Why can't Lansley leave GPs alone?

Are they capable of taking over the role covered by GPs? Probably not. Here's a list of what PCTs do. It is a PDF that is a list that goes on for 14 pages. Today Roy Lilley at nhsmanagers.net posted a communication from an NHS manager of what PCTs do:

• Cooperate with local authorities.
• Members of safeguarding children boards.
• Equalities and human rights.
• All the stuff to do with continuing care.
• Compliance with NICE decisions.
• Individual funding requests.
• Dealing with complaints.
• Public access to public bodies’ meetings.
• Freedom of information.
• Employment law.
• Corporate manslaughter.
• Medicines management regulations
• Etc Etc.

Read the full list and then try to work out how your local GP will be able to do it all.

Why can't Lansley leave GPs alone to do what they do best: medicine? Why does Lansley insist that they have to become managers?

Public Sector Pay

We are constantly told that the public sector has to be slashed because that is what has happened to the private sector. To justify this, the Conservatives give us examples of the worst private sector employers who are sacking staff or cutting pay and then saying: "if the private sector has to do this, then so should the public sector". But have private sector workers been hurting? The answer is no.

Incomes Data Service is an independent research organisation providing information and analysis and their data shows that private sector workers have not fared as badly as the Tories tell us. For example, this press release in March says that: 

The median pay settlement in the public sector during 2009 was 2.1 per cent, only slightly above the median figure for the private sector, of 2 per cent.

Further, things are getting worse for public sector workers (July press release): 

The median pay settlement level across the whole economy for the three months to the end of May 2010 remains at 2 per cent, unchanged from the three months to April. ... Pay settlements in the private sector continue to be centred on 2 per cent, which is the median level of awards in both manufacturing and private services. The median in the public sector, however, has fallen to 0.8 per cent, down from 1 per cent in the three months to April 2010. This is the result of an increase in the number of pay freezes and lower awards applied in the public sector over this period, ahead of the Government’s announcement of a two-year pay freeze from 2011.

So March to May the private sector had 2% increases and the public sector had 0.8% increases, less than half. Is this the message that you hear from the Tories and their friends in the Press?

Further, IDS say: 

In the private sector, pay freezes now account for just one-in-ten pay settlements, while in the public sector two-fifths of the pay reviews that took place in the three months to May resulted in pay freezes. Pay freezes are now the most common outcome of pay reviews in the public sector, with over 1.3 million public sector workers having their pay frozen in this three-month period. In the private sector, pay freezes recorded in this period were for the most part confined to care providers and electronics firms.

We are constantly told that the private sector is taking the pain of the recession and the public sector isn't. Yet just one in ten pay settlements in the private sector are pay freezes, but two fifths of public sector pay settlements are pay freezes. The actual figures show that it was the public sector that took the pain, not the private sector.

Franchising of the NHS

The Government is keen to break the NHS apart and scatter the pieces to the wind. Pulse now report that commissioning of care could be handed over to charities and pressure groups.

"Pulse has learned that at least one major charity has already held preliminary discussions with the Department of Health about taking on a commissioning role. It is understood the DH is sympathetic to the idea in principle, although it would be GPs’ choice whether or not to enter into such commissioning partnerships."

I have a chronic condition and I am a member of charity that is a support group for this condition. Do I want them commissioning my care? No. You may think this is an odd position, since surely a support group would want the best possible care for me? Yes, but they also want the moon on a stick. I recognise that it is possible to spend an unlimited amount of money on my care, I also recognise that often as you spend more you get less improvements, and there is a careful balance. I want my doctor to make these decisions, I want my GP to be my friend and advocate. I want my doctor to make the best decisions for me.

(A year or so ago I looked into how to get more involved in the governance of the charity and I found that it was inordinately difficult. Basically, the charity makes sure that only the "right" people can have governance positions. I am happy with that when it is simply a support group, but if they were to be commissioning my care then I would want to see far better, and more representative, governance.)

Handing over such commissioning to charities is heading for disaster.

Worse care is on its way

The Department of Health says that "within three years all NHS Trusts will become Foundation Trusts". As any NHS trust will tell you, a three year timetable is extremely ambitious, if not impossible. To be authorised as a Foundation Trust a trust has to prove that it has the financial stability to be able to handle its budget independently of the government.

The problem is that this is not as simple as it may seem. Hospital trusts have budgets in the hundreds of millions. Unlike the existing 129 Foundation Trusts, who were authorised at a time when there was adequate money in the NHS, the remaining 120 or  so trusts will be subject to rather savage funding cuts. The scandal at Mid Staffs occurred because (at a time of adequate NHS funding) they had to make efficiencies to meet the FT finance governance tests, and they allowed care quality to slip. In response to this, the authorisation tests were tightened to include quality measures too.

In times of adequate funding, the FT authorisation tests were tough, at a time of savage cuts in the NHS they are likely to be impossible. The government says that there is no option: NHS (acute hospital) Trusts will not exist in 2013. There seems to be only one way to square this circle: relax the criteria. Clearly, since there will be a shortage of money, it will be impossible to relax the financial governance criteria. So the only possible solution is that the care quality criteria will be relaxed. Basically, if your local hospital is an NHS Trust (ie, not a Foundation Trust) it will mean that in the next three years the deminishing numbers of managers will be desperately making cuts to try and keep to the squeezed budget and your care will suffer. There will be fewer clinical staff and waiting lists will lengthen.

After Mid Staffs we all hoped that such conditions would never happen again, instead the likelihood is that it will happen to at least one hospital in the next three years, and probably with worse consequences. The frightening thing is that it could be your local NHS hospital.

Incidentally, if your local hospital is already a Foundation Trust then they too are unlikely to continue to give high quality care. The reason is that they will be subject to the same straitened financial conditions and to balance their books they will have to compromise the quality of care. But, you ask, surely this will mean that they would be in breach of their FT authorisation? Indeed, and before Lansley got his greasy paws on the NHS such hospitals would be put on the equivalent of the NHS "naughty step" by being de-authorised as a FT and have the privileges of autonomy of their finances taken away. However, Lansley has said that he will legislate to remove the ability of de-authorising trusts. This means that once a trust is a Foundation Trust whatever it does it will always be a Foundation Trust.

It used to be the case that authorisation as a Foundation Trust was an accolade but now it appears to be precisely the opposite.

Moving closer to privatisation

HealthInvestor give an foresight of what to expect in the future. Cornwall & Isles of Scilly Primary Care Trust will not exist in 2013 because Andrew Lansley will legislate to close it down, so instead they have created a private company to employ their commissioners which they hope will contracted by the GP consortia in the future.

NHS managers in Cornwall have agreed in principle to the creation of a private company that would see primary care trust (PCT) commissioners spun out of the health service. Senior staff at the PCT will now proceed with establishing the community interest company, which would manage 2,400 workers, as the NHS starts to implement Andrew Lansley’s white paper reforms.

So does this matter? Well if you are a patient in Cornwall, ye it does because in the future rather than being treated by NHS district nurses, or having care in an NHS community hospital, you will have care provided by a private company instead.

The new venture will control an annual budget of £75 million and will manage 14 cottage hospitals, and a number of community services, such as district nursing.

This means that the hospitals will have been taken out of the NHS and the result of this will be that there will be no guarantee that they will survive. The private sector are licking their lips in anticipation of the rich pickings they can get. If the new "community interest company" goes into deficit, they will not be helped by the government. Instead they will do what any company in debt will do, and realise their assets. That means selling off hospitals. If a community hospital is sold off it will mean that NHS care will not be available in that area and hence the market for private care will be created.

UNISON and Unite are fighting the attempts to change NHS trusts (community services, PCTs or hospitals) into such social enterprises. It is quite amazing that at the moment only the Trades Union movement is willing to protect the NHS at the moment.

Ring fence, what ring fence?

We all know that there is no NHS ring fence. We know that "£20bn of efficiency savings" is actually £20bn of cuts spread over 4 years. That is not a ring fence. We can already see the effect of this cut because clinical staff are alre4ady being made redundant.

So what about the vultures, ready to pick the bones of what is left of the NHS? Of course, I am talking about the predatory private sector. HealthInvestor (advertising an event they are holding) say this:

The recession has forced Government to curb health spending, leaving an estimated “black hole” of up to £20 billion in health budgets up to 2014. Efficiency savings are likely to fall on acute care and GP services, with NHS Trusts tasked with making substantial savings and more efficient use of the NHS estate. 

