Dimwitted Dorries

This blog is called Tory Lies because I was incensed when I first heard David Cameron tell the country how he would "protect the NHS" since I had read the Tories NHS plans from 2006 and 2008 that said precisely the opposite.

If there is an embodiment of Tory Lies it is Nadine Dorries. If I was charitable I would say that it is not her fault. She is rather dim and she feels that she has to say something, and hence makes everything up on the spot.

Look at her latest blog post. So here she is castigating the £260 million spent on "management consultants" without explaining who they are. As it happens these are private sector contractors like lawyers, architects and IT consultants. This is very much the "any willing provider" policy that Tony Blair was keen to use in his scheme to get more private sector involvement in the NHS (something I was against), and it is something that Andrew Lansley will make compulsory. But dimwitted Dorries says:

"something Andrew Lansley put a stop to by imposing a consultancy spending moratorium on day one"

Umm tell me, does that mean that Lansley is going to cancel the "any willing provider" plan? No. I thought not. So in fact Lansley will increase the amount of money that will be spent on private contractors.

Then dimwitted Dorries says:

"The opposition have also begun to describe GPs as the private sector within the NHS."

Remember that this woman is a member of the Health Select Committee? She does not know that GPs are independent contractors? She does not know what a "practice" is? She does not know that GP practices make profits which are shared between the partners (or re-invested in the practice)? How dimwitted can she be?

But this really got my goat:

"GPs will no longer have the PCT breathing down their neck, watching every penny they spend and on who, telling them what services they can procure and which they can’t."

This sounds like GPs will have a huge pile of cash and will be throwing it around at every healthcare issue. No. GPs will be under immense pressure to save money in the next few years. Let's take one simple example. At the moment there are 152 PCTs and the cost of their commissioning work is £1.85bn a year. There will be an estimated 500 GP Commissioning consortia (which will inevitably duplicate the work of neighbouring consortia) and they will be paid £1bn to do commissioning. Lansley has not published the reasons why he thinks 500 consortia will be able to do the work of 152 PCTs for 54% of the money and the suspiciously rounded figure suggests that it is a number pulled out of thin air. Moving from 152 organisations to 500 organisations is the opposite of "economies of scale". If GPs are going to to commissioning at the standard of PCTs then they will have to spend more.

GPs will have no choice, they will have to do commissioning. Remember section 5.14 from the White Paper (something that Dorries clearly has not read)?

"the Government will not bail out commissioners who fail"

This means that if GPs do not have enough money to do the necessary commissioning from the management fees paid by the Department of Health then they will have to dip into their budgets for providing healthcare. Or worse, (and this is a real fear expressed by many GPs) they will not do all the required work like risk management and performance management. The GP consortia will provide "commissioning lite" which means that the large hospitals will dictate to a consortium the fees it will charge and that they will pay rather than negotiation between the consortium and the hospital. GP consortia will be too small to have any clout against the large hospitals (which, remember, will also be private-sector businesses and duty bound to maximise their income). Inevitably this will make costs rise.

Yes, many GPs dislike PCTs but most GPs appreciate the fact that they are there. Why? Well, up until now the Hippocratic Oath that defines the work that GPs do says that the GP must give the patient the treatment they need based on their clinical judgement. In fact, by law they have to do this because it is enshrined in their contract. But the White Paper says (4.4)

"bring together the responsibility for clinical decisions and for the financial consequences of these decisions"

This says that GPs will no longer make decisions purely on clinical grounds, they will be duty bound to make decisions based on the financial consequences. In the past it was the PCTs who handled the financial side, it was the PCT who had to find the money to allow GPs to make their decisions based purely on clinical decisions, but under Lansley the GPs will no longer have the insulation of passing the tough financial problems over to the PCTs. In the future a patient will not know whether the decision their GP is making is a clinical one, or a financial one. GPs, understandably, do not like this. Dimwitted Dorries does not seem to realise that this edict from Lansley will destroy the trust that patients have in their GPs.

Nudges

The Tories are well known for their admiration for the work of Richard Thaler, the author of Nudge: Improving Decisions About Health, Wealth, and Happiness. basically, you give people a nudge and then they do what you want (well, I guess there is more to it than that).

So here is one example of a nudge:

1. Take an authoritarian who will not listen to anyone else and will not compromise
2. Get the authoritarian to write his plans for the future which scares everyone shitless with the audacious scope for disaster
3. Tell them that there is no alternative (TINA (c) Margaret Thatcher) 
4. Wait and see what happens

After running around like headless chickens for a month or so most of the people will decide that since TINA the only way that they can guarantee any future for themselves is to try and be the first to implement the plans.

This appears to be the case with Lansley's plans for so-called social enterprises. Let's just put to one side that no one in the world has ever created the large number of large social enterprises att at the same time that Lansley plans. Let's just put aside that when the public finds out that by making all hospitals and community health services social enterprises is actually privatising the majority of the NHS. Let's just put all of that aside for a moment. Let's just consider commissioning.

The nudge here is a big bloody punch in the solar plexus: PCTs will be abolished by 2013. The big problem with this plan is that the PCTs do something useful: they have the expertise to be able to plan for the healthcare needs of an area. Lansley says that GPs will have to do this in the future, but most GPs say that they don't have a clue how to do this. This may mean that in some cases PCT commissioners will take on jobs with the new GP commissioning consortia and continue their work there. The problem is that there are expected to be about 500 consortia, as opposed to the 152 PCTs which means that the economies of scale are in the wrong direction. (No one explained this simple fact to Commissar Lansley, but then I guess they decided not to annoy him in fear of their jobs.) Another option is for the PCT commissioners to move to private sector companies, but contrary to what Cobnservatives tell you, the private sector is invariably more expensive than the public sector.

So now we hear from Pulse thatPCTs are thinking of becoming social enterprises and selling their expertise to the GP consortia:

'The advantages are there are a lot of skills within PCTs. I think it would be a disaster for the health service to make all these people redundant, put them into private companies to be sold back to the health service at increased rates. Nor do I think the private sector currently has the people or the skills to support all the potentially 500 consortia.' Dr Nigel Watson, chair of the GPC’s commissioning and service development subcommittee

So the Commissar gets his way. Before the law has even been written people are already doing exactly what he wants. Nudges clearly work.

GP Commissioning may cause a £2bn deficit

Sally Gainsbury from the Health Service Journal has been doing some excellent work trying to find out the consequences of GP commissioning. In the Health Service Journal today she has published an analysis of her work (available here, but you need a subscription to access it).

The main points are that the previous government trialled GP commissioning with a programme called Practice Based Commissioning. PBC is not exactly the same as GP commissioning because the GPs were given "indicative" budgets meaning that there would be no negative effects on the practice if they overspent. The study was on data of 3 years of financial returns for 33 consortia (2,000 GP practices or a quarter of all practices in England).

The results were that in total the PBC consortia overspent by 2.5% or £289m, with some 25% of consortia overspending by 5%.

Of the 159 consortia overspending, 47 did so by more than 5 per cent and 12 did so by more than 10 per cent. Five consortia overspent by 20 per cent or more.

If these results are applied across England then the GP Commissioning Consortia will overspend by £2bn. When asked about what causes the overspend Sally Gainsbury said that it was caused by GPs referring "sending more patients than they were profiled to hospital". In other words, they had too many sick patients who needed treatment.

The Department of Health responded to this study with the very unprofessional response of "nonsense". They point out that since PBC did not have the "stick" of overspends affecting them negatively there was no incentive not to overspend. This is a real admission that the whole point of GP commissioning is to force GPs to ration healthcare and so transfer the blame from the government to GPs. At this point I should mention White Paper section 5.14:

"the government will not bail out commissioners who fail"

In other words, the deficit from the overspend is your responsibility. The only way that a GP can prevent such overspends is to refer fewer patients and to do this on financial grounds only. GPs will ration healthcare, and will be seem by their patients as rationing healthcare. I do hope that those GPs who are enthusiastic about GP commissioning pay more attention to this: it will only lead to patients hating GPs.

Sally was interviewed on the Radio 4 Today programme this morning at the ungodly hour of ten to six. Luckily you can listen to the interview on iPlayer (listen here the interview is at 51m24s).

