacy

The whole idea of these plans is to shrink the state, and since the NHS is the largest employer in the UK and hence is the state, it goes without saying that Lansley wants to shrink the NHS.

"The Government's reforms will liberate professionals and providers from top-down control. This is the only way to secure the quality, innovation and productivity needed to improve outcomes. We will give responsibility for commissioning and budgets to groups of GP practices; and providers will be freed from government control to shape their services around the needs and choices of patients." (4.1)

There are those silly words again "liberation", "freed". The paranoia of Lansley must be clinical. Here's a clue to you, Secretary of State, the NHS is not an oppressor, quite the opposite, it is the embodiment of the cotton wool of the state caring for its citizens. Lansley wants to "liberate" us from this. He is truly evil.

GP commissioning consortia

What is commissioning? Well someone has to plan for the treatments that will be performed in the near future. So a commissioner determines how many operations will be needed next year based on last year's figures, and then looks in the locality for providers (hospitals) that can do those operations. For a larger locality (say a rural shire) this may mean several different providers. The commissioner then agrees contracts with those providers and this means that they can plan for the staff, facilities and consumables for the coming year. If the commissioner is lucky, the budget for next year will be enough to pay the providers.

At the moment commissioning is carried out by Primary Care Trusts (PCTs) which are local organisations each covering roughly 400,000 people. The PCTs know the local hospitals, know the health problems of the area and have the skills to plan for that population. The large number of people they cater for simplifies commissioning for hospitals because a hospital will usually get the majority of their patients from the area covered by a single PCT. (Tertiary hospitals – for example those who perform organ transplants – will typically treat patients from a much larger area.)

So let's look at the future for commissioning.

"In order to shift decision-making as close as possible to individual patients, the Department will devolve power and responsibility for commissioning services to local consortia of GP practices." (4.2)

GP practices typically cover 15,000 or 20,000 people and most experts say that it is impractical for commissioning to be carried out for such a small population. Lansley recognises this and he expects GP practices to work together as "consortia". Lansley has not yet decided how many consortia there will be. Experts say that they should cover at least 100,000 people so that may mean 600 consortia (quadrupling the number of commissioners?). However, Lansley has suggested that the figure will be lower, and some people have suggested 300, which is twice as many commissioning bodies as there are PCTs at the moment. The more consortia there are the more local their decisions are, but the more costly they will be because they will be duplicating work carried out by neighbouring consortia. Further, the more commissioning consortia there are it means that hospitals will find it more difficult to plan since they will have to handle more commissions. This increases administration for hospitals who are under pressure to cut administration by 30%. Is it possible? Probably not.

However, as you'll see (4.6) it is expected that most GPs will purchase commissioning from private companies. This is privatisation of commissioning, and private providers are likely to be more sympathetic to commissioning private hospitals.

So the bottom line is that GPs will be responsible both for clinical decisions and financial decisions. This is stated blatantly in the white paper:

"It will bring together responsibility for clinical decisions and for the financial consequences of these decisions." (4.4)

GPs should only make clinical decisions. When your GP tells you the treatment that you will receive you want to be assured that it is the best treatment from a clinical point of view and that finance should not be taken into account. This is the case at the moment. PCTs make the financial decision, GPs make the clinical decisions. If the PCT refuses to pay for your treatment then your GP is your friend, your advocate; your GP will represent you and will persuade the PCT to fund your treatment. When the financial and clinical roles are combined who will be your advocate? This is a nasty and dangerous policy.

I have written before about GP commissioning. In the 1990s it was introduced by the Major government when it was called GP fundholding. GP fundholding was optional and not all GPs decided to participate. The white paper gives its opinion about this:

"Fundholding led to a two-tier NHS;" (4.5)

Yes, the patients of GP fundholders had a poorer service!

By 1997 half of English practices were fundholding and so this meant that a comparison could be made between the two systems. The results showed that GPs who were fundholding referred 7% fewer patients to specialists. Think about this. If you are a patient of a fundholding GP there is a 7% less chance of you getting the specialist care you need. On the other hand, a hospital will get 7% fewer patients from fundholding GPs. If all GPs are fundholding, then this represents a real cut in the number of patients going to hospital and hence a cut in hospital funding. Remember that phrase "I will cut the deficit, not the NHS"? Are you starting to understand what a barefaced lie it was?