 Black hole? Curb spending? If the Tories had said this at the election they would have been accused of planning cuts, but instead they lied and talked about a "ring fence". 

NHS Alliance says timetable is unrealistic

Pulse report that the majority of their members support the concept of GP commissioning, but not the timetable suggested by Lansley:

A survey of more than 200 GPs, PCT managers and practice managers – due to form a key part of the alliance’s response to the consultation on the health white paper - found 78% of them backed GP consortia taking over commissioning responsibility, with only 16% disagreeing.

But only 35% of respondents believed health secretary Andrew Lansley’s timeline was achievable, with more than 54% of those who took part saying they believed the handover from PCTs would take longer to achieve than the planned date of 2013.

The timetable is significant because the changes will be a huge upheaval and will result in the closure of some GP practices and hospitals. Lansley is desperate to get the changes made as soon as possible so that they are irreversible and to give the new healthcare market a chance to settle down before the planned 2015 election. If the timetable is lengthened then there is a danger that the election will occur at the height of the upheaval and the public will "reward" the Conservatives accordingly.

Is the White Paper Too Ambitious?

This is an interesting quote from Anna Dixon, director of policy at the King’s Fund:

But Dixon doubts whether the proposals will be implemented as intended, with many details unclear, consultation yet to take place and negotiations needed with trade unions. Fresh legislation is necessary, which may prove difficult. “Andrew Lansley is said to be a man in a hurry, yet these issues suggest implementation could be slow,” says Dixon.


As with earlier reforms, warns Dixon, the very act of structural change may distract from achieving improvement – made worse by the public finances. “There is a real danger that the financial squeeze on the NHS, which will start to show within 12 months, could derail implementation of the white paper,” she warns. “Many providers will become financially challenged, making their ability to go it alone as a social enterprise organisation difficult if not impossible. And any appetite that does exist among GPs to take on commissioning…. is likely to be dampened by the challenges of having to deliver huge productivity savings.”

Dixon is suggesting that even if the Health bill passes through Parliament unscathed (which in itself is not a sure thing) the time table of changes is too quick, and the finance situation may well mean that trusts will not be able to implement the changes.

Last week I attended a public meeting in Coventry about the White Paper and a local GP said that he thought that the Lansley's policies were "designed to fail".

Election Analysis

Just looking at the Ipsos-Mori breakdown of the election results, I noticed some interesting figures.


The big gains in Tory vote (over 2005) were:
men 25-34 (+13%)
women 18-24 (+8%)

the big losses for Labour were
men 25-34 (-10%)
men 35-54 (-9%)
women 18-24 (-15%)
women 35-54 (-9%)
men DE (-12%)
women C2 (-15%)

Over all, the lead pf the Conservative over Labour compared to 2005 were
men 25-34 (18%)
men 55+ (12%)
women 55+ (12%)
men AB (21%)
men C1 (12%)
women C1 (10%)
women C2 (17%)

There is a lot here, but let's just pick two where there is a big swing of Labour to Conservative: men and women over 55. This is an important demographic because older people are more likely to vote (the turnout for 55-65 was 73% and for 65+ was 76%). Yet this is the demographic who most use the NHS and most use social care, they should be naturally attracted to the Labour policies in these areas. However, I think the reason why they switched from Labour was precisely because the Tory NHS and social care policies were deliberately down played by the Tories and then right-wing press.

Numbers Redux

An update on my previous post about parliamentary numbers. These are the number of ministers:

Cabinet members (23); 18 Tory; 5 LibDem
6 Tories ministers also attend

Minister of State (32); 26 Tory; 6 LibDem

Parliamentary Under Secretary of State (33); 28 Tory; 5 LibDem

Whips (non cabinet 5); 3 Tory; 2 LibDem

The LibDems have 57 MPs which is 16% of the coalition MPs. The LibDems have 21% of the main cabinet posts or 17% of the full cabinet. This means that the full cabinet is proportional.

Out of 99 ministers (Secretary of State, Minister of State, Under Secretary of State and whips) 18 are LibDem, this is 18% and clearly they have proportionally more ministerial positions than their overlords, the Tories. If they had ministers in proportion to their number of MPs then they would have 16 ministers.

If you think that the popular vote should be used, then the Tories got 10.8m votes and the LibDems got 6.8m; this means that the LibDems got 39% of the coalition votes, which should give them 38 ministers and 11 full cabinet ministers.

So the next time a LibDem berates you about proportionality you can point out that:

1. Compared to their numbers of MPs they have two too many ministers.
2. Compared to their proportion of the popular vote they have 20 too few ministers and six too few cabinet ministers.

 Either of these points should lead you a good discussion about coalition politics and proportionality.

"Divided" BMA Attacks White Paper

So the Ents have awoken. The BMA have described the NHS White Paper as being "basically a smokescreen for privatisation".

Pulse says that the BMA council spent "two days of often fiery talks", but go on to report: 

"Pulse has learned that the BMA Council passed a motion at its meeting earlier this week which reads: ‘The Council has significant concern about the direction of travel of the NHS reforms with respect to commercialisation of the NHS as provided in the white paper.’"

On GP commissioning Pulse says that the BMA expressed

"fears that the white paper could lead to a lottery of service provision by allowing decisions at local level rather setting central public health needs."

However, the issue that the BMA were most worried aout was privatisation:

GPC member Dr Helena McKeown told Pulse after the meeting: ‘We want to make clear that we have major concerns over the policy of any willing provider. There is a fear that GPs and clinicians could design entire services and then have their decisions overruled by Monitor on the basis of cost which could throw whole hospitals into chaos and open the door to private firms. The analogy I used is it's like the game Jenga - you could take one brick out and the whole thing could fall down.’

Healthcare Republic take a different point of view, choosing to quote BMA council member Dr Fay Wilson:

"The question was not whether to oppose privatisation but whether the whole White Paper should be opposed because it could lead to greater privatisation. We decided to stick to the previous policy, that of critical engagement, so we can help shape the reforms."

Clearly the BMA are not happy with the white paper, and so Lansley has a lot of work to do to persuade what is possibly the most influential union in the country.

Talking of influential unions, last night Unison told the BBC that it had succeeded in obtaining a judicial review against the NHS white paper consultation (the actual page on the BBC web site no longer exists). That was reported on the 1900 news bulletin on Radio 4, but two and a half hours later they put out a correction. Clearly there had been some cockup. The new press release was still encouraging, but the "success" was minor: 

"a high court judge, Mr Justice Collins, says ... there are arguments that may persuade a judge that there was a need for wider consultation based on what has been said and the provisions of the 2009 Act coupled with previous governmental statements"

A judicial review is vital because there has been minimal public discussion about these proposals (ask yourself, where in the mainstream press have you heard anyone saying that all English hospitals will be taken out of public ownership?) The government does not want a wide public discussion about the white paper because they know that the vast majority will be against the proposals.

Lansley Bails Out Hospital

To most of us a bail-out is free money. It is not. It never is because there are always strings attached. The banks (RBS, HBOS, Northern Rock) were "bailed out" by the government buying preferential shares in the companies, the banks got the money which they could use to pay off their debts, but the government has the shares which means that in the future they can sell the shares and re-coup their cost.

The NHS white paper says (1.22):

"We are very clear that there will be no bail-outs for organisations which overspend public budgets."

This says that the government will not give free money to hospitals who go into debt. It also means that the government will not give loans to hospitals that go into debt (remember: bail-outs, like the banks, can be loans too). The government's plan is that if a hospital goes into debt it should take out a commercial loan, presumably secured on the hospital's assets. Unless, that is, you are a hospital in Tory Berkshire, in which case Lansley will bail you out. Heatherwood and Wexham Park Hospitals in Wrexham, Berkshire is in debt, and so today Lansley announced that he will lend the trust

"to enable them to turn around their financial position while maintaining a high standard of patient care."

Just in case you thought that this was a bail out (like the banks were bailed out) he added:

"I have been clear that this is not a bail out - it will need to be repaid in full and is conditional on the Trust demonstrating that they will meet their ongoing commitments in terms of quality and financial stability."

So there you have it, yet more doublespeak from Commissar Lansley, just because he says that it is not a bail out (which it is) then that means it is not a bail out (but it is).

Actually, I am rather happy that Lansley has done this, because the next time a hospital needs a bail out and he tries to refuse we can always point him to the Heatherwood and Wexham Park Hospitals precedent.