100 day that spelt the end of the NHS

This is from Pulse

NHS Alliance: White Paper is about closing hospitals

It is true, GPs reckon that the White paper will give them an opportunity to take work off hospitals. I have said before that Lansley hates NHS hospitals Dr Donal Hynes, co-vice chair of the NHS Alliance, has confirmed that the intention of the White paper is to take services away from hospitals (quoted in Pulse):

'The critical issue facing the NHS is delivery of service improvement within budgetary restraint. To achieve this, GP consortiums will need to have community services aligned with primary care services so as to facilitate the transfer of work from acute hospitals. ... It is not only contrary to the direction of the White Paper but also will potentially provide a serious impediment to its implementation.' 

 If you "transfer work from acute hospitals" then it means the hospitals will have no income, hence they will close. Dr Hynes proves that Commissar Lansley hates hospitals.

GP Committee of the BMA responds

The GPC have provided their response to the NHS White Paper (available here). Here are some of their "lines in the sand" principles

GPs must always provide patients with advice, investigations or treatment where necessary. The investigations or treatment provided or arranged must be based on the assessment of needs and priorities, and on clinical judgement about the likely effectiveness of the treatment options.

GPs must give priority to the investigation and treatment of patients on the basis of clinical need, when such decisions are within their power. If inadequate resources, policies or systems preclude this, and patient safety is or may be seriously compromised, the matter must be drawn to the attention of the appropriate authority.

This seems to me to be rejecting the White Paper sections 4.4 and 5.12 which says that GPS should "align clinical decisions in general practice with the financial consequence". GPs, understandably, do not want to be held accountable for any financial consequence, and neither should they be.

GPs involved in commissioning need to receive adequate resource and support to undertake the work involved in commissioning services for their patients and the wider population.

GPs are quite frightened by the potential that taking on the commissioning role will put their practices in financial risk. They are frightened that Lansley may decide that GP consortia will have to take on the debts of the PCT they replace, and that the resources being offered by the Department of Health are too limited to cover the work they will commission and so they will be liable for any overspend. The are concerned about the White Paper section (5.14) which says "the Government will not bail out commissioners who fail". The GPs are rightly worried about this because GP commissioning will be compulsory (but see below).

GPs must not accept any inducement that may affect or be seen to affect the way they treat or refer patients.

This is the GPC saying that they do not want to be seen to be using patients as cash-cows. It will be a fundamental change in the relationship between the patient and doctor if the patient thinks that the doctor regards their treatment as a down payment on their next Mercedes. It is yet another swipe at sections 4.4 and 5.12 of the White Paper. However, remember that GPs are private businesses so they cannot completely rule out the prospect of making some more dosh:

If GPs have financial interests in organisations providing healthcare these interests must not affect the way GPs prescribe for, treat or refer patients. If a GP has a financial interest in an organisation to which they plan to refer a patient they must tell the patient about these interests.

This is rather weak. It is saying that if the doctor wants to get some money out of a patient (directly, or indirectly through NHS commissioning) they can use their unique trust relationship to persuade patients that this is OK simply by telling the patient that it is so. The GPC must hold the high ground here, they should say that a GP should NOT refer a patient to an organisation where they have a financial interest. If such a referral is needed then the patient should be given a second opinion.

Consortia should be required to consider the implications of their decisions on their local population, patients within other GP consortia and the wider NHS health systems, and wherever possible, consortia should ensure that NHS providers are the providers of choice. Consortia must be committed to reducing healthcare inequality wherever possible.

This statement will upset Lansley immensely because it will kill his "any willing provider" policy and also it will render his policy of competition within the health service as pointless.

Public and patient involvement should be integral to the work of consortia. Challenging decisions concerning treatment priorities may need to be taken based on a mutual understanding of the constraints of limited resources, and the obligation to use such finite resources wisely. The consortium must be accountable to patients and the public who will need to participate in such decisions.

GPs are "scared witless" that the public will blame them for healthcare rationing. The GPC appear to think that "patient involvement" will insulate them from this criticism. Unfortunately, this is rather optimistic. GPs will be blamed.

Resources liberated from service redesign or changes in referral patterns will need to be reinvested in patient care. GPs must not personally profit from a commissioning budget surplus , which should be used for patient services. There must be no integration of the commissioning budget with payments to the practice for providing essential primary medical services under their GP contract. This will ensure that trust remains between patients and their GP.

This is the "Mercedes down-payment" argument that I mentioned above.

Practices will be expected to engage with commissioning consortia. It must be accepted that the relationship between populations, patient need, budget and financial activity is complex and in this regard consortia will be expected to act with integrity and leadership when considering the accountability of practices. No sanctions should be taken against practices where it can be demonstrated that GPs are acting within the expectations of the principles outlined in this document and where professional and contractual obligations are being fulfilled.

This is finger pointing at White Paper section (5.14), GPs are saying that if they try their best they should not be held financially responsible. There is fat chance that Commissar Lansley will agree to this.

It will be interesting what the GPC will do if they feel that Lansley has not addressed their concerns.

UPDATE:
Pulse have reported that the GPC is unhappy that the government will re-write their contract to make commissioning compulsory and "will instead push for it to be offered as an optional enhanced service".

New £50 million cancer fund already intellectually bankrupt

That is the title of an article in the Lancet. It is extremely damning, as summed up by this extract:

Scratch the surface, and it quickly becomes clear that what this fund represents is not the victory for patient groups that some believe. Rather, it is the product of political opportunism and intellectual incoherence.

The idea is that Lansley will provide £50m between now and April and then (supposedly) £200m a year divided between the ten Strategic Health Authorities (SHA). If a doctor wants to prescribe a cancer drug that has not been approved by NICE (and hence will not be funded by a PCT) s/he can appeal to the SHA panel for the money. The money is limited and so there is no guarantee that the appeal will be successful. The Lancet says that this will lead to a postcode lottery:

This raises the spectre of appeals being granted or declined not on the basis of patients' conditions, but because of where they live: either because their SHA has exhausted its share of the fund, or because their SHA is using stricter funding criteria.

Further, they say that to meet the demand the fund should be £600m rather than £200m, so the same issue will continue: people will claim that they are not getting the drugs they need. The creation of this fund is purely political and is taking away the ability of experts to do what they are paid to do. Lancet comments:

Remarkably, health ministers claimed that the fund would not undermine NICE. But, let us be clear: it not only undermines NICE, it undermines the entire concept of a rational and evidence-based approach to the allocation of finite health-care resources.

We really have let idiots into the Department of Health.

Private money for public health?

I try not to write about LibDems because I regard them as deluded human shields. However, it is interesting to read this blog from the equalities minister the LibDem MP Lynne Featherstone has cottoned to the fact that Lansley's changes to the NHS will be damaging. Here's her blog post in full (2 August 2010):

Andrew Lansley, according to this morning’s Guardian, is removing the cap on NHS hospitals making money from private health provision.

Concerns have been raised as to whether this will create a two-tier system of health provision and reversion to longer waiting times for NHS patients with private patients jumping the queue.

If those concerns could be addressed – would it be a good thing to reap the profit for the NHS given that it is NHS training that our doctors and consultants get?  If private money could be poured into the NHS rather than watch those profits go to private providers would that be a good way to address the looming funding gap (with the caveats as above) or not?

Please Lynne read the NHS White Paper. Lansley's plans are that private patients will be allowed to use NHS facilities - the OFT will use competition law to force (former NHS) social enterprise hospitals to open access to private companies to their facilities. Do you really think that a private patient will wait in a queue behind NHS patients? Of course not.

OK time for an anecdote. In the early 90s a friend, who I shared a house with as a student, was diagnosed with cancer. He was a trainee accountant and his company had paid for health insurance for him, so he was entitled to private treatment. In actual fact he was treated by an NHS consultant doing private work in his spare time in a private hospital. The doctor decided that my friend needed an MRI scan. In those days MRI machines were so expensive that a single  hospital could not afford to fund one, so five local hospitals funded a machine. The MRI machine was installed in a container lorry and driven around the area spending a few days at each hospital. My friend's doctor booked him for the scan and to this day I remember the look of horror on my friend's face as he describe to me the disgraceful scene. He told me how he was taken by private ambulance to the hospital, put in a wheelchair and taken to the MRI lorry. There was a long queue of NHS patients: beds, people in wheel chairs, the walking wounded on chairs. He was wheeled straight to the front of the queue and had his scan. He was mortified. That is what private healthcare is all about.