"We envisage putting GP commissioning on a statutory basis," (4.6)

"a reserve power for the NHS Commissioning Board to be able to assign practices to consortia if necessary" (4.6)

"On a statutory basis" means that there is no option: whether a GP likes it or not, they have to do it, and the NHS Commissioning Board will enforce this action.

"[GPs] will not be directly responsible for commissioning services that GPs themselves provide" (4.6)

This is, of course, the chicken-and-egg question. All GPs treat patients and refer those patients they cannot treat to hospitals. So who will decide how much work a GP practice will perform and how much they will be paid? Wait and see.

At the moment PCTs commission healthcare from GPs and hospitals. They also commission work from pharmacies, dentists and opticians. So who will do this work when the PCTs are abolished (see 4.16)?

"[GPs] will not commission the other family health services of dentistry, community pharmacy and primary ophthalmic services. These will be the responsibility of the NHS Commissioning Board, as will national and regional specialised services, although consortia will have influence and involvement." (4.6)

This is a huge level of centralisation. At the moment these services are commissioned locally by PCTs and hence there is local accountability. The new super-quango, the NHS Commissioning Board, will take over these powers. But they are not limited to commissioning these services:

"The NHS Commissioning Board will calculate practice-level budgets and allocate these directly to consortia. The consortia will hold contracts with providers and may choose to adopt a lead commissioner model, for example in relation to large teaching hospitals." (4.6)

"GP consortia will include an accountable officer, and the NHS Commissioning Board will be responsible for holding consortia to account for stewardship of NHS resources and for the outcomes they achieve as commissioners." (4.6)

So this is who will commission GPs. The hugely powerful super-quango, the NHS Commissioning Board, will commission GPs and determine the additional funds that the GPs are responsible for through their commissioning consortia. But unlike PCTs (who do this work at the moment) there is no public accountability. So if your GP refuses to prescribe you a drug there is nothing that you can do about it. With PCTs there is an appeals board.

"Monitor and the NHS Commissioning Board will ensure that commissioning decisions are fair and transparent, and will promote competition." (4.6)

Note that word competition. We will return to that later on.

"GP consortia will have the freedom to decide what commissioning activities they undertake for themselves and for what activities [...] they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies." (4.6)

This makes the private sector service companies salivate. Roy Lilley from nhsmanagers.net says:

"Commissioning will be managed and influenced by the private sector. The provider side of the NHS will be moved into the private, social enterprise, sector and the NHS will no longer provide services, employ staff or have a responsibility for pensions. The NHS becomes a 'brand' that is franchised to any suitable willing provider; services commissioned, monitored and quality checked by regulators."

Frightening, huh?

"GP consortia will have a duty of public and patient involvement, and will need to engage patients and the public in their neighbourhoods in the commissioning process. Through its local infrastructure, HealthWatch will provide evidence about local communities and their needs and aspirations." (4.6)

So commissioning is statutory but patient involvement in commissioning is merely "a duty"? Where is the accountability?

An autonomous NHS Commissioning Board

We have heard a lot about this "NHS Commissioning Board" so who are they and what will they do? I will go into a lot more detail in another blog post, but first let's have a look at what the white paper has to say.

"through commissioning guidelines, [the NHS Commissioning Board] will help standardise what is known good practice" (4.10)

"[NHS Commissioning Board] will hold GP consortia to account for their performance and quality" (4.11)

This means that the NHS Commissioning Board will tell GPs what to do: a huge centralisation of power. The Conservatives pledge to make decisions local is rapidly draining away. Their plan is to put far more power into an unaccountable quango.

"[NHS Commissioning Board will host] some clinical commissioning networks, for example for rarer cancers and transplant services, to pool specialist expertise" (4.11)

"[NHS Commissioning Board will commission] GP, dentistry, community pharmacy and primary ophthalmic services; national specialised services and regional specialised services set out in the Specialised Services National Definitions Set; and maternity services." (4.11)

This is a centralising power grab from local commissioners. If you are not happy with the maternity services in your area then you will not have the right to complain to a local body, instead, it will be a national, and unaccountable quango. You will have little chance of changing their decisions.