UPDATE:

Roy Lilley adds the details. His entire post is worth a read, but start at the second piece "Trust gets massive bail-out". Lilley points out that out of a budget of £214m it needs to save £46m. Why is this the case? Lilley says: "The problem is simple to diagnose; there is just not enough money in the local health economy". The issue is that there are other hospitals in the region (too many?) and that there is not enough money to go around. No-one likes their local hospital closing, and a responsible Health secretary would get together all the stakeholders in the area to come up with a credible plan. Then start a wide public consultation to get the public's point of view and respond to it. Instead we have a Health secretary obsessed with the market. The bail-out is £18m over ten years and Lilley comments:

"Lansley is oiling a slippery slope with money he doesn't have.  The sad story of this hospital is not untypical.  There will be many more like it and they won't all have an ex-employee who is an MP, with mates in government, to help bail them out."

Last night (23 Sept) I attended a public meeting where several GPs said that the white paper was designed to fail. That is, NHS hospitals will be starved of staff and when they fail - as they inevitably will - the Health Secretary will say that the NHS is not fit for purpose and will invite in the private sector.

Increasing the Postcode Lottery

NICE is evidenced-based. They evaluate treatments and determine if they are effective clinically and cost effective. There is some controversy over their role, but since there will always be a shortage of money there will always be rationing of some kind. NICE aims to make sure that the rationing is equitable and evidence-based. A totally free-market system is likely to end up in the drug companies charging what the patient will pay, rather than the cost, or value of the treatment. Whatever the Daily Mail say about NICE, we should all be thankful that NICE are calm, sensible and base their decisions on facts.

So we have this bizarre new policy from Commissar Lansley to change to "value-based pricing". I have already said that this is a nonsense policy, and I have pointed out that their example of Lucentis is nonsense since the drug was priced specifically at "what the patient would pay to keep their sight" rather than the actual cost of the treatment.

Now we see that the government is changing the role of NICE (Healthcare Republic). A Department of Health spokeswoman said:

"[NICE's] role will increasingly focus on how to deliver authoritative advice to clinicians on the most effective treatments and on development of quality standards, not acting as an arbiter on the availability of drugs."

This is a serious change. David Willetts says "NICE will continue to offer advice but we will ensure more decisions are taken at GP level". The problem is when there is a ptient sitting in the surgery, will a GP say "there is a drug that you can take, but it is expensive and will only give you a few extra weeks, and may even shorten your life"? This is, in effect, what NICE were saying when they declined to recommend Avastin. It is far better for this decision to be made by a separate, evidence based body.

And then there is another problem. Since NICE is a national body (that is the N in NICE) their decisions affect everyone. The problem with forcing GPs to make the decision is that different GPs will make different decisions based on the same evidence. GPC deputy chairman Dr Richard Vautrey says:

"When it comes to high cost drugs, whether it be NICE or consortia making decisions, the reality is the money is simply not available for everyone to have everything that they want. Patient care will not be improved and the changes risk widening postcode prescribing. It is also likely to be a recipe for chaos if this is implemented at the same time as scrapping practice boundaries. The danger is that patients simply register elsewhere in the country just to get a particular drug and this will cause great problems to those practices who try to offer good quality care to remote patients."

Bizarrely Willetts says that this could result in GPs prescribing quack remedies like homeopathy (Pulse):

"They will have the ability to prescribe things like homeopathy even if they do not meet any NICE requirements. If GPs do detect very strong patient demand, they will be able to respond to that. Under our new role, there will be greater scope for GPs to respond to patient demand."

Any system which allows a patient to demand distilled water treatment from their GP is certainly going backwards. Willetts is supposed to be the Science Minister, so why is he promoting a system that will allow the NHS to pay for quack remedies? That is not science.

Awards

Everyone likes to be appreciated, I certainly do.

Many years ago a magazine told me that one of my books had been nominated by their readers as the best book published that year so I was invited to the "awards ceremony" (OK dinner at a restaurant in London). Of course I was excited. However, when it came to the "ceremony" it turned out that I came second to a book which I had been given by the publisher (ie I didn't even pay for it) and I felt was poorly written and technically incorrect in many places. My books are neither, so how did I come second?

Well, it was the methodology of the voting. The magazine had asked its readers to email-in the titles of their favourite books. This was not a survey, carefully balancing the respondents to make sure that they are representative of the "community" (like opinion polls). And neither was it an expert and informed panel (like the Man-Booker prize). No, the people who voted were those that like voting: a self-selected electorate. I was happy with the result, because it gave me a free dinner in a swanky London restaurant, but I did not tell anyone that I had come second to an inferior book.

After the awards were handed out I congratulated the winner and we chatted for a while (well, the drinks were free) and I asked him what the sales of his book were like. It turned out that his inferior book had sold third of the sales of my book. (That book of mine has sold 40,000 world wide, which is not bad for a $50 technology book.)

So why do I mention this? Well I find that I am now number 85 in the Total Politics list of the most popular Labour blogs, and because of this I am entitled to use the image above. The problem is that this is just as worthless as coming second in the best book of the year list. The methodology of the Total Politics list is ropey at best: you email TP your top five list of blogs and they then generate the list according to the categorisation of your blog as registered on their site. Yet again, the people voting are self-selected; there is no effort to make the "electorate" representative of the population of the UK, or of internet users, or of political blog readers.

It turns out that I was right to list my blog as "Labour" rather than "left-wing". There are far more "left-wing" blogs than Labour (even though some on the "left-wing" list, like Red Rag, are clearly Labour blogs), so it is easier to get on the Labour list than the "left-wing" list. For example, if you compare the top 100 left wing blogs with the top 100 Labour blogs you'll see that Stilettoed Socialist, Ellie Gellard's site, is listed as number 100 in the left-wing blog list but number 42 in the Labour blog list. Assuming that the same number of votes puts Ellie's site at those two positions (which is a reasonable assumption), this indicates that you have to get more votes to get a placing in the left-wing blog list than the Labour list. My site is 40 places below Ellie's site on the Labour list, which shows why my site is not in the left-wing list. Indeed, all of the top 42 Labour sites are in the top 100 left-wing list and so the Labour list is a subset of the left-wing list (as you would expect). Clearly being partisan is a good thing!

So drawing a parallel to the anecdote I gave above, I had a look at the traffic to my blog. No I won't tell you the figures because I don't want the people reading this to feel too exclusive! But I certainly cannot feel superior like I was knowing that my book sales were better than the book judged "better" than mine.

So I have put the Total Politics "award" gif on my site's sidebar knowing that actually it came from just a handful of votes. I suppose it is like being a LibDem minister: you have to achieve far less to be appreciated far more!

GPs are Revolting!

Pulse report that "the BMA is riven with divisions over how to respond to the white paper" and there they have been unable to come to a consensus. Further, Pulse says:

The GPC will say it backs plans to put GPs in the driving seat on commissioning but will demand answers to a set of outstanding concerns, including:

• lack of detail about managerial support for GP consortia
• GP consortia being saddled with debts from failing PCTs
• GPs being locked into long-term deals with private firms, including PFI agreements.

Further Pulse reports that Dr Jane Lothian, secretary of Northumberland LMC, said GPs were torn.

'In terms of concept, we are extremely positive. The thing we are concerned about is the destruction of SHAs and PCTs. As much as we love to spar with them, everybody has work-ed very hard to get the system working. We’re very concerned organisational memory will go.'

Bad strategy is that which you cannot afford

On the PM programme yesterday, BBC Radio 4, Eddie Mair interviewed Colonel Richard Williams who commanded the SAS in Afghanistan. It is worth a listen all 8 minutes of it starting at 22:20 (iPlayer). Colonel Williams is very calm and precise, and as a commander of the SAS he was clearly very experienced about the deployment in Afghanistan.

The main message of the interview was that the problems the army suffered in Afghanistan between 2001 to 2007 were because of poor military design and not from a lack of resources. He said that it was: "not a political issue, that is a military issue".

Mair asked Williams about the result of "the poor judgement" and Williams said there were two: the loss of life and the loss of Britain's reputation as the "primary, most effective, world-class counter insurgency force". Williams added that "Since 2007 I think a lot of work has happened to recover that reputation, but there are still deficiencies".

These are serious admissions, but who is to blame for the problems? Colonel Williams said that "there were a series of arguments which were presented to the commanders on the ground which forced them (in their own words) to the nine outposts of which Sangin was one" and that with six helicopters they "could only really support perhaps three operating bases". The "arguments" were being presented from the high command in the military and imposed on the commanders on the ground, imposed on the people who knew that they only had the resources to operate three bases.