Lynne, I am glad that you have recognised that there is a problem, but there is no "clever thinking" way out of this. The fact is Lansley's plans are deliberately to create a two tier system that will mean that the poor will be treated like shit. Please think over this issue some more, and then come to the right decision that Lansley truly is a monster and not someone who you should be in coalition with. Please kill these plans before they do real damage.

NHS Commissioning Board

Lansley is washing his hands off of the NHS, he basically cannot be bothered to be responsible for anything that involves work. One of the ways that he will do this is creating a super-quango called the NHS Commissioning Board. According to Alisdair Stirling in Pulse:

But Dr Jenner believes it will have to be big. ‘It will need quite a lot of regional offices. Apart from managing at least 500 consortiums they have the other 5% of things consortiums don’t do. My guess is that there could be 30 regional offices but it could be more.’

Hardly a cost-saver, but then none of this is about saving us any money, it is all about Lansley selling off anything that isn't nailed down. Worryingly:

In common with other boards, the NHS Commissioning Board is likely to have a chief executive and executive directors as well as a chair and non-executive directors. This means the likely involvement of the Appointments Commission and a possible way in for the private sector in non-executive director roles.

So the private sector will be in charge of the privatising. I guess that makes sense.

Unison Fights the NHS White Paper

Unison have started a judicial review about the undemocratic way that Lansley is implementing his plans for the NHS before he has been given Parliamentary approval. From politics.co.uk:

The union claims that the day after the white paper was published, NHS chief executive Sir David Nicholson wrote to all NHS chief executives instructing them to start implementing the proposals "immediately".

Unison then says it wrote to Sir David telling him the order was illegal, because it failed to properly consult the public, as required under the NHS partnership agreement, the NHS Constitution and section 242 of the NHS Act.

Karen Jennings, Unison head of health explains:

"The NHS Constitution enshrines the principle that the public, staff and unions have an absolute right to be consulted," she wrote.

"And that means not only on how the proposals are to be implemented, but also whether they should go ahead in the first place.

"The Department for Health's refusal to recognise this clear and important legal duty leaves us no option but to issue legal proceedings as a matter of urgency."

This government has no electoral mandate, and encouraged by the fact that they can govern without a mandate they are completely ignoring our democratic rights and parliamentary procedure.

PCT Deficits

The way that most NHS care is funded is through Primary Care Trusts (PCTs). The Department of Health uses a magic formula based on the population covered by the PCT to determine the big pile of cash that the PCT will be given. And it is a big pile of cash, for example, my local PCT (by no means a large one, about 535,000 people) is handed around £800m a year (about £1500 per head of population). The PCT then has to pay GPs (about 9%), deliver mental health (10%), community services and continuing care (15%), pay dentists, opticians and pharmacists for their NHS work (10%) and pay for our prescriptions (10%). The bulk of their money (48%) goes to hospitals.

The remaining 3% goes to pay for managing this huge amount of money, but what do those managers do? Well they have to use their experience and knowledge to determine what the healthcare needs are for the following years and agree contracts with the suppliers of those services. They also have to manage things like performance benchmarking and risk assessments. If they do their job well then at the end of the financial year they will have kept within their budget. If they are doing very well they may even make a surplus.

Unfortunately the magic formula used by the Department of Health does not necessarily provide enough cash for the healthcare needs of an area. Or maybe there is an unexpectedly large number of people getting ill one year. Or maybe the PCT managers just got their sums wrong. The result is that some PCTs generate a deficit. Earlier this year the Guardian published some research that said that a third of PCTs had generated a deficit. The NHS Alliance go further and suggest that "as many as three quarters were hiding debts by borrowing money from other trusts".

Commissar Lansley wants to hand 80% of commissioning over to GP consortia. GPs are understandably wary about this. (There are a few loud mouthed GPs who think that this is the best thing since their last pay rise, but they are at the dimmer end of the spectrum since they have not yet even seen the fine print of the deal.) The problem is that the GP consortia will replace PCTs which leaves the tricky question of: what happens if the PCT has a deficit? Does the debt get split between the consortia in the area? (Remember that GP commissioning will be compulsory.)  The Department of Health is being very cagey about this issue.

Healthcare Republic reports:

GPC member Dr Nigel Watson said GP commissioning would be a 'non-starter' if consortia had to begin operating with large deficits. 'If you're going to be a consortium's accountable officer why would you take that on starting with a deficit?' he said. 'They have to resolve this.'

GPs clearly are not happy about taking over PCT deficits and so Commissar Lansley will have to come up with a solution. Most likely he will write off PCT debts so that consortia will be handed balanced accounts. If this happens it will be yet another addition to the ever growing costs of the most dimwitted and costly experiment in the history of the NHS.

However, even if PCT debts are written off one still has to question why a PCT went into deficit in the first place. It is not necessarily poor management. As I said above, the Department of Health has a magic formula which does not always get it right. The NHS White Paper says that the government will not bail out a consortium that goes into debt. If the magic formula is wrong then GP consortia starting with a balanced account will not avoid going into debt and there will be no public handout. GPs are rightly worried about this situation and if they feel that there is a serious financial risk (remember that GP practices are private businesses) then they could well send Lansley back to the drawing board to come up with a plan more palatable to them.

Perhaps the GPs will require that Lansley creates public organisations that insulates them from financial risk and also takes the blame for decreasing funding? Perhaps some kind of trust for funding primary care? Hmm.

This is from Anna Dixon's blog at the Kings Fund:

"The other factor likely to make implementation more challenging is that the reform proposals themselves dismantle the very apparatus used in the past to get things done in the NHS – targets and performance management by strategic health authorities and primary care trusts. A reliance on choice and competition and the motivations of professionals and clinicians to drive the changes is a gamble."

This sums up my attitude: "choice and competition" will not improve the NHS in the short term and in the medium, term it is likely to make the service worse for many people as competition closes down under performing hospitals. Ms Dixon concludes:

"If the proposals are to succeed, the government needs to engage and motivate clinicians and managers to work effectively together. They ultimately will lead change across local health economies and deliver improvements in quality and productivity. It is unlikely that managers, who face potential redundancy, and clinicians, who are being given new responsibilities without any increase in pay, will feel ‘liberated’ by the government’s plans. Instead, the government runs the real risk that these structural and organisational changes will distract from the real task of clinically led service change"

 It is almost as if Lansley's plans are designed to fail. I wonder who would step in to provide healthcare in the UK if that happens?

Andrew Lansley is the Dr Beeching of the NHS.

Private Centres in NHS Hospitals

This is from International Medical Travel Journal:

Manchester's Christie Hospital plans to treble its private income from £10 million to £30 million within 10 years thanks to a deal with US-based private hospital group HCA which will see the company pay £14 million for a new private cancer centre. 

That would be the Hospital Corporation of America, "the largest private operator of health care facilities in the world". In the 1990s it merged with Columbia Hospital Corporation. This is what Wikipedia has to say about them:

In December of 2000 Columbia/HCA pled guilty to Medicare and Medicaid fraud and agreed to pay criminal fines, civil penalties and damages of over $840 million.[5] In 2003 HCA agreed to pay an additional $871 million in civil penalties and damages for cases of fraud and kickbacks. The total of over $1.7 billion for these cases made it the largest fraud settlement in US history at the time. Then-CEO Rick Scott was ousted by the board of directors but he was not criminally prosecuted. In 2009, Rick Scott also spearheaded Conservatives for Patients’ Rights, the largest-membership lobbying group against healthcare reform.

These are the sort of people we are handing our NHS over to. Fightening, isn't it?

More Worries Over GP Funding

According to Healthcare Republic

45 per cent of GPs feel they are being pushed too quickly into consortia, and that 55 per cent think their autonomy and independent contractor status are at risk

Part of the reason why GPs are reticent is that GPs may be handed debts of PCTs. The Department of Health is apparently either clueless or are hiding what will happen about the issue at the moment.

Although there are some GPs who are enthusiastic about GP commissioning, most seem to regard the plans as a "poisoned challis".

GPs unsure about White Paper

GP newspaper in conjunction with the Family Doctor Association have surveyed 700 of their members and have found that 41% think that it will create a postcode lottery; 71% think that it will increase private involvement and only 19% think that it would improve patients' experience. The results are reported in Healthcare Republic.