"[NHS Commissioning Board will be responsible for] allocating NHS revenue resources to GP consortia on the basis of seeking to secure equivalent access to NHS services relative to the burden of disease and disability;" (4.11)

The NHS Commissioning Board will hold the purse strings. You will not be allowed to vote them out. There is no accountability.

A new relationship between the NHS and the Government

Let's get this right. The Conservative government believe in a small state and the NHS represents "big state" so by default the Conservative government hates the NHS. Labour governments typically love the state, and love the NHS, so the new relationship is a shift from love to hate. Easy, right?

"the Secretary of State will hold the Board to account on delivering improvements in choice and patient involvement, and in maintaining financial control" (4.14)

This indicates that the NHS Commissioning Board will get their orders from Lansley. The statement indicates how he will wield this power. Through this "choice" agenda, Lansley will impose his privatisation plans.

"The legislative and policy framework. Responsibility for Department of State functions will remain with the Secretary of State. This includes determining the comprehensive service which the NHS provides" (4.14)

"The mandate [of the NHS Commissioning Board from the Secretary of State] is likely to be over a three year period, updated annually. The mandate will set out the totality of what the Government expects from the NHS Commissioning Board on behalf of the taxpayer for that period." (4.15)

So Lansley is allowed to decide which services that the NHS will provide (and pay for)? With this power how Lansley will be able to introduce co-pay and health insurance, which are the second term plans of the Conservatives (and Nick Clegg).

Freeing existing NHS providers

More nonsense phrasing in this nonsense white paper: NHS providers are not shackled, so they cannot be "freed".

"Our ambition is to create the largest and most vibrant social enterprise sector in the world." (4.21)

This is a hugely ambitious and risky plan. Social enterprises are private companies. Yes, you read that right, the government want to privatise NHS hospitals.

Roy Lilley (nhsmanagers.net) says:

"Social enterprises are not part of the NHS. Neither are they part of the public sector. They are businesses. They have a social purpose, but they are a business. They are only 'different' because they generate 'profits' that must be recycled into the business and not taken out as dividends or profits."

So when the white paper says

"As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises [...] Foundation trusts will not be privatised." (4.21)

Lansley is clearly lying.

"Patients will be able to choose care from the provider they think to be the best." (4.21)

This is the Patients' Passport that David Cameron devised for the 2005 election and the public rejected. The man just could not take rejection, could he? The problem is that every patient that goes to a private provider is one less that will go to the local NHS hospitals and hence this is a cut in the hospital's funding. Patients must be made aware of this savage equation.

"As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients." (4.21)

These are effectively management-buy-outs and they are not necessary because Foundation Trusts already have the power "to use their front-line experience to structure services around what works best for patients". This is not about patient care it is about privatisation.

"we envisage that some foundation trusts will be led only by employees; others will have wider memberships" (4.21)

Foundation Trust memberships are patients and the public and are the mechanism whereby the trusts are kept to account. However, this statement only mentions Foundation Trusts not social enterprises. The white paper does not say what, if any, governance arrangements will be required of social enterprises. The most likely arrangement is as little as possible.

However, even though Foundation Trusts will only survive another three years, their governance model of Foundation Trusts will be changed for the last few years of existence:

"we intend to consult on [...] whether we should enable foundation trusts to tailor their governance arrangements to their local needs," (4.22)

At the moment, if your local hospital is a Foundation Trust then you will have an opportunity to vote for, or stand as a governor. This opportunity will be changed as it is "tailored".

"We will complete the separation of commissioning from provision by April 2011 and move as soon as possible to an "any willing provider" approach for community services, reducing barriers to entry by new suppliers." (4.24)

"Any willing provider" means that the service will be contracted to a private provider. This statement means that the provision of community services – district nurses – is being privatised.

Economic regulation and quality inspection to enable provider freedom

Gosh, that weasel word, "freedom", again. Those poor hospitals should complain to the UN.

"Our aim is to free up provision of healthcare, so that in most sectors of care, any willing provider can provide services, giving patients greater choice and ensuring effective competition stimulates innovation and improvements, and increases productivity within a social market." (4.26)

What more can I say? This is privatisation.