When Mair asked who was responsible for those poor decisions between 2001 and 2007, Colonel Williams said "They rest with the military. In all of the discussions that I was privy to, but not necessarily part of, the military requested a series of resources relative to the tasks outlined. They were given those resources and in both cases be it Souther Iraq or Afghanistan they didn't deploy those resources as effectively as they should do."

Mair reiterated: "you're saying, in essence, that they [the military] did have what they wanted but they made a mess of deploying it?" Colonel Williams agreed. He said "it is slightly unfair of the military to blame the politicians for a lack of resources when actually it was a bad military design." He said that one of his favourite guidelines was "Bad strategy is that which you cannot afford" and explained, "if you have only six helicopters then [you] design an operation that six helicopters can support." He went on to explain that the military in Afghanistan designed operations that they did not have the resources to implement and that when he was asked for his opinion about the challenges in Helmand, he specifically told his superiors the dangers of over stretching the deployment, but his warnings were ignored.

This backs up Brown's constant assertion that he met all requests for resources, which the Conservatives constantly attacked. But rather interestingly, he puts the blame for the problems squarely on the military leadership.

Social Enterprises

Ask anyone what is the greatest British institution and they will answer: the NHS.

Ask them to tell you what they they think embodies our NHS and they will say: our NHS hospitals.

Yet in 2014 those three letters N-H-S will be removed from the signs of every hospital in England, for good reason: they will no longer be part of the NHS.

The reason is section 4.21 of the NHS White Paper: 

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

Rather than there being one organisation, the NHS, owning all hospitals, the White Paper policies will fragment the system into 250 separate, independent organisations. A social enterprise is not publicly owned, it is not publicly run. They are private companies with a "social purpose" and this typically means that they are not-for-profit. In fact the government says that they will be "employee-led" which effectively means management buyouts. Currently NHS management remuneration is approximately a third that of the private sector (NHS Confederation), so you can imagine that one of the first things that the board of a (former NHS) social enterprise hospital will do is give the board a huge pay rise and there will be nothing that you can do. If you complain about an NHS hospital to your local councillor ot MP they will be able to lobby the hospital management and make sure that changes are made: this is the advantage of public ownership. But if you complain to your councillor or MP about a (former NHS) social enterprise hospital they will shrug their shoulders and say "it is nothing to do with me". and of course it will not be, your complaint would be the same as making a complaint about someone being rude to you at Sainsburys or Tescos.

But the government, when it says "the largest social enterprise sector in the world" are admitting that this has not been carried out anywhere else in the world. They are admitting that it is an experiment: they are experimenting with our very lives!

A social enterprise hospital is not part of the NHS. This will have profound effects on staff in terms of pay and conditions, pensions, job mobility and training.

The Transfer of Undertakings (Protection of Employment) regulations - TUPE - will apply when a hospital becomes a social enterprise. This will transfer NHS employment T&C to the new business, including the right to continue to contribute to the NHS pension. But the regulations apply only to that one transfer. So if an employee moves to another hospital (as is common currently in the NHS) the employee will be moving from one business to another and treated as a new employee in the new business. This means that they will be employed under new conditions and will no longer be able to contribute to the NHS pension.Ultimately NHS T&C and the NHS pension will be phased out.

This is likely to have an important effect on job mobility since employees not wanting to lose the right to continue contributing to the NHS pension will be reluctant to change jobs. When it comes to pay bargaining, there will be no national pay rates. This will mean different hospitals will pay different rates and the result will inevitably mean that pay will not match inflation. And it will mean that the big teaching hospitals will be able to pay higher rates and attract the more able staff, whereas district general hospitals will pay far less and be unable to attract the best staff and the quality of treatments will suffer.

Currently NHS training is funded by central government (Multi-Profession Education and Training levy - MPET). This is around £6bn annually paid by the Department of Health to Strategic Health Authorities which pay for the training of doctors, nurses, scientific and admin staff. However, this payment from central government not only covers the training costs, but also the salary of the employee while training. For example, as a doctor learns more then progressively more of their salary is paid by the hospital. In two years of foundation training the Department of health will pay first 100% and then 50% of the doctor's salary, in the four years of specialty training the Department of Health will pay between 50% and 100% of the doctor's pay. The same is true for trainee nurses staff.

A social enterprise hospital is an independent business, the government will have no responsibility for the training of their staff (why should it? is the government responsible for the training of BAe's staff or GlaxoSmithKline's staff?). The White Paper is coy about this £6bn of training it simply says (4.33): 

"Healthcare employers and their staff will agree plans and funding for workforce development and training; their decisions will determine education commissioning plans."

Note that there is nothing in the White Paper that says that there will be continued funding MPET, it does say: 

"All providers of healthcare services will pay to meet the costs of education and training. Transparent funding flows for education and training will support the level playing field between providers."

It is estimated that it costs £350K to train a junior doctor. If there is no guaranteed funding from central government then this cost will be a huge burden on hospitals (£350k is about 60 hip replacements). If this cost is put on student doctors then it will dissuade students from lower income families to train to become a hospital doctor. Currently the BMA say that a medical student graduates with a debt of £37k (or £45k for a London university); that debt is a powerful force against lower-income students going to medical school, and consequently medicine is a predominately middle class profession. But imagine the effect of the student having to take out an additional loan of £350k to train as a hospital doctor. This will dissuade even middle class students, and we will return back to the days of Sir Lancelot Spratt where only the very richest could even think of becoming a hospital doctor. (And since the very richest do not have a monopoly on brains and ability, hospitals will inevitably be staffed by less able doctors.)

Social enterprises will have profound effects on patients too. At the moment you are treated within the NHS, so if you need more specialist care from another hospital you simply move to another part of the same organisation. When hospitals become social enterprises (and in Oliver Letwin's words "compete for patients") you will be regarded as a source of income, rather than a patient. So will a hospital be willing to lose a source of income to another competitor? No. Currently we give doctors our trust that their decisions will be made on a purely clinical basis. But in the future, every clinical decision will have a financial effect on the hospital: your doctor may be making a financial decision and not a clinical decision.

When a hospital becomes a social enterprise it will no longer be financially secure. The reason is that currently risk pooling is provided by the government. The government effectively says that there will be NHS hospital services in your area and if your local hospital goes into debt the government is there to provide interim financial support while the hospital is reconfigured. The Conservative government is removing this guarantee (the only service they will guarantee is A&E), they say that the market will make the provision, so if your local hospital does not have sufficient funding and it goes into debt, then the market is saying that a hospital is no needed in your area and so the hospital will close. The government are explicit about this in the White Paper section 1.22:

"We are very clear that there will be no bail-outs for organisations which overspend public budgets."

This is a sink or swim policy.

Hospitals also get risk pooling insurance through the NHS to pay for medical negligence and also for a wide range of non-clinical liabilities including personal injury sustained by visitors to NHS premises, to claims arising from breaches of the Human Rights Act, the Data Protection Act and the Defective Premises Act and also cover for defamation, professional negligence by employees and liabilities of directors. As a social enterprise a hospital will have to cover all of these itself through commercial insurance policies and an inevitable rise in costs.

The fact that the government no longer wants to provide risk pooling for the NHS shows that it is shirking its responsibility to its citizens.

So will these hospitals have a secure future? No. The so-called "ring fence" is a fiction, it was simply a ploy to deceive the electorate into believing that the NHS was safe in Cameron's hands: it is not.  The Kings Fund say that to be funded enough to provide the current service the NHS needs a year-on-year increase of 4% to 6% which is far more than the RPI increase that Lansley is promising.

The NHS has to make £20bn of efficiency savings by 2014. What this means is that there will be £20bn less money over those four years than is needed to provide the service. It is most definitely a cut, it may be smaller than the 25% cut that other public services are suffering, but when you consider that inflation in healthcare is twice CPI and that demands on the NHS increase every year as the population ages, just standing still with an annual inflation increase is difficult enough. To make £20bn of "efficiency savings" is nigh-on impossible.

This is in the face of a further cut in hospital funding when the government cuts the money paid to every hospital for each procedure (treatment, clinic appointment, operation), so that they are paid only the "best practice" or lowest rate. (Remember when we last had a "pay the lowest rate" policy? It was in the Thatcher years when they introduced "competitive tendering" in cleaning which resulted in filthy, unhygienic hospitals. Well Lansley wants that policy to be applied to clinical procedures too.)