What is Lansley Up To?

Health Policy Insight have an interesting scoop, you should read it over on their website. Basically, onm the sly, the Department of Health has bought 48.75% of Dr Foster Intelligence from the NHS Intelligence Centre (an arm's length organisation) for £8m. They didn't tell anyone that they were doing this. This goes against Lansley's free market privatisation ethos, after all, Dr Foster Intelligence is just the sort of organisation to hand over to the private sector since there are plenty of private sector companies in the same business.

Smells fishy.

White Paper Criticisms From The Centre Right

The Bow group, the oldest of the centre-right think tanks, have produced a report on the NHS white paper and they express concerns. In effect, they are saying that the NHS is a huge organisation and no one has ever made such large changes to such a large organisation and so the risks are high.

They say that Lansley is making wild claims about how much money he says he will save:

"the White Paper is not so clear on where precisely the pledged £20 billion will be saved and is even less clear on what constitutes the promised 45% cuts in “management costs”"

They go on about these wild claims even suggesting that the plans have no basis:

"Although we know that PCTs and SHAs are under “death sentence” and will soon be wiped off the NHS organogram, promises to “clear backroom staff”, “cut bureaucracy” and “make efficiency savings” confer a degree of vacuity that does raise important questions about how the theory will be mapped into practice."

Their conclusion is not encouraging:

"To put it bluntly, Andrew Lansley will either be remembered as the great reformer or the great failure."

My opinion is that if Lansley is allowed to go ahead with his plans, he will be known in the future as the Dr Beeching of the NHS. Their final statement is all too true, and rather chilling:

"After all, the NHS is just too important for failure to be an option."

Spending Review Website

This Conservative government is rapidly gaining a reputation for not having a clue about the internet and "social media". We have seen the laughable attempts at "crowdsourcing" through Nick Clegg's vanity project the "Your Freedoms" web site (which mostly attracted vile racist suggestions) and the Treasury's spending review website is not much better. Of course, we all know that the reason for these websites is to give legitimacy to what the Conservatives have already decided to do, but you would have thought that they could have put some effort into making it appear that they are paying the suggestions some attention.

After receiving some 44,000 responses the Spending Review website is now asking the public to rate the suggestions. My guess is that this is just a displacement activity to get people to waste their time reading this drivel when they could spend their time reading actual government policy and then taking action. Lets have a look at some of the suggestions for the NHS.

Get the ratio of people managers to beds right. If you have more people managers than beds you're doing something wrong.

What is the point of this statement? It is just saying "do your job properly"? Does the questioner actually know what the ratios are, and does s/he have an idea of what the ratio should be? As I have mentioned before, just 3.6% of NHS employees are managers as opposed to the population as a whole where 16% say that they are managerial (ONS figures).

Here's one that crops up several times:

Charging for doctors appointments so people don't go for minor things.

So what are these "minor things"? They don't give a list. I have a clue for them: the patient is not qualified so how will they know what is minor and what is a symptom of something serious? I think that charging any money at all will break the unique relationship that patients have with the NHS, so I don't want to advocate any such scheme. However, if the respondent had thought just a little bit they may have decided that fines are a better scheme because the people who would be penalised are those who have actually transgressed. (Of course, fines are not a good idea because they could dissuade someone with a serious condition who is frightened of being fined.)

Turn the heating down in hospitals by 1 degree. Hospitals are always too hot surely they can save on the heating a bit.

What? Does the person who has suggested this know that the people in hospitals are often extremely ill and some cannot control their own temperature? Hospitals are not overheated wastefully and wilfully, the temperature is set for clinical reasons. You cannot simply make some blanket suggestion of reducing the heating. Now if s/he was talking about clothes shops, I would agree: they are overheated and turning their heating down would affect no one adversely. But you cannot say the same thing about a hospital.

Just to show that Nick Clegg's vanity site is not the only place for racists:

Introduce strict controls on the useage of the NHS, particularly for non- nationals

Oh dear this must be from a Daily Mail reader: "foreigners are using our hospitals and not paying". Non-nationals do not get free healthcare. If they are from the EU then they are covered by reciprocal agreements, if they are from a non-EU country then they will get a bill. Simple. The fact is, since the Internal Market was introduced the exact cost of every treatment is recorded (this is why there are so many administrators), so it is possible to present a bill for treatment. My local hospital is in a tourist town and quite a few tourists end up in A&E. The hospital has a department specifically for issuing bills to non-nationals and ensuring that they are paid (including the use of debt collection agencies in the patients' country). A little bit of research could have prevented the need for this suggestion.

Gosh I am getting tired of reading this drivel, I'll go and do something more productive.

Numbers

John Redwood has responded to Simon Hughes call for a Lib Dem veto on Coalition policies by saying that the arithmetic does not add up:

"The truth is simple. If all Lib Dem backbenchers vote against a Coaltion government proposal, even with Labour support, the government will still win the vote. ... It is only if more than 40 Conservatives vote against the government and Labour opportunistically agrees that the government might lose."

This says more than is immediately visible. The fact is that the Tories have 306 MPs (John Bercow is the Speaker and does not count as a Conservative MP) which is 48 more than Labour. Since there are 57 LibDem MPs (and 28 other MPs) then it is possible that if all LibDem MPs vote with Labour that this Conservative government could be defeated. There are 650 MPs and, since the five Sinn Féin MPs do not participate that means a majority requires 323 MPs.

However, that is not what Redwood said. He said "If all Lib Dem backbenchers vote against a Coalition government proposal" There are 20 so-called "frontbench" Liberal Democrat ministers and ten or so junior ministers (33 LibDem ministers in total), so that means that there are only 24 backbench LibDem MPs, which means that there could never be a majority against the Conservative government (306 Tory MPs + 33 LibDem ministers is more than the majority of 323).

Basically, Redwood is pointing out the only reason why there is a disproportionate number of LibDem ministers - it is to guarantee a government majority. A lot of Tory MPs are still smarting over missing out of ministerial posts that they thought that were theirs, and this resentment will continue, but they will remain disappointed because Cameron cannot have fewer than 17 LibDem ministers (306 + 17 = 323) since that is the only way he can guarantee a majority.

Actually, I disagree with the assertion that 40 Tory MPs would have to vote against the government. That figure assumes that all LibDems would vote with the government (306 + 57 - 40 = 323, which is still a government majority), Cameron can only guarantee the LibDem ministers so that means that if 17 Tory MPs vote against the government it would lose (assuming 33 LibDem ministers and all the other 22 sitting MPs vote against the government). It is unlikely that 17 Tory MPs would vote against the government, but some could abstain. The number of "rainbow coalition" (without LibDems) MPs is 14 (SNP, PC, Alliance, SDLP), so added to the number of Labour MPs and the backbench LibDems gives a figure of 296. If 40 Tory MPs abstained then the government would have 299 (306 + 33 - 40). If 45 abstained then the government would lose. (This does not take into account the eight DUP MPs, if the Conservative cuts in Northern Ireland are deep then these MPs may well vote against the government, meaning that just 38 Tory MPs would need to abstain.)

It seems to me that the campaign against the cuts should concentrate on persuading 40 Tory MPs to abstain.

No NHS Savings "for years"

The Nuffield Trust have produced a briefing paper about the NHS white paper. They say that

"[the government's] approach carries significant risks. Competition and patient choice are both currently weak, and it is not known how much of either is needed to encourage providers towards better performance."

and that

"PCT commissioning is also weak and GP commissioning consortia are likely to take several years to develop adequate skills for the job."

This is damning, they are saying that these plans are not based on good foundations. Further they report:

"The reforms are substantial and will require significant management expertise to implement smoothly. They will occur at the same time as the NHS faces financial challenge, management capacity is being slashed and arms-length bodies are merged or abolished. A real concern is whether this level of reform can be implemented without risk of major failure."

Finally this statement is significant:

"The move to outcome targets rather than process targets is welcome. But given that waiting for care is such a key part of patient experience on which the NHS is judged by the public, and the miserable history of long waiting times in the NHS in the past, waiting times should remain firm targets."

Lengthening waiting lists is a key policy of Lansley's to move people over to private care or to persuade people to contribute co-pay. There is a proverbial cat in hell's chance of Lansley ever agreeing to reinstating the 18 week referral to treatment target even though this target is extremely popular with patients.