"[The role of Monitor] Promoting competition, to ensure that competition works effectively in the interests of patients and taxpayers. Like other sectoral regulators, such as OFCOM and OFGEM, Monitor will have concurrent powers with the Office of Fair Trading to apply competition law to prevent anti-competitive behaviour;" (4.27)

Monitor currently regulates Foundation Trusts and ensures that they maintain quality levels in finance and healthcare provision. Now they will be in charge of creating a free market of healthcare and they (and the OFT) will apply competition law to healthcare provision. This is worrying. Polly Toynbee says:

"Monitor is to become a competition regulator, whose first duty is to enforce a free market. Opening everything to the market means all NHS contracts fall for the first time under EU competition law, so tenders must be advertised internationally. GPs favouring local providers can be challenged in court if their consortium rejects a cheaper offer from a loss-leading large company: cue extreme disruption for local hospitals losing out to private bidders."

This means that unelected EU commissioners will decide who runs your local hospital. Did you vote for that?

Monitor's scope and powers

This section covers Monitor's powers and I will list the significant changes.

"Monitor should have proactive, "ex ante" powers to protect essential services and help open the NHS social market up to competition" (4.28)

This means that the unaccountable quango, Monitor, will make decisions about the providers in your area. If they decide that too much work is carried out by your excellent NHS hospital, they will have the power to remove services and hand them to private providers. Monitor will become another arm of the Lansley privatisation machine.

"[Monitor will be able to] require monopoly providers to grant access to their facilities to third parties;" (4.28)

The is Lansley's pledge (given at their smug manifesto launch at Battersea Power Station) to "invite-in the private sector". In effect, it means that if a private company likes the look of your NHS hospital's facilities, Monitor will demand that they be allowed to use them. Private providers can come in to NHS hospitals and use NHS facilities. Nasty, eh?

So with this power to close down NHS services to provide "competition" and to force NHS hospitals to allow private providers use their hard earned facilities, Monitor is clearly the friend of the private sector. And it gets worse:

"Monitor's powers to regulate prices and license providers will only cover publicly-funded health services." (4.29)

This means that there is one law for the NHS another for private providers.

Training and education

At the moment the state pays a large amount towards the training of clinicians. Sure, tuition fees claw a small proportion back but largely we regard the training of clinicians to be a social responsibility because we all benefit. (In my opinion, the move to tuition fees was an abomination, the state should pay for all training and simple income tax should claw back the advantages that people get from this state sponsored training.)

"In future, the Department will have a progressively reducing role in overseeing education and training. [...] Healthcare employers and their staff will agree plans and funding for workforce development and training; their decisions will determine education commissioning plans. [...] All providers of healthcare services will pay to meet the costs of education and training." (4.33)

This means that NHS hospitals will be responsible for funding training. This is a huge new expense for NHS hospitals, so will the government provide more money? (Hint: no.)

NHS pay

I am not sure why they have this section because all hospitals will be social enterprises and hence responsible for their own employment policies. In this section paragraph 4.35 complains that currently ministers have too much control over pay and paragraph 4.36 says that "pay decisions should be led by healthcare employers rather than imposed by the Government". However, as is typical with this nasty government, they say one thing and do another because at the moment they have imposed a pay freeze on the entire NHS.

NHS pensions

This section says nowt.

It is important to remember that hospitals are supposed to become "social enterprises" and this means that each hospital will have the responsibility of providing pensions rather than the NHS. Employees will no longer be allowed to accrue contributions to their NHS pensions – ie from the point that a hospital is privatised as a "social enterprise" employees will not be allowed to make more contributions to their NHS pensions and will have to take out a private pension.


NHS hospitals will be privatised as "social enterprises". They will be commissioned by GP consortia, and the most likely model will be the consortia buying commissioning from private services companies, so this is privatisation of commissioning. There will be an "any willing provider" policy which means private companies will be asked to do NHS work and healthcare will be subject to competition law, from the UK and the EU, which may result in the EU competition commissioner specifying that an NHS provider cannot provide services. Monitor will enforce this competition and will also force NHS hospitals to allow private provider use their facilities. There will be a massive centralisation of power in the new super-quango called the NHS Commissioning Board who will commission GPs and determine how commissioning consortia will commission hospitals, and the Board will have the responsibility of commissioning dentists, opticians, pharmacies and maternity services. And Lansley will get to tell them how to do this.

Wake me up please, this must be a nightmare.

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