Each hospital will be a separate business, and they will be expected to "compete for patients". This is not the spirit of co-operation and collaboration that we are used to in the NHS. But the government is serious about this. They even want to make hospitals subject to Competition Law (and why not? they will be real, private businesses). White Paper section 4.27 says:

"Monitor will have concurrent powers with the Office of Fair Trading to apply competition law to prevent anti-competitive behaviour"

This means that any other business (social enterprise, or private business) will be able to launch a legal case against your local hospital for being a monopoly provider. This is not an idle threat. In most cities you could argue that there is competition because the concentration of several hospitals merely means that you as a patient have a small extra distance to travel to use a competitor. But in rural areas this is not the case. There is typically just one hospital trust covering a large area and by necessity it is a monopoly. Your local hospital could provide an excellent service, but will still be subject to cases brought under competition laws. And once hospitals are subject to UK competition laws, they will be subject to EU competition laws, which means that cases can be brought against your local hospital being a monopoly supplier by an EU healthcare company.

The White Paper also says (4.28)

"[Monitor will] require monopoly providers to grant access to their facilities to third parties"

This means that private providers (or even other former NHS hospitals, now social enterprises) will be allowed access to your local hospital's facilities. As you walk the corridors of your local hospital you will see the uniforms of doctors and nurses of your hospital, as well as Serco, HCA, Spire, GHG and many others. You will also see private patients using the facilities in your local hospital, and inevitably they will go straight to the front of any queue. Even if your local hospital refuses to treat private patients (as my local hospital does and has pledge to continue to do) they will not have the choice because Monitor will force them to allow private providers to use their facilities.

Kingsley Manning, a partner in Tribal’s healthcare business says: 

"The opportunities for the sector may come when NHS trusts who have been told they must become foundation trusts fail. Then there will be a chance for the private sector to step in."

The private sector are simply waiting for (former NHS) hospitals to go into debt so that they can take them over. This is, of course, the whole purpose of the White paper.

All of this is concerning. The government intends for all hospitals to be taken out of public ownership, subject to vicious cuts in funding and left open to the predatory actions of the private sector. Thankfully, UNISON is spearheading a campaign against social enterprises. Currently it is community health services that are under threat, but in the future it will be every hospital. If you value the NHS then you should fight to keep your NHS hospital public.

Do LibDem hearts still beat on the left?

This is the title of a post over at Next Left. Here Sunder Katwala provides a write up of a fringe meeting at the LidDem conference. One comment from Norman Lamb piqued me.

Remember that when the whole "Death Tax" argument flared up, it was Lamb who was most effective in pointing out that the Conservatives were talking nonsense. Lansley had called Burnham's social care plans a "Death Tax" and gave as an alternative an unworkable, underfunded, optional scheme. Burnham went to pieces showing that he was completely unable to attack an unworkable policy when it was presented by a bully like Lansley. Lamb, however, was calm and thoughtful and pointed out with great effect that Lansley's plans could not work. Lambs attacked panicked Lansley into providing more policy details on the hoof and consequently killed Lansley's argument.

Here is the quote from Lamb:

"It is a Coalition of independent parties. It is not a pact."

But this is not what has happened. The LibDems have been subsumed in government. Even their greatest "achievement", the raising of the income tax allowance, was not a unique LibDem policy. David Cameron said before the election that he wanted to do this, but it was too expensive and so was not a priority for him. In other words, the policy that was implemented was not a LibDem policy, it was a Tory policy.

Then we have that worthless rag the "Coalition Agreement", the Conservative government are simply not following it, and the LibDems are unable to do anything about it. (Like everything in this government there is no accountability.) In the CA there is a LibDem policy that PCTs (Primary Care Trusts, the organisation that allocates NHS funding locally) should be replaced with elected Health Boards. However, the Conservative government are not doing this, instead, they are replacing PCTs with semi-autonomous, self appointed GP Commissioning Boards. In other words, the very worst of the PCTs (that they are appointed and face-less) are being spun as the strengths of the new system. So what happened to the LibDem "moderating influence"? Lansley (who Lamb locked horns with effectively at the election) simply said "we had a look at elected Health Boards and decided that they would not work" and instead went back to his original idea, another policy that has not been tested and (according to most GPs) will not work.

The coalition is still in its honeymoon. In a years time LidDems will be weeping about what little influence they have had. If Lamb, or more significantly, Clegg, was true to his word he would stick rigidly to the Coalition Agreement and not allow a millimetre of deviation (I think someone else said something similar recently), because once the CA is seen as being optional the Tories will simply make no attempt to follow it, nor try to accommodate Libdem policies.

LibDem Emergency Motion on NHS

Here is the text of the emergency motion to be debated at the LibDem conference tomorrow.

Emergency Motion 4: NHS White Paper
10 conference representatives
Conference notes the recent government white paper Equity and excellence: Liberating the NHS.

Conference further notes that existing Liberal Democrat policy:
A. Proposes increased local accountability for the NHS through directly elected Local Health Boards.
B. Supports empowerment of patients and equity for patients, particularly those with mental health problems.
C. Acknowledges the risk of destabilisation of NHS services through the use of private sector providers and sets criteria to minimise this risk.

Conference believes that:
i) The NHS is best served by co-operation and collaboration between hospitals.
ii) The patients with some of the most difficult healthcare requirements, such as elderly patients with multiple medical conditions, are likely to benefit the least from a competitive market, and suffer most where there is lack of co-ordination between providers of services.
iii) GP-led commissioning consortia are unlikely to have sufficient expertise in negotiating contracts to eliminate the risk of exploitation by corporate suppliers, and will need to procure specialised and often more expensive commissioning support, creating significant potential for conflicts of interest.
iv) A more fragmented health service often leads to poor opportunities for clinical training.
v) The white paper proposals will tend to increase choice and service provision in affluent and densely populated areas, and by attracting more services to the centres of population will reduce or remove services in poorer and more sparsely populated areas.

In particular conference restates the principles that every provider should:
a) Meet all NHS standards for Quality, Information and Communication.
b) Demonstrate that it provides value for money and does not undermine the local health
economy.
c) Ensure that no NHS patient shall receive a diminished service as a result of the introduction of a new provider.

Conference therefore urges the Coalition Government to:
1. Legislate to ensure that no company or organisation that offers services in support of the
commissioning process should either provide healthcare services directly, or have commercial links to a company or organisation that provides healthcare services.
2. Include in their plans explicit powers for local authorities to intervene if local services are at risk.
3. Ensure that any contract with a provider that does not train clinical staff should include a levy to support training of clinical staff in NHS facilities.

Conference also calls on all Liberal Democrat-led local authorities to use the proposed strategic role given to them in the white paper to protect the sustainability of an integrated health service, and to improve cooperation and communication between providers.

Applicability: England.

This is an interesting motion, not the best (that would be to scrap the entire white paper) but it shows that some LibDems are not happy with the intention that hospitals should "compete for patients" (not co-operate and collaborate as mentioned in the motion). The motion also infers that the white paper will fragment the NHS (this is the result of making every hospital a social enterprise) and that this will be bad for patients. It also says that the likely effect of the white paper proposals will be to provide a worse service in less affluent and more sparsely populated areas. Further, in reference to Lansley's intention to close hospitals by not "bailing them out" the motion says that local authorities should have explicit powers to do this.

I doubt if the Lib Dems have enough backbone to challenge Lansley this way, but it will be nice if they do.

Evidence that Lansley is wrong

Here's academic evidence that Lansley is totally wrong in his plans to change how hospitals are paid. Lansley's idea is that when you create a quasi- free market people will use the hospitals that give the best service and so quality goes up. Even a five year old will tell him that this is nonsense because (d'oh!) people much prefer to use their local hospital and so want that hospital improved. (Tony Blair got this idea at the beginning of his rule, but lost his way when his rich friends told him it would be better to use their private companies instead.)

Here is a blog post from Bristol University's Centre for Market and Public Organisation. OK, so the title first put me off "Healthcare competition saves lives" but the evidence is very interesting.