Mixed Sex Accommodation

No one thinks that mixed sex accommodation is the preferred situation, but there are more important things. Indeed, Lord Darzi (someone who knows a lot about healthcare) has said that single-sex wards across the NHS was an "aspiration that cannot be met". It is right to try and achieve this aspiration, but not when it could affect care.

There was no real policy decision that wards had to be mixed sex, the situation just became the norm as wards became more specialised. The problem is that modern healthcare is high tech and expensive. Sometimes there are expensive pieces of equipment and patient beds are configured to use it, but more significant are the skills of the staff - it is better to group together the patients with a similar condition and have the staff with the specific skill within the ward than to have the skilled staff moving between wards.

The problem with an obsession with single sex accommodation is that it puts a non-medical need above medical needs.

There have been a lot of complaints over the last decade about mixed sex accommodation, and for good reason. Culturally we are conditioned to be acutely aware of the sexual differences between men and women. When we are in hospital we are at our most vulnerable so our deepest conditioning and concerns become amplified. Without a cultural change we will always have this problem: people prefer to be treated with people of the same sex.

The last Labour government recognised this and brought about a programme to change mixed sex to single sex wards, but rightly they recognised that this was secondary to improvements in medical care. They also recognised that such a policy is very expensive and so grants were made available. From April this year all hospitals in England are supposed to be compliant with single sex accommodation and in February this year the department of health announced that "97 percent of NHS trusts meet single-sex accommodation standards".

I have written about this before but it is worth mentioning it again. Bed occupancy rates are high, because empty beds are expensive resources not being used. There's a general rule of thumb that a rate of 93% is a good compromise between the cost effectiveness of using all resources to their full extent and having capacity so that a free bed is available when needed.

However in the last few years there have been a lot of pressure on hospital beds. Last September the NHS framework for continuing care came into force without additional resources for local authority social services. Patients cannot be discharged if continuing care arrangements are not in place for them. The result was that bed occupancy at hospitals rose last September. This is a problem that can only get worse as deep cuts are made in local authority social services departments. Further, in the last year there has been an unexpected rise in emergency admissions which has no correlation with explainable factors like weather conditions. The bed occupancy rate across the NHS is very high and it will get worse.

In an ideal world a hospital will have two of everything. But this is not an ideal world. You cannot simply take two wards and say that from this point on one will be male and one will be female. Instead, wards have to be reconfigured with single sex bays so that the same specialised staff can treat both male and female patients without the patients seeing each other. However, single sex accommodation is not simply the sleeping arrangements: there must be no contact at all between patients of different sexes. This means that patients must be able to use a bathroom without walking past a patient of the opposite sex. To do this bathrooms have to be moved and perhaps additional bathrooms have to be built. This will be costly and will reduce the numbers of beds.

Another problem to bear in mind is that when you are upgrading a ward to single sex what do you do with the patients? The high bed occupancy rate means that there are not enough free beds to move patients during the changes. It takes a lot of organisation to arrange for the additional beds, and often this means moving more than just one ward since the most vulnerable patients must be protected. In the past I have spoken to some hospital managers about this issue and they have pointed out to me how complicated the process can be: they told me that you need a lot of time, and resources to make alternative arrangements.

Let's be clear about this, the previous Labour government said that all hospitals had to be compliant from April 2010, single sex compliance is not a new policy. What does compliance mean? If a patient is put in a ward/bay with patients of the opposite sex and there is no clinical justification then there is a breech of compliance. However, there is not just one breech. If there is a bay of six beds with five women and a man is put in the free bed then that represents six breeches of compliance and each breech carries with it a financial penalty. (There are no limits to the amount of fines that can be applied.) That Draconian policy came from the previous Labour government, and hence it shows how serious they were about the issue.

So if there was already a push towards single sex accommodation (and 97% compliance) what is the problem with Commissar Lansley's latest diktat that all hospitals have to be compliant by the end of this year?

Well the first thing is that it is uncompromising: compliance will have to "apply to all wards except for intensive care and A&E". This discriminates against the smaller hospitals who do not have the resources to duplicate expensive equipment and expertise. Under the current rules if there was a clinical justification then sexes could be mixed. Lansley is not compromising. When I spoke to a hospital manager about single sex accommodation a few weeks ago she said that often when it came to single sex compliance the hospital were "offsetting privacy against safety" I know which I would prioritise. Lansley is prioritising single sex accommodation compliance over clinical needs.

There is also the issue of the timescale. Currently 97% of trusts are compliant, which appears that the majority of work has been done. However, the last 3% are an issue because they are the more difficult cases. They are the older hospitals where the age of the buildings give rise to more problems, and they are the smaller hospitals which do not have the resources or staff to make the re-configurations. It takes time and money to complete the remainder. The problem is that Lansley has said all hospitals must be compliant by the end of this year, just four months. As I have said above, a lot of planning must be done to provide extra accommodation, and Lansley has rather dimly put his deadline in the middle of the period when hospital occupancies are the highest. Presumably the simplest way to make extra capacity available is not to have the patients in the first place. So in the next weeks expect hospitals to postpone elective operations until next year. This will significantly increase waiting lists. Think about this: if you need an operation, and the choice is either sooner in a mixed sex ward, or later in a single sex ward, which would you choose?

Then there is the money. The last government provided grants for hospitals to convert mixed sex wards to single sex wards. This government will not. Lansley has already announced that Foundation Trusts (about half of all hospital trusts) will not have access to public money. This means that to finance single sex accommodation Foundation Trusts will have to take out commercial loans.This is pushing hospitals towards privatisation or spiralling debt.

Lansley is deliberately creating a situation where NHS hospitals will fail. The decision about single sex accommodation will deliberately increase waiting lists and put hospitals into debt. This is yet another part of Lansley's sink or swim policy which is intended to close NHS hospitals.

UPDATE:

A spokesman for the Royal College of Nursing says: "They want to be able to protect their privacy and maintain their modesty. However, in a survey covering 82 different aspects of patient care, single sex wards came 62nd overall."

NHS Services Closure

First read these two statements:

"We will stop the forced closure of A&E and maternity wards, so that people have better access to local services, and give mothers a real choice over where to have their baby, with NHS funding following their decisions." (Conservative Manifesto 2010, p47)

"We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services." ("The Coalition: our programme for government", 2010)

These are very clear: the closure of a local service will only happen if there is local support for the decision. This is a controversial approach because on the one hand local people will never agree to the closure of a local NHS service, but on the other hand smaller units cannot support the expertise that is needed and this can put patients at risk (for example The Oxford Cardiac Centre at the John Radcliffe Hospital). Like it or not, there must be some central control based on expert opinion, but the local population must be informed about the reasons.

At the election Andrew Lansley was clear about this, for example, at a protest at Solihull in May about the planned closure of a maternity unit:

Mr Lansley told The Observer [that] a Tory government would stop the closure of maternity and A&E units if elected, and said hospitals were now "overridden with bureaucracy." "These decisions must be brought back to a local scale," Mr Lansley added. "We must consult openly with GPs and then the public."

You cannot mis-interpret this statement; Lansley says that GPs will be consulted and then the public, and closure will happen only if they agree with the plans. This is a very popular message and is the sort of thing that politicians say to get elected. But then when they are in charge of the service they have a re-think. Now Lansley is responsible for the NHS he is reneging on his manifesto pledges:

"Maidstone and Tunbridge Wells NHS Trust plans to move maternity services away from its local district general hospital to the PFI-built Pembury hospital. But a survey of 127 local GPs found that 91% opposed the plans, believing both hospitals should provide consultant-led maternity services."

This is quite clear: the local GPs want the unit to remain open. So what is Lansley's response?

"Health secretary Andrew Lansley has said plans to close a maternity unit in Kent will go ahead despite opposition from local GPs."

New politics? No, just the old politics of promising one thing to get elected and then doing something else when you are in office.

UPDATE:
Pulse report that

"The BMA, the NAPC and the Family Doctor Association have all told Pulse that trusts in different parts of England have been forging ahead with proposals, including the closure of hospital A&E departments, maternity units and children’s services, against the wishes of the local GPs. "

In addition they say that "in the capital a string of trusts in northeast London are pushing ahead" with closures. However, there are worrying signs of infighting between GPs and the very managers who they will depend upon to do commissioning when (if) GP commissioning goes ahead. Pulse quotes Dr Peter Swinyard, chair of the Family Doctor Association as saying:

‘When the night of the long knives comes and PCTs are abolished, the good PCT managers will find themselves a home in GP consortiums. Those who have behaved irresponsibly and ignored the wishes of GPs will find themselves down at the dole queue with no future ahead of them.’

This is a level of bluster that Commissar Lansley likes. The fact is, most GPs do not know how to do commissioning and do not want to do it, come the "night of the long knives" it may well be the case of GPs having to beg the PCT commissioners to come and work for them.

What is clear is that the empire building is clearly started and some GPs are very keen to become fully fledged captains of business rather than what the public really want from them, which is to be doctors.

Drug Rationing - Will GPs Want To Do It?

This comes from Roy Lilley at nhsmanagers.net but it reflects what I have said before on this site.

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

"GP consortia will align clinical decisions in general practice with the financial consequences of those decisions." (5.12)

This is basically saying that GPs will have to wear two hats: doctor and accountant. Many will continue to proscribe what is needed and the consequence may well be that their practice goes into debt (however, they will have to bear in mind (5.14) which says that the government will not bail out GPs who go into debt). But some - too many - will ration care because this is exactly what Lansley wants.

One thing that patients must realise - Conservative governments regard them as a drain on the taxpayer.

nhsmanagers.net have commissioned Prof Chris Newdick to write about the consequences of these sections: available here. He points out that GPs have a duty to provide care according to need - he calls this "a special Hippocratic right in primary care". He says that the current 2004 version of the GPs regulations require GPs to prescribe the medicines which "are needed for the treatment of any patient" and this is "needs-based, not resource-based" and so in direct contradiction to sections (4.4) and (5.12) of the white paper. This will not please GPs.


Further he points out another issue that I have touched upon. Prof Newdick points out that "the NHS Constitution requires PCTs to have systems which explain how and why the NHS cannot afford some expensive treatments".  This will be the responsibility of GP commissioners, and ultimately the people who employ them, the GPs. Prof Newdick says:

"This is unfamiliar territory for many GPs, with legal and ethical problems. Will Nye Bevan’s needs-based, Terms of Service duty to prescribe have to go?"

and the answer is undoubtedly Yes.

Lansley thinks that patients are drains on the economy and he cares not one iota for them (otherwise, why would he legislate away any responsibility that the Secretary of State for Health has for health provision?) If you are a patient then in the next few years you will pray for a miracle cure because you'll not longer be able to rely on Lansley to provide treatment for you.

Divide and Conquer

(For some of these links you may need to subscribe to Pulse magazine.)

Andrew Lansley may want to go down in history as the Dr Beeching of the NHS, but he is no fool. He knows that the only people that can scupper his plans are GPs. GPs have brought down Health Secretaries in the past and Lansley is determined that this will not happen to him. As always the best course of action is divide and conquer: get your enemies to fight each other so that you do not have to.

So first I see that the NHS champion Dr John Lister is leading a spirited campaign to get the BMA to show some backbone and fight Lansley's plans. Dr Lister has written a detailed reply to the BMA Chair Dr Hamish Meldrum in response to his letter to GPs where he recommends "critical engagement" with Lansley over the NHS White Paper. Dr Lister points out that this is inconsistent with the BMA's anti-privatisation campaign "Look After Our NHS". He goes through, point by point, the BMA's priorities for the NHS and shows how the proposals in the White Paper violates every one. Dr Lister then points out how powerful the BMA is and then pointedly reminds them how

in 1946 the BMA chose badly and wound up on the wrong side of the debate in opposing the launch of the NHS in 1948

However, he then describes how the BMA have since fought hard for the NHS and commends them on this. But he has a warning:

Sadly it seems that the current stance of the BMA could result in the GPs again lining up on the wrong side of the debate, as the current government contemplates the definitive reversal of Bevan’s nationalisation of the hospital network, which laid the groundwork for the NHS.

Dr Lister points out that there are clearly many GPs who oppose the changes proposed by Lansley (and is currently implementing without Parliamentary approval) and that Meldrum's policy of "critical engagement" is more likely to split the opinions of GPs which will be to Lansley's advantage.


Now Pulse goes further and describes the various GP groups fighting each other. The National Association for Primary Care are fully behind Lansley and they even "urge the Government not to dilute its plans"   even though 60% of their members are opposed to GP commissioning.

The NHS Alliance however are

"calling for the Government to shelve its plans to scrap all PCTs by April 2013, claiming that some trusts should be allowed to remain in place, if not permanently, at least until GP commissioning groups have proved themselves capable of taking over"

The Royal College of GPs and the NHS Alliance are consulting their members to see what approach to take, but from their leaders' statements it appears that they regard Lansley's plans to be very risky.


The divide and conquer approach is working, and it appears that Lansley's stooges are the leaders of NAPC who are recklessly pushing hard for Lanley's plans while the BMA's Meldrum and the more cautious doctors' groups are hoping that they could moderate Lansley's plans. However, Dr John Lister highlights the folly of this approach:

There is no sign so far of compromise from Mr Lansley. On the contrary the prospect of pulling the BMA in behind the proposals and splitting the ranks of health workers has strengthened the government’s hand, giving ministers confidence to stand firm, making it more likely that they will discount other opposition from health unions as ‘self-interested’.

It is most unlikely that this stance [of critical engagemwent] will be viewed with much respect by health ministers, who will simply regard it as a strengthening of their position — and an indication that if they keep the pressure on they can get their way with the BMA. And it seems that there is no fall-back position to be adopted if the gamble of “critical engagement” falls flat, and the government presses on with those aspects of the White Paper that the BMA regards as unacceptable.

Perhaps GPs should learn from the trades union movement: united we stand, divided we fall.

GPs will be "paid not to treat you"?

Seriously.

I have said before that Lansley hates hospitals and the proof has been revealed by Pulse magazine (subs required) which says:

Pulse exclusively revealed that the Government is planning to tie practices pay to their effectiveness in bringing down hospital referral rates.

That is, GPs will be paid more if they do not refer you for specialist treatment. Lansley hates hospitals. He quite rightly identifies that the public equates the NHS with hospitals and so to achieve his aim of crushing the NHS he has to close hospitals.

As I have pointed out before, the last time that GPs were given the purse strings (GP fundholding) the result was that you were 7% less likely to be referred to a specialist in a fundholding GP. Think about that. Understandably fundholding was popular with GPs who profited from it, but was very unpopular with patients (who pay them!) who felt that their doctor was more concerned with the cost than the clinical outcome.

However, this is far too tame for Lansley. Pulse quotes a report from the Kings Fund and say:

"Up to a third of GPs’ referrals face being rejected by their local commissioning consortium ... could mean GPs having every decision to refer having to be approved by their consortium leaders."

So not 7% less likely to be referred to a specialist, but 33% less likely. And you may find your doctor says to you "I think that you will need an operation, but I cannot book you until accounts have approved the treatment ... and they only approve two thirds of treatments". The next few years will be a frightening time for patients.

Analysis of the NHS White Paper

The following is a series of blog posts from Prof Paul Corrigan who was a senior health policy adviser to Tony Blair and credited with being the architect of NHS Foundation Trusts. They make an interesting read from someone who has a deep understanding of the NHS.

0. How does the political philosophy of “Liberating the NHS” work and where are the limits of this new liberation theology?

1. What is the responsibility of the National in the English NHS?

2. What is the responsibility of the National in the English NHS?

3. Who is providing health care and how are they organised?

4. What are the transactional relationships between commissioners and suppliers and how are they organised?

Here's an interesting comment from #1

admin on 20 Jul 2010 at 10:11 am


This is an important point. The resources for the NHS will only be coming from national taxation but within the White Paper the accountability will be coming from local government. This means that parliament will have the responsibility of paying for the whole of the NHS without any accountability and local government will have all the accountability but with none of the responsibility to raise payment.

If I was a local councilor I would say that the Government has to spend more money. If I was an MP I would refuse to raise any money for the NHS without some accountability to me.


The passage of the Bill through Parliament will be interesting…

Privatisation of Foundation Trusts Started

It is reported in the Financial Times that Lansley has ruled that Foundation Trust hospitals cannot use public money for capital projects. This means that if a FT hospital needs a large piece of equipment like an MRI scanner, or new buildings, for example to meet the single sex target, they have to take out commercial loans.