• It found that hospitals located in areas where patients have had more choice since the NHS reforms [the choice of any hospital in the NHS] had higher clinical quality – as measured by lower death rates following admissions – and shorter lengths of stay than hospitals located in less competitive areas.
• the hospitals in competitive markets did this without increasing total operating costs or shedding staff

There is a caveat: "One reason that the policy may be having this impact is the fact that prices are externally fixed." This is important because the hospitals were nominally not competing on price. In actual fact they were because two hospitals in the same area would be paid exactly the same amount for each procedure. But crucially, the Payment by Results payment system said that if a hospital provided the service for less than the fixed payment they could keep the surplus to be re-invested in the hospital (conversely, if a service generated a deficit then the hospital would have to cover it with surpluses from other services). A hospital generating large surpluses could provide more services, so there is an incentive to become more efficient. However, the fixed payment (or National Tariff) is calculated from the average cost of the procedure and so over time (as more hospitals get more efficient) the average will go down.

• Research for the UK showed that when competition was introduced in the early 1990s in a regime that allowed hospitals to negotiate prices as well as quality there was a fall in clinical quality in more competitive areas. Waiting lists, however, declined for these hospitals.

This is important because it says that if commissioners (the people who actually pay for NHS care) can negotiate on price then the quality will go down. This is exactly what Lansley is planning! He intends to replace Payment by Results (based on the average price) to a system where the price is "best practice " (ie the cheapest) and is the starting point for negotiation since commissioners will be able to negotiate down from this value. This is a return to the system in the early 90s and CMPO says: "Competition under fixed prices appears to have beneficial results whilst competition where hospitals bargain over price and quality do not". The conclusion is interesting:

If competition is to work, price regulation has to be retained.  A free-for-all in prices would mean a return to the “internal market” of the 1990s, a regime in which hospitals competed vigorously on waiting times and ignored aspects of quality that are more difficult to measure. In addition, the tendency of the UK government to merge failing hospitals needs to be looked at carefully. Mergers are popular with finance ministries in NHS type systems because they remove what is often seen as ‘excess capacity’. However, while there are gains from removing poor managers when a hospital fails, removing capacity by merger will limit the extent of competition and may stifle the impetus given by competitive forces to improve outcomes for patients.

Lansley does say that there will be a premium on the "best practice" price for quality. As the CMPO blog says "quality" is difficult to measure, so it is unlikely to affect hospital income.

30% cut in NHS administrators

Yup, that is Lansley's plan, the clueless idiot. Why do I say he's clueless? Well, there is always some administration needed (like ensuring patients' notes are in the right place, that diagnostic tests are done at the right time and the results are on the doctor's desk when the patient visits) so cutting administrators is just plain daft.

For example, I attended a meeting at my local hospital a couple of weeks ago and they presented the results of a study they were doing on "patient pathways". Basically they performed some case studies of several patients listing the time that was taken for various activities: consultant visits, treatments, nurse contacts, meals sleeping and just waiting for one of the other activities. The last activity: just waiting, took the majority of the time. length of stay in hospital is directly related to costs: each hospital bed is an expensive resource and a patient in a bed waiting for treatment/tests/consultation or discharge is preventing another patient using the bed. The presenter gave an example of a patient having a blood test and pointed out that if this happened after four then the results would not be available before the consultant went home, meaning that the patient would have to spend another night in the hospital.

All of this is project management: you need someone to make sure that tests are done promptly, and that the results are available at the right time. Yes, you may also persuade consultants to change their working patterns but this is a management issue.

So now we have Lansley dictating that management is going to be cut by 45% and administration by 30%. How the fuck does he think that can be done? A good manager saves money, s/he makes the system efficient, cutting management by some arbitrary figure is nonsense.

So I was rather interested to see that junior doctors spend more time on administration than on formal training. With the diktats from Lansley about cutting management and administrators, junior doctors will find that they will have far more non-clinical work to do. And, of course, that will increase the drop-out rates (one in four currently).

Have a read of this doctor's account of the administration that she was required to do, and I challenge you not to think "but surely there is an administrator who can do it for you?"

Rationing

One of the most unpopular parts of the White Paper is that it explicitly says that GPs will have to ration healthcare. An odious task. Well, since there are huge cuts (efficiency savings are cuts) to be made in the next 4 years, many PCTs are thinking ahead and cutting already. Pulse report that cuts are being made to:

• treatments for back pain
• refusing all requests for IVF
• tonsillectomy
• counselling
• hip operations

If you are in pain because of a back problem or a hip problem would you like to know that you will not get the care you need because Cameron lied about not cutting the health service? It is happening now.

But PCOs [Primary Care Organisations] are not cutting for fun. Indeed Pulse this week reveals many are panicking that they are not cutting quickly enough, with mid-year projections suggesting they are heading to bust budgets or miss efficiency targets. The likely outcomes are grim. PCOs may cut faster and deeper, shrugging off concerns over access to treatments and perhaps ignoring the new requirement, at least in England, to consult with GPs. Or they may shirk the budgetary challenge, in the knowledge they won’t be around to carry the can. If that happens, GPs will face a mountain of debt when they take over commissioning – debt the GPC concedes is likely to become the profession’s problem.

...and remember the Daily Mail? They complain all the time about some expensive, ineffective treatment that according to their rather dim, uneducated "journalists" are miracle cures being denied to us by the nasty people at NICE. Well Pulse says that the treatments that NICE recommends will be too expensive for the meagre budget that Lansley is giving GPs:

But it will not only be debt that becomes GPs’ problem. So will the legal duty to provide NICE-approved treatments, with consortia risking being sued if they fall short. As NICE green-lights more and more treatments, without worrying about anything as inconvenient as a budget, so the pressures on GPs will increase.

Pulse say that NICE should not be recommending as many treatments as they do:

NICE, too, should reform, by making recommendations within a notional annual budget, so GPs are not left with all the tough financial calls. Otherwise, the cynics on GP commissioning could be proved right – that it is just a way to shift blame for rationing onto GPs’ shoulders.

Now before you scream "bring in the private providers!" have a look at another report from Pulse.

GPC chair Dr Laurence Buckman told Pulse: ‘PCTs that have contracts with private organisations to provide hip surgery have for a long time had very restrictive criteria given to them by the private providers. So much so that you’ve got to be an Olympic athlete to get your hip replaced in some places.'

The sarcasm at the end of that quote is essentially saying that the private contracts cherry-pick: they will only do the easy cases. The private sector is NOT the solution.
 referral.'Buckman continues:

‘There are several people who presently are offered treatment for various illnesses who may not be offered treatment in the new world. If there’s evidence to show that that’s actually better for them, that the treatment is worse for them, then that’s not bad care, that’s good care. But where restrictions are put in merely to save money, I don’t think any of us would accept that.’

 Rationing will come, and you will have Lansley and Cameron to thank for it.

GPs to have child protection responsibilities

Thought that was the responsibility of local authority social services? Well it will be the responsibility of GP consortia under Lansley's plans.

"It also reveals GP consortia will take on the responsibility for child safeguarding from PCTs, although it admits this is beyond the experience of most PBC groups.
'This will be an important new role for GP consortia and one which will go beyond the experience of most existing GP commissioning groups,' the DH report said."

Yet another case of GPs being told to do something that they do not have the skills to do.

NHS Maternity Services

The obvious place to co-ordinate maternity services is GPs. That's obvious, so obvious that you probably feel insulted that I even thought to mention it.

However, Commissar Lansley, showing that he is completely clueless about healthcare, decided that commissioning for maternity services should rest with the super quango, the NHS Commissioning Board. Bizarre!

Actually, it is "outrageous" as one exasperated GP exclaimed at a recent GP meeting (reported by Pulse). Perhaps the Prime Minister might have a re-think, considering his recent change of circumsstances, and clearly the Department of Health think it is bonkers:

"A DH representative said it would take on board all feedback from delegates, and hinted at a possible U-turn. ‘A lot of people struggle to see how this fits with the general philosophy,’ he admitted. "

Conflict

An article on the HSJ website today is titled: "Conflicting messages from the top hint at growing resistance". It reports that Andrew Lansley and the top civil servant in the NHS, Sir David Nicholson, are providing conflicting messages about the planned changes. On the one hand Commissar Lansley is attacking just about every part of the NHS in his attempt to break it apart into private corporations. On the other hand, Sir David recognises that if any change has to be made it has to be done by the people who work for the NHS and hence he is carefully asking for help. The HSJ article gives the 18 week target as an example:

Mr Lansley trumpeted the end of the 18 week waiting target, Sir David chooses to specifically remind NHS chief executives that it “remains a constitutional right” and commissioners have “a responsibility to ensure that commitment is met”.

This is a clear conflict, especially since Lansley made targets a political issue (even thought he is totally wrong about targets, because patients really do like them since they guarantees them prompt care).