The decision “raises the question of whether this is a step towards privatisation”, said Sue Slipman, director of the hospitals’ collective organisation, the Foundation Trust Network.

Bear in mind that the NHS White paper says that all hospitals have to be come FTs by 2014, so this is simply saying that Lansley no longer wants to take any responsibility in the provision of healthcare. A Health Secretary who cares not a jot about healthcare provision. Worryingly, the FT also reports:

Fifteen of the 129 have recorded a technical deficit in the financial year just ended. And a small number have significant losses and are struggling with their cash flow, according to Monitor. ... John Appleby, chief economist at the King’s Fund think-tank, said: “Given that these are meant to be the best performing NHS hospitals, it is worrying that, even ahead of the spending squeeze, some are struggling financially.” 

NHS Privatisation

I made this video to show the consequences of the NHS White paper on our NHS.

Too Many Managers in the NHS

This was the clarion call of the Tories during the election. In fact at a hustings the Tory candidate wheeled out the tired on statistic that in 2009 the increase in the number of managers rose five times more than the increase in the number of nurses. This was his justification for cutting the numbers of managers in the NHS. Unfortunately, the format of the hustings did not allow me to put him straight on this nonsense statistic.

First, managers make up 3.6% of the NHS workforce. Yet ONS figures say that for the UK work force overall 16^ of working people are managers.

Second, the numbers of managers in the NHS goes up and down. In 2004 and 2005, for example, the number of managers went down. So why carp about an increase?

This last point has been highlighted by recent figures from the NHS Information Centre that says that

"The NHS employed 1151 fewer managers and senior managers in March this year than in April (a 2.8% fall)"

Have we seen the Conservative government congratulating the previous Labour government on this "excellent" reduction in the number of managers? No, of course not. The fact is the rise in NHS managers in 2009 was used politically, and Lansley knows damned well that to keep the NHS running under his damaging privatisation plans he needs managers. This fall of 1000 managers will make Lansley sweat.

More on NHS Privatisation

The government is now looking at privatising NHS Professionals the agency that provides temporary staff. So if your local hospital needs extra staff to cover sickness cover for its staff they usually look to NHS Professionals first. The organisation currently manages 50,000 staff who provide two million shifts a year. According to Karen jennings of Unison:

Ms Jennings said the move risked undermining the original purpose of NHS Professionals - "because private agencies were ripping off hospitals by charging them outrageous fees for recruiting or finding staff for shifts".

She added: "It makes no sense at all to bring back private companies who will want their slice of the action in return. This proposal is purely about Tory plans to promote privatisation and hive off parts of the NHS to private companies, regardless of the consequences on patient care."

At the moment the government wholly owns NHS Professionals and since the current Conservative government regards the organisation "as a business, not an agency" it is ripe for privatisation and so they are investigating into ways that private companies can "invest" in the organisation. The result, as ever, will be higher costs to pay for profits. Money that should be going into healthcare will nbe paying dividends for shareholders.

However, the plan may be illegal. A website, chiefofficers.net, that says that it is "written by senior business people, for senior business people", ie people who are in favour of privatisation, says:

"[a] question arises as to whether this is a lawful activity under securities laws [governing the public sector in Europe]. The general principle is that it is illegal to seek investment in a company except in very limited circumstances. A public offering that does not fall within those exceptions will often result in serious penalty for those who are convicted of the various offences related to the conduct."

It shows the incompetence of this Conservative government when a website like this is saying that they are privatising in a way that is illegal.

More NHS Cuts

A week ago I wrote that I was worried that our democracy was in danger because Commissar Lansley was pushing through his changes to the NHS without parliamentary approval. Now it appears that UNISON is to request a judicial review to halt the NHS cuts that David "I will cut the deficit, not the NHS" Cameron has fully endorsed.

"The government's white paper will change forever the NHS as we know it. These sweeping changes were not part of any party manifesto and it is outrageous that these changes are being brought in without consulting the public, patients, staff and unions," said Karen Jennings, Unison head of health.

"The NHS constitution enshrined in law the right to consultation and yet, in writing to NHS managers, Sir David is working on the premise that the consultation is only about the best way to achieve pre-determined outcomes - this makes it nothing more than a paper exercise and a sham.

In a frighteningly autocratic and politically-motivated response to Unison Sir David Nicholson said

"he was unwilling to reconsider his position and that he intends to carry on with his proposals"

Make no mistake, this is a civil servant saying that changes to the NHS must be started now, before proper public consultation and before parliamentary approval. This autocratic civl servant, no doubt under pressure from the extreme right-wing forces in the government, are changing our country in an authoritarian and non-democratic way. What else will these right-wing extremists do?

What about our democratic right to withdraw our labour? During the election, aware that Cameron would head the most right wing government we have ever seen, one of the themes of my campaigning was that I was sure that the only way that Cameron could push through his changes was to ban public sector strikes. Since Osborne was using the term Emergency Budget I was sure that Cameron would accompany it with a bill to restrict public sector strikes. I was a little premature, since the main cuts are due in the public spending review due to published in the Autumn. However, the government's vast army of spin doctors are at work persuading employers that they need these new changes. The BBC are reporting that a ban is imminent:

"Mike Emmott, CIPD employee relations advisor, said: "It is also incumbent on the government to consider the policy options open to it for reducing the risk of disruptive and damaging industrial action by public service employees, such as banning strike action of those involved in the delivery of essential services.""

Prescription Rationing

Yes, it is coming. The most vulnerable in our society - the sick - will find that in David Cameron's Big Society they are too expensive to be kept alive.

I have type 1 diabetes, I have had the condition for 35 years, ever since I was a boy. It is not my fault, it is a genetic condition. I am kept alive by regular injections of insulin. I take two, a short acting one (about £2 per ml) and a long action one (about £1.80 per ml). Without the insulin I would be dead in a few days, or maybe a couple of weeks. If I have too little insulin, or the wrong type, then it leads to complications. Insulins have changed a lot in 35 years, and understandably my control was not perfect when I was younger when I took the older, less effective, insulin. I am paying for that now. Five years ago I lost the sight in my right eye, but an operation from a skilled NHS surgeon restored my sight. The operation clearly cost money, and this is the cost of the poor control that the old insulins offered. Keeping your sight is a big incentive to look after yourself.

Insulins have changed over the years. Some have given improvements, others have not. Different people are suited to different insulins. I use human insulin - produced commercially by genetically engineered yeasts - and these suit me. They are not perfect, but my control is good enough to reduce the likelihood of complications. The human insulins I take are very common and are the cheapest on the market. Inevitably, when new insulins become available they will be more expensive and the drug companies will try to get as many people to use them.To do this their marketing people will tell doctors how wonderful the insulins are, and while this maybe true for some people, it is not necessarily true for all. 

About a decade and a half ago insulin analogues became available on the NHS and these were supposed to be the wonder drug for diabetics. I tried one short acting insulin analogue for a year (current price of this £3.20 per ml, so 50% more than my current insulin) and my control went haywire. I could not manage my blood sugar and I put on weight. I decided to go back to the human insulin and my control returned. So I was back on the cheap, but suited-to-me, human insulin.

Sometimes the drug companies use less acceptable methods to persuade you to move to their new products. Five years ago the manufacturer of the short acting insulin I take said that they would no longer produce it. (Interestingly, I can still find it sold online at £2.40 per ml.) Can you imagine how I felt? This was a drug that kept me alive and I was given just 2 months notice of it being withdrawn. Luckily I had a scheduled appointment with my diabetic specialist before that deadline. The recommendation from the drug company was to use their short-acting insulin analogue (current price £5 per ml). This was equivalent to the one I had tried five years before and with which I had problems. So my doctor put me on another short acting human insulin from another manufacturer (current price £2 per ml), and it turns out that I am suited to that. The drug company wanted the NHS to pay two and a half times more.

At the same time the doctor thought he could improve my control by changing my long acting human insulin to a long acting human insulin analogue. When I got home I looked up the new insulin on an internet pharmacy and found that it cost four times as much as the human insulin I was using before (current price £7.50 per ml as opposed to £1.80 per ml). Is the cost a problem? Well not really, if you consider that better control could mean that I avoid costly treatment for the complications of diabetes.