As a civil servant Sir David has to do what his political master tells him to do, but as we well know from Yes, Minister, the Sir Humphrey's of Whitehall usually know best and implement what they know to be best.

Look at how the decent majority killed the poll tax

Brendan Barber, the General Secretary of the TUC, said this in the Indy yesterday:

"As people begin to see the unfairness of the cuts, the more support our alternative will win. Already we are getting the first hints that ministers are beginning to worry how voters will respond. That is why I look back to the poll-tax campaign for inspiration. That was the last great U-turn carried out by a Conservative prime minister. It went because the decent majority stood up and said that it was fundamentally unfair. MPs returned to Westminster to tell whips and ministers that their normally placid and safe seats were in uproar. There may have been disorder in central London, but that was an unwelcome distraction. The poll tax was abolished because Middle Britain said no."

For the last couple of months when people have asked me how to fight the NHS plans my advice, timid as it may sound, has been "go and complain to your MP, your county councillor, your district councillor and your town or parish councillor; make them known that you will not vote for someone who supports these plans". The only way to make Cameron change his mind is if he thinks that he will lose councillors in their thousands and lose LibDem support in Parliament and lose the support of enough of his MPs to make his position untenable.

This is how we will fight this policy and we can succeed. And besides, I've tasted the boots of a police officer, in my youth, and it didn't achieve anything; and anyway, I am just too old to pick fights with people younger than me.

Interesting Comments

These are interesting comments from Health Investor:

"Not only does coalition health secretary Andrew Lansley face similar anti-privatisation heat from Liberal Democrat backbenchers [as Blair did from his backbenchers], but he’s also under fire from fellow Tories, peeved that the NHS has been sheltered from spending cuts. At the same time, he’s announced that the vast majority of NHS managers are going to be sacked, then subsequently slagged-off independent providers and consultants for being “wasteful”: these are exactly the same people that are supposed to help make the white paper a reality. It is going to require a Herculean act of political strength to push the white paper through and, right now, Lansley is as weak as a baby."

The cat's been let out of the bag

GP commissioning is just one part of the White Paper. Far more important is Lansley's plans to privatise NHS hospitals. The private sector are not happy about this because they are inefficient and bloated and cannot match the cost-effectiveness of NHS treatment. However they do see an opportunity.

Kingsley Manning, a partner in Tribal’s healthcare business says:

"The opportunities for the sector may come when NHS trusts who have been told they must become foundation trusts fail. Then there will be a chance for the private sector to step in."

The cat's been let out of the bag.

GPs show "fierce opposition" to commissioning

Pulse report that the RCGP performed the largest survey of GPs yet and found that there is "fierce opposition" to GP commissioning.

"It warned plans for GP consortia to replace PCTs risked destabilising the NHS, and could swamp practices with extra workload and take clinicians away from the front line, while opening the door to the private sector."

The RCGP says:

"GPs will be seen as the purse-holders: this could reduce public trust and decrease their ability to advocate for patients, and they will be blamed for failures and cuts in services"

If Lansley cannot get GPs on board, the plans in the White Paper cannot be implemented.

Details about GP Consortia and Junior Doctor Training

Sir David Nicholson has written to various important people in the NHS to tell them about Commissar Lansley's plans. The document is available from the Department of Health website. Here are some pertinent points.

It is our intention that GP consortia would be statutory public bodies. We have said that each consortium would appoint an Accountable Officer and a Chief Financial Officer who would have responsibilities and accountabilities as leaders of their NHS organisations. However, beyond this the governance arrangements would be a matter for the consortia themselves to determine.

GP practices already make a key contribution to the overall quality of patient care and to the effective use of NHS resources. We propose, subject to discussion with the BMA and the profession, that a proportion of GP practice income should be linked to the outcomes that they achieve collaboratively through commissioning consortia and the effectiveness with which they manage financial resources.

GP consortia would be NHS bodies and NHS employers. The intention is that they would be statutory bodies, with powers and functions set out through primary and secondary legislation. We propose, however, that they would have flexibility in relation to their internal governance arrangements, beyond essential requirements for example, in relation to areas such as financial probity and accountability, reporting and audit.

Monitor would also have concurrent powers with the Office of Fair Trading to enforce Competition Law within the health and social care sector. These would be statutory powers that could be enforced outside of Monitor's licensing regime and could, therefore, be applied throughout the sector, including in primary care, and to all types of provider.

This looks like GPs will be subject to Competition Law.

The White Paper makes it clear that it is time to give employers greater autonomy for planning and developing the workforce alongside greater professional ownership of the quality of education and training. ... It would be set within the context of delivering appropriate investment in workforce education and training, whilst ensuring better outcomes for patients and value for money. It would also need to ensure appropriate checks, balances and accountability. The arrangements for education commissioning and delivery would be transparent and more efficient.

This seems to indicate that training will be the responsibility of hospitals. The "investment" part is important because at the moment training (and the salaries of trainee doctors and nurses) are paid by the Department of Health. The "investment" may indicate that individual hospitals will be responsible for this training cost. Considering that it costs £350k (or about 60 hip operations) to train a junior doctor this is not an insignificant cost. If doctors are made to shoulder this cost it would completely rule out any student from a low income background becoming a hospital doctor.

Private Healthcare LOVES The Tories

They really do. Here is the HealthInvestor Barometer the survey of private health providers. Look at the results for these questions:

Q: Which political party will do most to speed the recovery of the UK independent healthcare market?
A: Conservative 58%; Labour 10%; LibDem 2%

Q: Will the new government support the recovery of the UK independent healthcare market?
A: 64% agree/strongly agree

Q: Which political party will do most to expand the role of the private sector in the NHS?
A: Conservative 58%; Labour 8%; LibDem 2%

Q: Will the new government accelerate the expansion of the role of the private sector in the NHS?
A: Yes 86%; No 2%

Q: Is there a level playing field for providers to compete for primary care [GPs] contracts in the NHS?
A: Yes 14%; No 66% (see my post earlier today)

Q: Is there currently a fair market for secondary care providers [hospitals] to compete for NHS patients?
A: Yes 18%; No 69%

Q: Will budgetary pressures in the NHS boost demand for private care provision over the next two years?
A:Yes 79%; No 12%

The last question I quote above is the most important, the private sector expect the government to squeeze the NHS deliberately to force people to buy private healthcare. They say in the report:

"And our experts are almost unanimous in predicting that the looming real terms cut in the NHS budget will boost demand for private care provision for the next two years."

The interesting point is that the private providers do not believe in the talk of a "ring fence" and expect huge cuts in NHS funding. I agree with them, the "ring fence" will not survive the auntumn spending review.

More optimistically (for me) is that 75% think that the recession in private healthcare is not yet over (Yay! Let's hope it never does recover!) and that 55% think that the recovery will be 2013 or later. While the document does appear to be a glowing endorsement of the Conservatives there is this interesting comment:

"there is rumoured to be plenty of opposition in the Conservative ranks to the reforms so the vote could be a major test for the coalition whips"

I have always felt that the best way to fight Lansley's plans is to target the crucial 50+ grey vote in Tory areas. When they realise that these plans will affect them they will complain to their MP and that will force Lansley to re-think.

GPs worry

It is very clear that the main aim of the NHS White Paper is to privatise hospitals, but what about GPs? Well they are mostly small businesses and although Lord Darzi's reforms tried to bring in the big multi-nationals into primary care in a kind of "Tesco kills the small grocer" style, the changes implemented incompetently. The GPs were spared once, but now there is a new attack: Lansley's White Paper.

The Royal College of GPs have noticed that the White Paper spells the start of the end of the small business model of GP practices. Prof Steve Field, the RCGP chairman, said there was

'clear evidence' that if consortia were not big enough, many would fail.' But he called for failing consortia to be offered support or merged with neighbouring groups, instead of allowing private firms to take over.

How long will it be before you'll see a Virgin GP clinic in your town? Remember, to be viable a consortium has to be large, a population of 100,000 is the minimum, the GPC is talking about much larger consortia. So if a large healthcare company like Virgin takes over a consortium they will effectively have the monopoly over primary care in your area. Although you will have the choice to register with a new GP, the size of the consortia will mean that your "choice" will be to use a GP practice many miles away - in the next town, or county.