It turned out that I was not suited to the expensive long acting human insulin analogue. And after three years of battling with my blood sugar I took another unilateral decision and changed back to the cheaper long acting human insulin.

Why do I mention this? Well today I see that the National Prescribing Centre have issued cost-cutting guidelines to GPs and the long acting insulin analogue that I was using until the beginning of last year is on the list.Voluntarily my body had saved the NHS some money and cut my costs of long acting insulin usage by a quarter. However, it worries me how far this cost-cutting will go.

The figures I have give above are from here, of course, you cannot buy insulin without a prescription. If you want to know how much my insulin costs per day, here are the figures.

3 x 0.24 ml @ £2.00 per ml = £1.44

0.70 ml @ £1.80 per ml = £1.26

Total = £2.70

There's no NHS ring fence

I have railed about this before, but I think I have to keep repeating it until people start to listen: there is no NHS ring fence.

The NHS is the public service, publicly owned, paid out of general taxation. The funding for the NHS, the publicly owned service, is being severely squeezed by this disgracefully dishonest government. And then mantra of this government is that what is a loss for the public sector is a gain for the private sector. NHS hospitals are being purposely pushed towards bankruptcy by Lansley's plans while with the other hand he is handing public money over to the private sector and opening up the system to co-pay.

Take for example this news story:

"Up to 600 jobs are to go at Reading's Royal Berkshire Hospital (RBH) by 2015 to save £60m, the BBC has learnt. Chief executive Edward Donald said the hospital still needed to save millions even though funding for the NHS as a whole was being ring-fenced."

So what we are seeing here are cuts to an NHS hospital and the wheeling out that bizarre statement that NHS funding is "ring fenced"? If it is "ring fenced" then why are the cuts necessary? Why does RBH have to cut £60m and where will that money go?

Oh and who could take seriously a Chief Executive who makes such a glaring grammatical error as this?

"Mr Donald said the hospital would be looking at what it could do differently "to get through the same amount of work but with less people"."

I know it is pedantic, but it is a basic rule of English grammar: if you can count it, then use fewer. If he does not know that, then no wonder he's been hoodwinked into thinking that there is a "ring fence".

It's all about pensions

Think about it.

A social enterprise is a private company, which means that its employees are not NHS employees. When an NHS trust becomes a social enterprise it will take its employees out of the NHS. Those employees will take their NHS pension with them and they will continue to contribute to their NHS pensions. But new employees will not get an NHS pension, they will have to start a private pension. And if an employee moves from one "social enterprise" trust to another they will be moving from one private company to another. This means that if they had a right to contribute to an NHS pension in their previous place of employment they won't in their new one. The result of this is to slowly wipe out the government's responsibility for providing pensions in the healthcare sector.

Social Enterprises: It's all about pensions. I do hope the unions catch on soon, because once they do all hell will break loose.

Risk Pool

I missed this during my read of the NHS White Paper.

"[Monitor will have] powers to levy providers for contributions to a risk pool;" (4.27)

The reason for this is that Monitor will have

"powers to protect assets or facilities required to maintain continuity of essential services; [and] authorising special funding arrangements for essential services that would otherwise be unviable" (4.27)

in effect, Monitor will demand a payment from every provider and this will be used only to provide essential services should a provider goes bankrupt. In effect this means that if your local hospital goes into debt (which will become more likely under the new funding plans) then Monitor will be able to step in and save A&E and nothing else.

Prof Maynard at Health Policy Insight has this to say about the situation:

Monitor – the provider insurer of last resort
Monitor is also to tax all providers, public and private, to create a risk pool which can be used to bail out failing trusts. What will be the basis of this taxation?


If the greater risks are taxed more, these marginal entities will be driven further into insolvency. Or are the best endowed to be taxed more, to keep the marginal and often badly-run trusts in business?


Why should Plain Crap FT be bailed out by Staggering Along FT? And if this is judged right and Plain Crap cuts its quality to stay in business, how will Monitor and CQC reconcile their anxieties about patient safety?


Remember Mid Staffs?!

Further, if the hospitals who perform the most risky procedures will be taxed more, then wouldn't this be an incentive against performing those procedures?

A similar situation occurred at Mid Staffs, and I recommend that you read the Francis report for more details. Volume 1, Section G, paragraph 50 says:

The latest figures for Mid Staffordshire show an astonishing apparent recovery. The HSMR from the Dr Foster Unit for 2008/09 was 89.6. In the Good Hospital Guide 2009, produced by Dr Foster Intelligence, the hospital is now in the top band as one of the top 14 hospitals with a patient safety score of 93.83 against the top performer (100) and the lowest of 0.00. This is, of course, a different measure than mortality, though the patient safety score does include it. The figures were announced during the period when the Inquiry was holding oral hearings in Stafford and were touched on by witnesses at the Inquiry. Mr Sumara told me that:


"I think there are four elements in why Dr Foster is different… which I have no evidence for and I can’t give you any detail. One is that the coding is just better now. The second one is we don’t do strokes any more. The third one is we don’t do MIs [myocardial infarctions] any more and the fourth one is actually because we have improved that emergency care pathway, your chances are you will get to see the right doctor quickly if you are medically ill. I think that will make a big difference to outcomes eventually. But I have got no evidence to say that has done the trick. In many ways do I care because all I am interested in is can I get it right every time? It is a bit of reassurance."

The HSMR figure for April 2007 was 127, but this fell to 89.6. What does this mean? Well HSMR is essentially a measure of greater mortality at the hospital. The expected mortality is indexed at 100 so 127 means that mortality is 27% greater than expected (I caution you against regarding this to mean that those 27% more people died "needlessly").

So what caused the fall? Look at the items I have highlighted in Mr Sumara's reply. The hospital have stopped doing two types of work which have high risks of death - those patients are now someone else's problem. Mid Staffs had to do something about their HSMR figures, especially since the dumber-than-dumb tabloid press were making out that the hospital was some kind of charnel house killing 400-1200 people (a nonsense figure that the Francis Report dismisses). So they simply stopped doing risky work. Problem solved.

If Monitor's tax on a hospital is too high for the hospital to pay then won't they have the incentive to stop doing risky procedures to reduce their "risk pool tax"? If so then where do those sick people go?

What's the value of your reputation?

And how much would you sell it for? This is an interesting issue and it is being debated by GPs and accountants. Currently the Government owns a brand called the NHS. It has an immense reputation not only here but also abroad. How much is that worth?

Companies often buy and sell reputation. Mergers and takeovers may be to take over a product or intellectual property, or it may be simply to purchase a company name, and hence the reputation that goes with the name. Reputation is clearly an asset and has a value. Professionals often buy and sell reputations, it is called goodwill.

Since the inception of the NHS in 1948 selling the goodwill in GP practices has been illegal, but the Blair government relaxed this in 2004.The rules say thata practice with a list of patients cannot sell goodwill, but a practice with no list of patients (for example a Alternative Provider Medical Services - APMS - contractor) can sell their goodwill. Also out-of-hours, additional and enhanced services are not covered by the ban.

Goodwill is valuable and solicitors and accountants are used to the concept of buying and selling it. Laurence Slavin at healthcarerepublic says that "a goodwill valuation of 50 per cent of turnover is not unusual". Slavin also gives an example where if the ban on the sale of goodwill is repealed then  hypothetically the partners in a GP practice (the doctors) could sell the goodwill to an APMS and become employees of the new practice on a salary but also eligible for profit share. The APMS then runs the practice as a private enterprise. Andy Cowper, the editor at Health Policy Insight, says that the value of the goodwill of GP practices is around £8bn and currently it is owned by the Secretary of State for Health, Andrew Lansley. Cowper asked Lansley recently:

"who will own the goodwill and intellectual property in GP commissioning consortia, and will there be an asset lock on these?
"

Lansley replied,

"I see no basis on which consortia could realise and distribute goodwill".

 According to Policy Exchange

"The prohibition of the sale of goodwill on GP practices further adds to market distortion by preventing the sale GPs practices at true and fair value."

and they recommend:

"As part of the process of introducing fundholding to GP practices [ie GP Commissioning], restrictions on the sale of goodwill in GP practices should be lifted. This will enable high performing GP practices to take over poorly performing practices."

It would be interesting to see how long Lansley thinks he can resist allowing GPs to sell goodwill.