Changes that will lead to no changes

There is a lot of speculation about how many patients would be covered by each GP consortium. There has been general comments that it is infeasible for a consortium of less than 100,000 patient to do commissioning. England has a population of about 50 million and there are 150 or so PCTs so at the moment, on average each PCT covers about 330,000 people. So it is rather interesting that Healthcare Republic are reporting that the GPC is recommending that GP consortia should "federate" because they say that "consortia covering populations of less than 500,000 will struggle to manage risk". In other words there will be about 100 "federations" compared to the current 150 PCTs.

Can someone now explain why we need to go through the costly changes (that Lansley says will cost £1.7bn, and the Manchester Business School says could cost £3bn) when we will get essentially the same organisational structure?


UPDATE:
The former DoH commissioning chief Mark Britnell has said that GP consortia must be "at least the size of PCTs". While the chair of the RCGP, Professor Steve Field, said last month that just "a few expensive patients" could cause a small consortium to overspend.

Lansley Plays Hardball

So Andrew Lansley knows that the key to getting his denationalisation of the NHS policies accepted is to get GPs on side. They are the key part because they will be in charge of the new rationing system. GPs are not happy. So what does Lansley do? Well he decides to annoy GPs by telling them that their pay will be frozen for two years. Pulse reports that the Department of Health have said that they will not consult the Doctors’ and Dentists’ Review Body over these two years which means that there will be no contact between the GPs' representatives, the GPC, and the Department of Health even to discuss expenses.

It seems as if Lansley is deliberately goading the GPC. GPs argue that they will have to take on additional responsibilities with GP commissioning, and they want incentives to implement Lansley's demand that fewer patients are referred for hospital treatment. (Question: Did Lansley say at the election "vote for me because I want to stop you getting hospital treatment"? No, I thought not. But, I did say that this would happen.)

Their chair, Dr Buckman, is already attacking the government over Lansley's plans to put GP commissioning into the GP contract, which Dr Buckman says is unacceptable. GPs are starting to get vocal about their opposition to Lansley's plans. Yet Lansley is gaily telling everyone that

"GPs across England have fully endorsed his plans"

Yet Pulse say that they have plenty of comments from GPs opposed to the plans, indeed they even report one GP calling for legal action to be taken.

Meanwhile GPs at a meeting in Birmingham have called for a legal challenge to the white paper because of what they claimed was the threat to single-handed practices.
Dr Martin Jones, a GP at the meeting pushing for the move, said: ‘It was recognised that many single-handed or smaller practices are at risk of going under if the white paper goes ahead.’

So how can Lansley say thathe has enthusiastic support when there are still serious concerns over his plans, and when he is deliberately picking a fight with GPs over their pay?

I think that soon Cameron will regret putting such a pig-headed bully in charge of the NHS.

Patient Groups Concerns Over NHS Changes

This a rather excoriating article in Healthcare Republic. It reports the results of a survey by Patient View who surveyed 887 patient groups, representing more than one million patients. They are extremely cynical that Lansley's changes are for the better:

• respondents identified cutbacks as their main fear, despite a pledge to ring-fence the NHS budget
• fear cuts to central monitoring services such as the Audit Commission will lead to a decline in NHS standards
• three quarters do not believe that the government wants to hear their views
• none of the patient groups had been directly consulted by the DoH on the future of the NHS

It is quite clear that the government has the view that it is right and everyone else - regardless of their experience and expertise - is wrong. As Alexandra Wyke, managing director Patient View, says:

‘If you’re going to encourage community groups to get involved in a "Big Society", it might be a good idea to talk to them first’.

Is the GP stance on the White Paper crumbling?

Key to Lansley's privatisation of the NHS is getting GPs on side: if Lansley cannot get their approval the idea will die. The BMA have a long established principle of Keep Our NHS Public and therefore the BMA's General Practitioners Committee (GPC) also hold this view and have provided their opinions through a document called The principles of GP commissioning which includes the statement

"wherever possible, consortia should ensure that NHS providers are the providers of choice."

This has now been challenged by the NHS Confederation are warning that this could be illegal (Healthcare Republic):

Nigel Edwards, NHS Confederation acting chief executive, said GP commissioners should not ‘simply dismiss what non-NHS organisations can offer.’ ‘This principle is doubtful in law and unwise in practice,’ he said.

As I have said before, divide and conquer is the way to achieve your goal, and here is clearly a case of GPs divided.

GPs are slowly forming a view about GP Commissioning

I have always felt that the Ents in the Lord of the Rings were an allegory of the United States; the turning point of the tale was when the powerful Ents decided to give their support to the humans fighting the Orcs.

In Britain, GPs are Ents. Immensely powerful when mobilised, but usually too aloof to take sides. There are now rumblings coming from GPs. Yes, there are some that support Lansley's plans (the NHS Alliance and the National Association of Primary Care are the main cheerleades), but the bulk of GPs are still keeping out of the fray. Now Pulse is reporting that  the GPC is starting to develop a policy towards the White Paper:

"Negotiators are now saying they [GPC] do not support Mr Lansley’s proposal to write commissioning into the GP contract, which they fear would spell an end to the UK-wide contract and substantially weaken their negotiating hand."

The GP Ents are stirring, but will it be enough?

More on GP Commissioning

It is clear that GPs are the lynch pin in Lansley's plans. If he cannot persuade GPs to carry out his plans then the de-nationalisation of the NHS will not occur. Lansley is bullish and arrogant, he believes that when he says "jump" everyone will jump. That is a very foolish attitude to take, since GPs have ruined the careers of better Health Secretaries than him.

So today we hear that Lansley has decided that GPs will be paid £9-10 per patient in management fees for performing commissioning. This will not go down well with GPs. I have heard many GPs saying that the red line is a figure of £12 per patient. Healthcare Republic says:

"A £9-10 fee per patient equates to roughly a third of the management budget PCTs currently receive."

Yet again, there is no supporting evidence that high quality (and safe!) commissioning can be performed for a third of what PCTs are paid. Yet again, Lansley has picked a figure out of the air and is making everything fit that figure.

Understandably GPs are not happy. If they are paid a third of what they need to do the work then they will have to find the rest of the money from somewhere else. And that means cutting into their profits.

Lansley is making the work of GPs far more difficult and this will ultimately result in a worse service for patients. Healthcare Republic reports that the changes in the White Paper are making many GPs think that now is the time to take early retirement:

Essex LMCs chairman Dr Brian Balmer predicted a 'bulge' in retirement as GP commissioning reforms in the White Paper take effect. Dr Balmer said: 'there will be a significant number of GPs who say this is not the kind of general practice they want to do and maybe think now is the right time to go.'

Brian Keeling, chairman of Lincolnshire Local Involvement Network, says 'We have a high number of GPs close to retirement and reforms giving a lot of extra responsibilities to them. It doesn’t take a genius to see that people will see it as a good time to move on' 

This is very concerning. Not only does it mean that the numbers of GPs will fall which will have effects on things like the availability of appointments, but it means that the immense wealth of experience will be lost.

And all of this is avoidable.

UPDATE: More on PCT debts

Pulse reports that it is very likely that GP consortia will have to take on some of the debts of the existing PCTs. This seems rather bizarre since you could argue that the debts have not been caused by the GP practices which are part of the consortia, and so why should they shoulder the financial cost.

The Department of Health said last week it could not guarantee a clean financial slate for consortia when power transfers, heightening fears that GPs could inherit hundreds of millions of pounds worth of debt from cash-strapped trusts. Dr Buckman acknowledged that GP consortia may have to accept responsibility for some modest debts, but warned the policy would ‘not get off the ground’ if they are forced to start from ‘a position of very serious debt’.

Perhaps as an indication of the pressure being applied to Dr Buckman by the Department of Health, he makes a statement that is not unlike Rumsfeld's "known unknowns" comment:

He said: ‘There are several kinds of debt. There’s the debt that inevitably occurs as a result of managing patients. We can argue whether it should or should not transfer to the new consortia. I think if it did transfer it's something we would have to manage and cope with. I don’t have a huge problem with that. Where I do have a problem is where for example the body of GPs opposed things and are now having them visited on us, like Darzi centres and PFI schemes, that the vast majority opposed. There is a whole series of things that were brought in by the previous Government that this Government is now reversing, and we’re going to be saddled with that debt too? I don’t think so.’

Well, I am sure that most GPs are saying: debt is debt, if I did not cause it, why should I be responsible for it? Dr Buckman does, however, point out that unless the Department of Health sorts out the issue GPs will refuse to participate. It is a pity that he's already started the negotiations by conceding so much already.

Cameron's Lies

I leave it to Political Scrap book to put it succinctly: