Mutuals

Just because it is in the Government's "Making Quality Your Business" (AKA the NHS Initial Public Offering) document, I thought I would blog about mutuals and social enterprises.

First: why are the government so excited about mutuals and social enterprises? Answer: because it absolves them completely from doing it themselves. The government does not want the responsibility of providing public services. Kinda lazy, really.

Mutuals

The model of mutuals that we are use to, are organisations that are owned by their customers. The building societies are the most well known example, where some customers save their money (and are paid interest) and others borrow money (and pay interest). There are no shareholders so no dividend payments. The organisation is owned by the customers and is run for the benefit of its customers.
Other than building societies, there were insurance and pension companies who were mutuals. As part of the selfish 80s attitude the Thatcher government legislated so that mutuals could demutualise and as a result few building societies remain. Cameron calls himself a "son of Thatcher" so it is rather surprising that he is now championing an organisation that Thatcher clearly hated to destruction. Cameron has not commented on whether mutualised public services will be prevented from demutualising, but it is a distinct possibility because the mutuals will not be publicly-owned and so can determine themselves what happens to them.

The building society model is that the customers own the mutual, and in the NHS the "customers" are us. As a public service we already own the NHS! Public Benefit Corporations are a form of mutual owned by the public. In this case the organisation has a public membership (non-fee paying) who elect governors to oversee the board of directors who run the organisation. The idea is that the public owns the Public Benefit Corporation and provides public governance. This is the model used for Foundation Trusts.

The mutual model that the government is pushing for the privatisation of NHS services is staff-led mutuals. In this case the mutual is owned by the staff and is a profit-share organisation. This is very different to the publicly-owned Public Benefit Corporations, because a staff-led mutual organisation is not publicly owned. Mutuals are usually profit-share: if they make a profit they distribute this between the mutual owners. Since a staff-led mutual is owned by the staff, this means that profits are shared between the staff. However, be aware that while all staff are equal owners of a mutual, some are more equal than others, so the result of profit share may well mean that those who earn the most get a bigger share of the profit.

Social Enterprises

Social enterprises have two important aspects: they serve a social purpose and they are not-for-profit. Not-for-profit does not mean that they do not make a profit, it just means that all surpluses they make are re-invested back into the social enterprise. If you think that this describes every public service, then you are right! Every public service is not-for-profit and serves a social purpose. However, social enterprises are not publicly owned, and the government's enthusiasm for social enterprises highlights that the reason is the actual ownership of the organisation, not how the organisation is run. The government wants to absolve itself from the responsibility for providing public services.

It is important to reiterate many times that neither mutuals, nor social enterprises are publicly owned. The government has no responsibility for them: once they get a contract to provide a public service this does not guarantee that they will always provide the service. The mutual or social enterprise is just yet another service provider. Indeed, they will be treated exactly the same as Serco, Capita or G4S. Except, of course, these large private service companies have millions to spend on marketing and will easily outbid the mutual/soc ents when their contracts expire.

If a mutual or social enterprise goes bankrupt then the government has no responsibility (however, if you are part of a employee-led mutual or co-op, then you will be liable). Will there be much to be liable for? Well, of course there will be, every business has assets and mutuals and social enterprises will need to purchase such assets possibly through commercial loans. They may have to purchase the asset of the NHS organisation they are replacing, which will result in public assets moving into private hands.

Since mutuals and social enterprise are private, non-public companies, and they are intended to provide at least 10% of NHS services, this is clearly privatisation of the NHS.

Bring and buy sale of the NHS

Yes it it privatisation, don't let the phrases "mutual" and "social enterprise" make you think that the government's plan are anything but privatisation. (I'll cover that issue in my next blog post) The government have just released their master plan for their initial IPO of the NHS, the PDF is here.

The government is not going for all out privatisation, instead they will do it piecemeal. The idea is that willing workers will buy up a service from a hospital and then provide it cut price back to the hospital. This is, of course, the best business plan since Enron thought "I wonder how we can make accounting a bit more exciting?" So in the future your local hospital will be a bit like a franchised department store: your blood taken by PhlebotomistRUs ("we promise only to wear fangs at Halloween!"), analysed by OneHourPathLabs ("three for two offer every Thursday") and then your Virgin Healthcare consultant will tell you what's wrong with you before flicking through his luxury yacht catalogue. What possibly can go wrong with that?

The interesting thing is that Foundation Trusts are largely immune to this initial IPO, and NHS trusts can turn down your get-rich-quick idea if taking over a service from them is likely to affect their application to be a Foundation Trust. To be frank, if your plan to take over a service will not affect the trust's FT application then you shouldn't touch it: NHS trusts are cash strapped, so they will only want to lose loss making services.

However, I found it interesting to see what they say about FTs:

If you work in a Foundation Trust, you will have to talk through your proposals with your manager and decide on the best approach to take. As Foundation Trusts are independent organisations, their boards are not obliged to support proposals to develop staff led enterprises. However, Foundation Trusts may well be interested in innovative proposals that will improve patient care.

So FTs don't have to do everything the government tells them to do. The phrase "boards are not obliged to support proposals to develop staff led enterprises" actually means "the government wants to force FTs to do this, but we can't". Revenge of Milburn?

However, whoever wrote it does not know much about FTs because significant policy decisions like outsourcing or privatising services should be approved rubberstamped by FT governors, but there is nowt there about FT governors. Why governors? Well FTs are public benefit corporations which means they are publicly owned and have a public membership. The membership elect governors who oversee the board's actions. So something as significant as selling off a service should be reviewed by the FT's governors. I bet that no FT council of governors have yet challenged a board's decision.

Is this the right way to make laws?

One thing that really pisses off residents in an area is when a large company builds a hideous facility and then applies retrospectively for planning permission. Yet this is happening to the Health and Social Care Bill.

Is it right to implement a law before it has been approved by Parliament and then say that the law must be passed because it has already been implemented? Pulse reports that the government will make amendments to the Bill in the Lords but "the principles remain the same, as does the clear direction set out by the reforms". The magazine quotes Dr James Kingsland, special adviser on commissioning at the Department of Health, who said that:

Government advisers were calling for more communication with GPs on the ground, rather than for much tinkering with the bill itself

So we should not expect any real changes to the Bill. Further they quote a source saying:

"What isn’t going to happen is some sort of rowing back. There are not going to be major changes to the reforms. The horse has already bolted on that one. We’ve already got more than two thirds of the country covered by pathfinders. We’re beyond the tipping point."

Is this the right way to make laws? Don't the public have a recourse against a government acting in such a thoroughly undemocratic way?

Health and Social Care Bill: Full Steam Ahead!

Will the Health and Social Care Bill be substantially changed? I think not.

Cameron's "chairman of the board" role to leadership has clearly failed with the Bill. He has allowed a thoroughly unpopular bill to get this far through Parliament with very few amendments. This shows that Cameron has been lax and inattentive.

Cameron created the execrable "Patients' Passport" policy for the 2005 election that the Tories lost, so he knows something about NHS policies and how not to get them implemented. So Cameron knew that Lansley's policies were controversial, and as a consequence he refused to discuss the details of Lansley's plans at the 2010 election. Competition was not mentioned, the cull of skill NHS staff was not talked about, and never did Cameron say that he would implement the £20bn cuts that McKinsey had recommended. Cameron (or most likely, his strategist, George Osborne) was successful in deflecting any scrutiny of Lansley's plans.

Yet, when pitched against one of the most unpopular Prime Ministers in recent times, Cameron failed to get a majority, so clearly his general message did not convince the public. If Cameron had been honest about Lansley's policies he would not have gained the number of seats he currently has, so clearly the policy of obscuring Lansley's plans was a success. Look at the parliamentary numbers. Cameron has the minimum possible number of MPs. The number of Lib Dem ministers he needs to guarantee a majority reflects exactly the proportion of Lib Dem MPs in the House. Any fewer Tory MPs and Cameron would not have a majority with the combination of the Tory MPs and the "payroll vote" meaning that Lib Dem backbenchers would be far more powers. If Cameron had been honest at the election about Lansley's plans, it would have reduced the number Conservative MPs, and hence the likelihood that the Bill would have existed.

The public were conned at the election, and they are now starting to realise this. The deception at the election was successful, and further, Lansley was given a free reign after the election by Cameron to implement his plans. In fact, Lansley was even allowed to extend them, since he realised in "late May, early June" that he would abolish PCTs and rescind one of his stated policies (in the "NHS Autonomy and Accountability" policy document, 4.28 to 4.30) "PCTs will remain local commissioning bodies" and the statement in the Coalition Agreement that "[the] local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs". Clearly breaking the Coalition Agreement within a month of agreeing it is serious, so why didn't Cameron notice this? A "chairman" is supposed to keep an eye on what the board are doing and make sure that cockups do not happen, but Lansley's policy was a massive cockup waiting to happen right from the publication of the Tory draft manifesto on health in Jan 2010 and it deteriorated as the policies were fleshed out in government.

The fact that the H&SC Bill has got this far is because Cameron allowed it to, a "chairman" of a corporation who oversaw a the development of a policy that would affect one sixth of the corporation's turnover and then suddenly decided that the policy was seriously flawed would have no choice other than to reconsider his/her position. Cameron will not do this, but even so, any substantial changes to the Bill will reflect very badly on him.

Changes to the Bill will also reflect very badly on others in government. Oliver Letwin and Danny Alexander were asked by the Prime Minister to review the Bill at the end of last year. According to Cameron they "had questioned health secretary Andrew Lansley "forensically", and had heard "good answers"" consequently they gave the Bill their approval.

And then there is Lansley, who has consistently said that the Bill must not be amended. (Sarah Wollaston has complained about this, she was told that only government amendments would be allowed - hers would not). Indeed, the committee stage of the Bill has been the longest of any bill since 2002, it has had 100 votes on amendments, and not a single opposition amendment was accepted. This is a Stalinist grip on the committee. Lansley's response to the white paper consultation was basically "full steam ahead!" and his response to the Lib Dem Spring Conference motion was that the Bill will not be changed. He is intransigent, and any significant changes to the Bill will be deeply damaging to him.

Call me cynical, but I do not think that Cameron will allow such damage to happen, only cosmetic changes will be made to the Bill.

Much of the talk about amending the Bill emanates from an article from the political columnist in the Times, Rachel Sylvester. The artcle simply says that the Bill is in trouble, it does not say that it will be substantially changed:

"ministers insist that the broad principles will be retained"

"David Cameron ... is now said to be coming round to the idea of making some 'clarifications' on the speed and scale of the proposals."

"a Tory Cabinet minister says: 'The Bill is not quite as scary as people have made it seem'"

None of this indicates that the major policy issues of "Any Willing Provider", removing the responsibility of the government to provide healthcare, of removing accountability in commissioning, none of these will be amended. If they are taken out of the Bill then the Bill will no longer exist. What is being suggested is a new campaign to convince the public that they want the Bill. A charm offensive perhaps (although, it is unlikely to be fronted by any of the charmless health ministers).

As a final note. The review of the Bill at the end of last year was by Letwin and Alexander. Both signed it off. Both will be damaged if any substantial amendments are made to the Bill because it will appear that they did a bad job reviewing the Bill. The most damaged will be Alexander because, as a Lib Dem, this was never a bill of his party. In fact, why hasn't he been castigated so far? The Lib Dem Spring Conference said that they disagreed with substantial parts of the Bill Alexander signed off, doesn't that show how out of touch he is with the Lib Dem grassroots?

Do the BNP do better in Labour areas?

Any analysis of the 2010 election results shows that:

The BNP got votes in 338 seats and of these 160 had a Labour majority (47%), 152 had a Conservative majority (45%) and 24 had a Lib Dem majority (7%).(The other two seats were won by an SNP candidate and the Speaker.)

The BNP got more than 1000 votes in 281 seats and of these 134 had a Labour majority (48%), 134 had a Conservative majority (48%) and 12 had a Lib Dem majority (4%).

The BNP got more than 2000 votes in 91 seats and of these 60 had a Labour majority (66%), 29 had a Conservative majority (32%) and two had a Lib Dem majority (2%).

The BNP got more than 3000 votes in 26 seats and of these 19 had a Labour majority (73%), six had a Conservative majority (23%) and one had a Lib Dem majority (4%).

Of the BNP's ten largest majorities, eight were Labour, one was Conservative and one was LibDem. Of the BNP's 20 largest majorities, 14 were Labour, five were Conservative and one was LibDem. Of the BNP's 100 largest majorities, 64 were labour, 34 were Conservative and two were LibDem.

As ever, it all depends on what you regard as significant. It is clear that the absolute statement that the BNP do better in Labour areas is not true. Indeed, if you look at all the seats where the BNP got votes (or where they got more than 1000 votes) BNP voters are prevalent in as many Conservative constituencies as Labour. If you look at the constituencies where the BNP get larger votes, there are roughly twice as many Labour constituencies as Conservative, but it is clear that the BNP support is not confined to Labour constituencies.

Fighting a losing battle

"Ring fence the NHS"
"Liberate the NHS"
"Modernise the NHS"
"Save the NHS"

In the last year the Conservatives have changed their rhetoric several times. Each time they come up with a new phrase we realise that the old one was just hot air. The fact that the Conservative government have used so many phrases to describe what they are doing indicates that they are trying to hide the real reason behind their policy (hint: creating a healthcare market, and all that that entails).

When was the last time I remember a government pushing a policy that was unpopular and they refused to tell us the real reason for the policy? Oh yes, ID cards:

"Protect you from terrorism"
"Prevent benefit fraud"
"Protect your identity"

The last government used all of these excuses, and soon after they used the excuse it was debunked. The policy was thoroughly unpopular with the public and the new government (quite rightly) cancelled it. (I am sure that Labour would have cancelled it too, it was such an easy cut to make.)

Let's hope that Lansley's Bill goes the same way as ID cards.

Reason to vote against AV

Let's get this out upfront, I am #meh2AV: I really don't care if we have it or not. As Nick Clegg said before last year's election, it is a "miserable little compromise". It is not proportional (which is the Lib Dems' obsession). I do not think that AV will make any difference, but then I am in a good position to say this because the associated plan to remove 8% of the constituencies means that we cannot compare like-with-like.

To me, the AV referendum is not about the voting system, it is about the politics associated with those who vote for and those who vote against AV. The Mail on Sunday today illustrate this very nicely. James Forsyth points out that the two coalition partners are on either side of the referendum, which means that one of them will lose. He says that the coalition have agreed that there has to be "a set of 'policy wins' for the loser"

But there's increasing concern that the Lib Dems' consolation prize might come at the Tories' expense. One Cameroon told me last week he worries that if the Lib Dems lose the referendum they will disown the Coalition's NHS reforms. Already, Clegg has told his MPs that he is 'taking the lead' in the Government in trying to amend these reforms, while one of his senior allies is calling these changes to the NHS 'one reform too many'. The danger for the Tories is that Clegg will claim that he’s stopped them from damaging the NHS. This charge would do huge damage to Cameron – whose reputation as a different kind of Tory is largely built around his personal commitment to the NHS – and revive the charge that the Conservatives can’t be trusted with the health service.

If ever there was a reason to vote against AV, this is it.

Fundamentalism

Imagine there is a hypothetical service that we all use and you are asked to create a survey about change in the system. Nothing exists without change. Everything has to change, your survey is to determine the opinion of the public about how much change they think should happen. You have decided that there will be three responses:

Do you:

1. think the service is almost perfect and only minor changes are needed?
2. think the service needs some changes, but nothing too drastic?
3. think the service is so bad that it need completely replacing?

Do you think this is acceptable for the middle response? After all, if the respondent thinks that the service works fine then they will choose #1, and if they think the changes needed are fundamental, they would choose #3. So in this case #2 takes a middle line: changes are needed and improvements can be made. If the respondent wanted drastic, fundamental changes, they would choose #3.

So, now look at the latest survey from Ipsos MORI for the Nuffield Trust (pdf).

The first response says that the NHS needs only minor changes, the last response says that the NHS needs replacing (the drastic option). The middle-of-the-road choice, says that some changes are needed to make it work better. Well, of course that is true, and we can all come up with changes that will make the NHS better. But the significant issue is that Ipsos MORI says that if you choose the middle option you want fundamental changes. Surely fundamental changes means drastic changes? A fundamental change means changing the very basis upon which the NHS is founded. A fundamental change implies that the part of the NHS changed should be rebuilt. This is not middle-of-the-road at all, it is drastic.

Ipsos MORI are clearly leading the respondent into saying something they do not want to say. Further, look at the second response again:

There are some good things in the NHS but some fundamental changes are needed to make it work better.

Now take a look at the summary of the survey. Ipsos MORI say:

Just over half of respondents (56 per cent) thought fundamental changes to the NHS were needed, while a third thought that only minor changes are needed to make it work better

Well, no, the results do not say that. The results said that 91% people said that there were either "some good things in the NHS" or "on the whole the NHS works pretty well". That is quite a ringing endorsement.

Ipsos MORI added the "fundamental changes" bit into the middle response precisely because the intention was to try and get a result that says that the NHS needs fundamental, drastic changes. A better middle response would be this:

There are some good things in the NHS but some changes are needed to make it work better.

This says that the NHS needs changes, buit not drastic changes (that's #3). I reckon that this would still get the 56% vote.

Fundamental is a very important word. It is rather unfair to use it in the question in this way.

You will hear this result ("over half of the public want fundamental changes in the NHS") quoted by government ministers over the next few months. In the absence of any evidence that what they are doing will have any beneficial effect, they will still say: "but the majority of the public want it".

Ch ch changes...?

There appeared to be four new changes to policy with the appearance of andrew Lansley at the Health Select Committee

Any Qualified Provider

This is not a new policy, just a change of name. Rather than referring to Any Willing Provider Lansley kept referring to Any Qualified Provider. Of course, AWP only used qualified providers anyway (the providers had to be licenced with CQC) but the new name indicates a shift away from the appearance of there being a free-for-all, Wild West-style, of provision, to a more careful, thought out collection of careful quality providers. The new name will not mean any change in the providers who will be commissioned, and it does appear to be an attempt to reassure, I wonder who were the target of this reassurance?

Patient Participation Groups

This was mentioned by Dame Barbara Haskins (National Managing Director of Commissioning Development at the Department of Health) with respect to the GP commissioning consortia. No details were given and she did not say how they would interact with the Health and Well Being Boards and the HealthWatch groups, or whether these groups would be any different to LINks, but she gave the impression that there would be "patient participation groups" attached to GP commissioning boards. This is an interesting development. My local PCT has an "Active Members Group" that, as far as I can tell, seems very inactive, so perhaps this is a new name for them?

Scrutiny

Andrew Lansley did specifically say that "wherever the NHS pound goes there will be scrutiny" by the Health and Well Being Boards, in contrast to the current situation where current private providers are not scrutinised. This appears to be a new policy, although later in the select committee when he was pushed on "commercial confidentiality" he did not offer any concessions.Again, perhaps the former reference to scrutiny was reassurances, but to whom was not quite clear.

Clinician Commissioning

At one point, Sir Bruce Keogh (NHS Medical Director at the Department of Health) pointed out that: "we're not talking GP commissioning, we're talking about clinical commissioning", which seems to indicate a change in the current policy. There has been a fair bit of criticism since the publication of the white paper that there wasn't a mandatory inclusion of GPs or other clinicians (nurses, midwives, dentists, pharmacists etc) on commissioning boards. This even resulted recently in a Labour amendment to the Bill. So this change was interesting.

For most of the Select Committee, Andrew Lansley seemed quite subdued, and only a couple of times got a bit tetchy (when Andrew George mentioned "competitive tendering" and to a couple of questions from Valerie Vaz). This was quite a changed from the usual bullish Lansley we are used to.

So, perhaps the Lib Dem Spring conference and the BMA SRM have had some effect...

The 'N' and 'F' words

Nuclear, fission.

I bet you've started to feel a little unwell, just reading those words.

The problem is that because the most destructive weapons man has used (so far) have been nuclear and used a fission reaction people associate these two words with death.

In the mid-80s I started a physics degree at Nottingham and in the first year lab one of the experiments we had to do involved nuclear magnetic resonance. In short, each atom has a nucleus and you can make this vibrate with radio waves from an external source. As the nucleus vibrates it will also give off radio waves. If you do this in a magnetic field you can 'tune' the nucleus to produce radio waves of a particular frequency associated with the magnetic field strength and the atom's nucleus. This is a purely electro-magnetic technique: it does not use radioactivity, indeed, NMR works with non-radioactive materials.

The reason why undergraduate students had to do this experiment was because the department had a nuclear magnetic resonance research group. Three years later I started as a research student in the same department studying for my PhD in the semiconductor group. The NMR group had morphed into the MRI group. I asked the research students what had happened. The explanation was simple: they were developing techniques to scan people with nuclear magnetic resonance (for his work in this area the head of the group was made an FRS, then knighted and finally awarded a Nobel prize), but found that patients were reluctant to go near a machine with the 'n'-word in its name. So, like other groups studying the same technique, they dropped the 'n'-word and called it Magnetic Resonance Imaging.

The 'n--word is powerful. But so is the 'f'-word: fission.

Earlier this week, when the Fukushima spent rod pool was running dry the BBC "science" editor* quoted nuclear experts saying that without the moderating effects of the water there would be a fission chain reaction, and then he said, darkly, that this could spread nuclear materials many miles away from the power station site. I could not quite understand how the fission reaction would do this, after all, it happens all the time in the reactor core and not over the locality. Then I realised that the journalist was associating the fission chain reaction with nuclear bombs. He thought that a fission chain reaction in the spent rod pool was the same as the explosion that happens in a nuclear bomb. The 'f'-word has that effect on people.

[* that's an odd-job name if ever there is one: can he really be skilled in all aspects of every kind of science?]

Well, here's a clue for budding BBC science journalists: if it was that easy to create a nuclear bomb Iran would have had one years ago.

The 'f'-word and the 'n'-word are special, they make people invent new science.


Remember that the Fukushima reactors survived an M8.9 earthquake and a 5m tsunami. The cores remained contained even after these. The design also succeeded in that the control rods were placed between the reactor rods which stopped the fission reaction. "All" that had to be done now was to cool the core down from its operating temperature. The cooling system is normally powered by electricity generated by the power station, which had been shut down. The problem is that the tsunami also destroyed the backup diesel generators, so the operators flew in replacement generators . However, they found that they could not connect the generators to the pumps: they lacked a suitable connector.

So reflect on this: the failure at Fukushima is not in the reactor, it is not nuclear; the problem is electrical: they needed an electrical connector.

Labour and NHS Funding

Here's the evidence about how much Labour intended to spend on the NHS had the won the election.

The March 2010 budget said:

6.13 In the 2009 Pre-Budget Report the Government made a clear commitment to protect key frontline public service priorities in 2011-12 and 2012-13 and announced that:
• NHS frontline spending – the 95 per cent of near-cash funding that supports
patient care – will rise in line with inflation;

This says that Darling had allocated, for the two financial years 2011/12 and 2012/13, funding to rise with inflation. In real terms this is flat funding. (Bear in mind that between 1998 and 2009, in real terms, there was an average rise of 6% per year. Flat funding, while not a cut, would still feel bad.)

In the October Spending Review Osborne allocated, at that time, a real terms increase of 0.1% per year for the spending review period. However, Prof John Appleby of the Kings Fund has since calculated (using more recent OBR figures for inflation) that this is a real terms cut of 0.062%. Since this is a small percentage, I think that we can say that Osborne's figures mean flat funding for the spending review period. Indeed, Sir David Nicholson (the chief executive of the NHS) has acknowledged that the NHS will receive flat funding.

So basically, the Darling budget and the Osborne budget give the NHS the same amount.

Then there is the "efficiency savings" issue. In the 2010/11 Operating Framework, Burnham said that the NHS would have to make the £15-20bn "efficiency savings" over four years. These "efficiency savings" were identified by McKinsey although it is quite clear that neither McKinsey, nor the NHS, know where these "savings" will come from. The Labour "efficiency savings" are, say, £3.8bn to £5bn a year for each of 4 years. When Lansley took over the NHS the "efficiency savings" morphed into £20bn over five years (or £4bn a year for each of the five years).

We all know that an "efficiency saving" is a cut (it is Brownian), and that both Labour and the Conservatives have pledged to make them. We also know that attempts by government to make "efficiency savings" have always failed to hit their target. Put this together and it is reasonable to say that under Labour there would have been at least (but most likely, at most) £3.75bn "efficiency savings" each year and under the Conservatives there will be £4bn "efficiency savings" every year. That means that Labour would have spent more.

Now bear in mind that reorganisation of the NHS (for which the Conservative government has no mandate) will cost £1.7bn (government's figures) or £2-3bn (Manchester Business School) or £20bn (Civitas).

So given all of these figures it is clear that the Conservatives will spend less on healthcare than Labour would have.

So where does this idea that "Labour would have cut the NHS" come from?

The only reference seems to come from last June. Andy Burnham misinterpreted Cameron's pledge to "ringfence the NHS". Burnham (and, I suspect, most of the public) thought that would mean that the NHS would continue to get real terms increase. The Guardian in June 2010 said:

He said he assumed the Conservative commitment on the spending would lead to extra NHS expenditure, amounting to more than 1% a year, coming to more than £4bn over the parliament, which would mean even larger reductions for schools and local government.

Burnham, fully knowing that Osborne was intending to cut £80bn of public spending over the parliament spoke out saying that a 1% real terms increase for the NHS would mean cuts in social care, which themselves would affect the NHS:

"If this goes ahead [1% real terms increase in funding] they will hollow out social care to such a degree that the NHS will not be able to function anyway, because it will not be able to discharge people from hospital. If they persist with this councils will tighten their eligibility criteria even further for social care. There will be barely nothing left in some parts of the country, and individuals will be digging ever deeper into their own pockets for social care support."

Of course, we know that Osborne did not deliver 1% real terms increases, he delivered flat funding (just like Darling would have), so Burnham's quote is not relevant. However, I believe this is the source of the Conservative attacks that "Labour would have cut the NHS".

It is about time Labour put the record straight about their post-election plans for NHS funding and force the Tories to stop misleading the public.

Arse from Elbow

(initially spotted by @DRoseTimes from The Times and posted on Twitter) 

The rather dimwitted Conservative MP for Stratford-on-Avon, Nadhim Zahawi, showed that he could not tell his arse from his elbow yesterday in Parliament. During the opposition debate on the NHS Zahawi interrupted John Healy with this meaningless interjection:

16 Mar 2011 : Column 377

Nadhim Zahawi (Stratford-on-Avon) (Con): The right hon. Gentleman wisely started by saying that there is room for reform. The right hon. Member for Edinburgh South West (Mr Darling) had plans in his Budget for a 20% cut in the NHS. Will the shadow Secretary tell us which bit of the NHS he would cut to deliver that 20%?

John Healey: There is someone else who needs a copy of the Labour manifesto. He almost used his six minutes' allocation to make that intervention.

Several hon. Members rose -

John Healey: I am going to move on. If that is the best the Conservatives can do, I am going to move on.

Where on earth does Zahawi get 20% from? Could it possibly be he is getting confused with the £20bn "efficiency savings" that his government is pledged to deliver? (Under Labour, of course, this was £15-20bn, ie possibly less). Clearly the daft figure flummoxed Healey who moved on rather than pointing out what a dimwit Zahawi is.

OK, so you can excuse a person for making a mistake once, but dimwitted Zahawi continues to make them (hence the sobriquet). Later in the debate we had this exchange:

16 Mar 2011 : Column 382

Nadhim Zahawi: Does my right hon. Friend agree that the way in which the Opposition are conducting themselves, when they proposed a 20% cut to the NHS, is scaremongering among our constituents and entirely irresponsible?

Mr Lansley: My hon. Friend makes an extremely good point, and he made it to the shadow Secretary of State, who did not answer it.

Surely Lansley is not a dimwitted idiot too? It appears so because he seems to agree with Zahwai's nonsense 20% figure, even though he must know that an annual 20% cut (or even a cumulative 20% over 4 years) on NHS funding would kill the service: it is not possible to cut that deep without dire consequences!

Then, showing that he really is dimwitted, Zahawi then issues a Press Release demanding Healey tell him how Labour would have cut 20% from the NHS. One thing is for certain, the man does not care looking a complete fool!

(If you want to know how Labour would have funded the NHS had they won the 2010 election, have a look at this previous blog post - hint: they would have provided more money than Osborne.)

Reaction to Lib Dem NHS Motion

Let's have a look at the reaction to the Lib Dem spring conference rebel motion against the government (just joking, we all know that it will be treated as a little local difficulty).

Daily Telegraph: Andrew Lansley signals retreat over NHS reforms.

"Andrew Lansley has signalled a retreat over controversial plans to reform the National Health Service and give more powers to GPs."

But then they say

"Speaking on BBC 1's The Politics Show on Sunday, Mr Lansley said that if the Government could “clarify and amend in order to reassure people” then it would do so."

Clarification and amendments to "reassure people" are hardly a "retreat", it indicates that Lansley will only make minor changes. Nice inflation Telegraph!

The Independent: Coalition may backtrack on NHS reform plans

"The Health Secretary, Andrew Lansley, has signalled that he is preparing to make concessions to his controversial NHS reform programme in the face of growing opposition from doctors, unions and his own Coalition partners."

The Indy are far more cautious, indicating that Lansley will make concessions (ie, he won't admit that he is wrong, but will concede some issues to limit the opposition).

"Privately, senior Lib Dem figures fear that the health reforms could be disastrous to the party's reputation and electoral prospects if they are mishandled."

Further:

The party leadership said it would "listen" to activists' views. But Evan Harris, a former party health spokesman, said this was not acceptable. "Listening is not good enough," he said. "We want major changes in policy and significant changes to the bill."

Guardian: NHS reforms face overhaul after Liberal Democrats' rebellion

"The government's plans for a health service shakeup face a radical overhaul after the Liberal Democrat leadership was forced to bow to the strength of a grassroots rebellion fuelled by fear of privatisation and an undue emphasis on competition."

The Guardian are clearly drinking whatever the Telegraph are because they say there will be a "radical overhaul".

The Times: I have no idea, they have a paywall.

So what is the reaction from Number 10?

BBC News: NHS plans will not change significantly: Downing Street

"Downing Street has ruled out "significant changes" to government NHS reforms following their rejection by Liberal Democrat members."

So in other words: not much will change.

Liberal Democrats are not very effective, are they?

Lib Dems live up to their reputation

So we hear that Dr Evan Harris will propose a motion on the NHS at the Lib Dem spring conference tomorrow. What a pathetic action that is. Not that I think the amendments that Dr Harris is suggesting are wrong. It is the disingenuous way that he is showing how much he "cares" for the NHS. he is proposing this motion at a time when he knows damned well the amendments will not be made. He has been quiet on the Health Bill (and White Paper) for 7 months, the fact that he is speaking up now is more to do with putting some life into his political career than to protect our NHS.

The Health Bill is substantially the same as the NHS White Paper. As anyone who has read Lansley's response to the "consultation" will tell you, his reply to any criticism was "tough, I will have my way regardless". And this will be his response to Dr Harris. Either Lib Dem MPs are extremely dim (a possibility*) or they are in favour of this Bill. Why do I say this? Well, we have already had two votes in the Commons and a lengthy debate when Lib Dem after Lib Dem stood up and supported the Bill. If the Bill violates their "values" why did they vote for it in the Second Reading? Either they are very dim or they support the Bill. Simple as that.

It has been clear since the end of July last year what Lansley was proposing, so why is it now, seven months later, that the Lib Dems are standing up to oppose the Bill? The right time would have been in their September conference (and I would have gladly volunteered to have given a talk at their conference explaining why they should have rejected the White Paper). All of the things that Dr Harris is whining about were in the White Paper, and a motion at the September Lib Dem conference would have had far more effect than a motion at this conference.

So why didn't it happen? Well, let's assume that the Lib Dems aren't all dim (I know, it is hard to do*), if they had presented, and voted in favour of a motion similar to the one Dr Harris is promoting now, then there would have been a clear message to Lansley that the Lib Dems would not support his Bill. Lansley would have said "all or nothing" (and he would be right, because Dr Harris' amendments will destroy the foundations to Lansley's Bill). The result would most likely have put so much strain on the coalition that we would now be going into another general election. The central core of Lib Dem ministers, lovin' their new cars and flunkies (regardless of the loss of their Short Money) had to keep the coalition alive past such a delicate time. So people like Dr Harris who could have killed this Bill in September deliberately sat on their hands.

We have even heard from Dr Sarah Wollaston - a Conservative MP! - that she was told that the only amendments that would be accepted during the Committee stage would be those from the Government. For any other amendments - even those from Dr Wollaston - the government would whip its MPs on the Committee to vote down the amendment. So does Dr Harris really think that his motion will have any effect at all?

I expect the Harris motion to be passed and Lansley to say to Clegg "deal with your little local difficulty". The Bill will pass largely unscathed and Dr Harris will be seen as having tried to amend the Bill. The only winner will be Dr Harris.


[*] The first time I had a deep discussion with a politician who was in favour of a bill like the one being pushed by Lansley was about 2003. I was at a BBQ at my brother's and a guest there (his kids went to the same school as my brother's) turned out to have almost been the MP for Brent East. In the Lib Dem selection meeting to choose their candidate for the seat this guy came second to Sarah Teather, Teather won the seat and is now in government. The thing that was most striking about this guy was that he looked, sounded and had the same intellectual ability of Harry Enfield's Tim-nice-but-dim. I spent a couple of hours with him and he described to me a healthcare market just like Lansley's. Nothing I could say would change his mind. After that encounter I have never trusted Lib Dems: in public they say they support the NHS, but when you get them a bit tipsy at a BBQ they are more radical privatisers than the Tories.

A response to Paul Cotterill

I don't want to get into a tit-for-tat my-doomsday-prediction-is-worse-than-yours, but I thought I ought to respond to Paul Cotterill's article (@BickerRecord) on Though Cowards Flinch, The NHS is dead (part1): facing facts. Paul has got the facts right, but he's only talking about one part of Lansley's policies. I don't blame him for this, just about every one does, and when I give talks about Lansley's policie the first thing I do is set people straight: commissioning is not the chief problem, the problem is what Lansley is doing about providers. In other words, look away from GPs and look towards hospitals and community health services.

Paul takes a gloomy attitude that the NHS is already lost. I beg to differ, he may be right about some GPs (though not all) wanting to profit from commissioning, but he's only looking at part of the service. So while half may well be a "done deal" the other half of the policy has not started yet, and there are still many people in the NHS willing to fight to stop that part of the policy being implemented.

Lansley is already implementing some of his Health Bill proposals (without Parliamentary approval) by creating the GP commissioning Pathfinder consortia, and through these, make PCTs irrelevant. This is a one way process: re-creating PCTs would be extremely expensive, so it is better to constructively amend what is happening rather than to oppose it altogether. If the Health Bill was binned today even the most enlightened and public service orientated Health Secretary would not want to try and re-create PCTs.

I do not oppose GP being involved in commissioning, and most patients when asked if they would like their GP to decide about how their care is delivered they would also agree. Lansley knows this, and this is why he only talks about GP commissioning and "patient choice". His argument against his opponents are that they do not want "patient choice" and that they do not want GPs to be involved in designing patient care, both powerful political arguments. The problem is how Lansley is implementing this policy. Cumbria has had GP commissioning for a couple of years, but the significant point is that this relied upon the help from the PCT rather than the abolition of the local PCT: it worked because of collaboration with the PCT rather than in spite of it. (The opposition has failed to make enough capital out of Lansley saying before the election that GP commissioning would involve PCTs and then his sudden decision ten days after the election to abolish PCTs.)

My main objection to the abolition of PCTs is because they were a layer that isolated GPs from the cash. This, to me is the most important thing because I want my GP to make decisions about me purely based on clinical decisions. However, the White Paper (section 5.12) gives Lansley's attitude towards healthcare:

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

This statement thrusts a rusty blade of commercialism right into the beating heart of our NHS. GPs are being told by Lansley to view their patients as customers. There are two aspects to this. First these "financial consequences" may mean an income stream for the GP (directly or indirectly): a positive aspect for those GPs wanting to make a lot of cash (Lansley calls this "innovation"). But second, these "financial consequences" also mean rationing: the negative side, the side that GPs do not want to do, and patients wish did not exist. We all know that rationing occurs in the NHS, but we know that through clinical decisions (and the evidence-based policies of NICE) the rationing occurs on a basis of what is best for the patient and the community as a whole. Under Lansley's plans a patient can simply become too expensive for a GP practice.

Paul says that GP consortia won't use PCT commissioners and instead will resort to private companies. I agree that this has happened, but I doubt if it will be widespread. There is too much institutional memory within the current PCT commissioners and the knowledge they hold is valuable. Many of the "pathfinder" GP consortia are either existing Practice Based Commissioning groups or collections of PBCs. PBCs are geographically based and associated with PCT boundaries, thus PCT commissioners know the PBCs, and have had years commissioning for them, and so it would be a natural move from the PCT to the PBC GP consortium. A private company will not necessarily have the local experience. GPs are cautious, they understand that if commissioning goes wrong the consequences are dire (in particular, but not exclusively, the "financial consequences"), so they are more likely to take an attitude of "better the devil you know", and that is the PCT commissioners

However, the smaller GP consortia are an issue, because the income the receive may not be enough to employ the commissioners they need. These consortia are likely to either cluster with other consortia (in which case, why be separate?) or buy-in the commissioning. (See here for an analysis of the consortia sizes.) Lansley's number one mistake was not giving any guidance at all about GP consortia size and location. Although there will be a huge upheaval in the run up to PCTs being abolished, there will be years and years of upheaval as the smaller GP consortia merge (as they come to terms with the fact that "small is beautiful, but financially unsustainable"), and the large consortia break apart. In a decades time we will achieve a steady state: but at what cost to healthcare?

Paul says that the private commissioning companies will maximise their profits "firstly by focusing entirely on the core business of purchasing secondary care, to the exclusion of all other considerations around preventative and public health". Well, since public health accounts for just 3% of the budget it is not surprising that it will take a back seat. Here are figures from my local PCT (and I guess they are representative): Acute care 49%, mental health 8.7%, community services 7.2%, continuing healthcare 6.4%, primary care 23%. Incidentally, that 23% for primary care is roughly half for GPs and half for "additional GP services". This latter part is important because it is work that used to be carried out in hospitals but is now done by GPs. It is a sector that will increase dramatically over the next few years (remember what I said above about what GPs will see as the positive side to "financial consequences"?).

However, GPs will not be allowed to ignore public health. The Health Bill specifically says that GP consortia will be held to account for the health inequalities and outcomes in their area (they will have to produce strategy documents on these, and will have to provide annual reports indicating how successful they have been). Whether this will be a paper exercise or not is yet to be seen, but I can assure Paul that the Bill has addressed the issue. The Bill also gives local authorities more responsibility for public health, and again, it is unknown whether this will be successful.

Paul then says:

"Second, they will purchase as much private healthcare as they can, and the percentage of the care bought from the private sector will increase dramatically within a year or two.  As state hospitals lose their business, they will close or – more likely in the shorter term – be bought up lock, stock and barrel by the private hospital operators."

I think that the situation is far more complicated than this. First, there is not the capacity in private hospitals at the moment, and there is not the money for those private companies to invest. For example, today I heard that profits at BUPA "tumbled 72% to £118m in 2010", BUPA are not doing well, so how will they expand their hospitals to take on the nuge numbers of NHS patients Paul suggests? The US company Humana has even pulled out of the UK because they are "unconvinced that Andrew Lansley’s plans to hand over the commissioning ... to GPs in England will necessarily open up a lucrative market in commissioning support". So I am not convinced that the numbers of patients sent to private hospitals will rise dramatically. (In any case, the NHS has been outsourcing a lot to private health care over the last decade, can the rate increase more than it is now?) Second, there is not the expertise: the vast majority of consultants in the country are NHS-based, and the private sector gets their expertise from these clinicians. Herein lies the actual threat.

Cameron announced a few weeks ago that

"We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service."

Note that there is no mention of "patient choice", patients cannot choose to have a public provider, instead David Cameron will allow private providers to choose what services are available for the patient, through this new "presumption" that they will be able to take over NHS services. In practice, what this means is a private provider (or a collection of existing NHS consultants grouped as a company) can insist that they provide a service at an NHS hospital. The white paper (section 4.28) says that Monitor (the super-powerful economic regulator and headed by an arch-privatiser) will:

"require monopoly providers to grant access to their facilities to third parties"

The "monopoly providers" are NHS hospitals and the "third parties" will be these new groups of consultants. Think about it: there will be minimal start up costs to these companies and all the consultants need to do is get together and say to a hospital "we are now an Any Willing Provider for this service". In the future your NHS hospital will be run like a department store with "franchises" of Any Willing Providers running the facilities and providing the services.

Paul then makes the accusation:

"Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor."

I disagree, it will come through a government announcement. First, let me give some background. In 2005 in the Independent Nick Clegg (the collaborator and traitor he is) said:

"One very, very important point - I think breaking up the NHS is exactly what you do need to do to make it a more responsive service." Then he goes further, even refusing to rule out the insurance-based models used in mainland Europe and Canada.

"I don't think anything should be ruled out. I think it would be really, really daft to rule out any other model from Europe or elsewhere. I do think they deserve to be looked out because frankly the faults of the British health service compared to others still leave much to be desired."

It frankly amazes me that anyone wanted to vote for this Hannan-esque monster, but that, sadly, is history. It is clear, however, that part of the government (the Orange Bookers) want to kill the principle of "free at the point of use".

On the other hand, Lansley constantly says that the NHS will be "free at the point of use, based on need, not ability to pay". I happen to think that Nick Clegg said what Lansley believes, but through political expediency Lansley has to continue to quote the NHS mantra "free at the point of use". Health insurance will come through a different vector.

At no point has Lansley ever said that he will outlaw co-pay. It has not been talked about. Curious, eh? I mean, if the NHS is costing the taxpayer too much, why not ask for a reasonable contribution from the patient? We already have this in dentistry where you are offered private care as well as NHS care, and it happens in social care too (councils means test vulnerable people and then impose a standard charge which is a contribution to, rather than the full cost of the social care they receive). We have a form of co-pay with prescription charges, so why not apply a co-pay commitment for NHS treatment too?

As rationing starts to get bad (and it will) the middle classes will clamour for co-pay. The current rules say that if you pay for a drug that you need for your treatment then it means that you are receiving private care and so you have to pay for all of the NHS care. This is right. If there is a clinical need for the care then the NHS should provide it. NICE was created to identify what was clinically required, and hence what the NHS will pay for. Lansley's policy is to neuter NICE, it will be merely "advisory". It won't be too long before patients feel the effects of rationing and the postcode lottery.

In a few years time, to placate the middle classes affected by the postcode lottery, Lansley will sanction co-pay, he will say that those who can afford to pay extra will be allowed to. We will see co-pay introduced into primary care first, followed by acute care.  Of course, not everyone can afford co-pay, and this will result in insurance companies providing products where the middle classes can pay an affordable monthly premium so that in the event that they need to pay for NHS co-pay the insurance company will provide the payment. (This is not what Americans regard as co-pay: to them co-pay is more like the car insurance excess that we pay; insurance pays the majority but patients are expected to pay a contribution out of pocket. What I am talking about is a top-up contribution, for patients to get extra care.) Indeed, the BMA consultants conference even voted that NHS patients should be allowed to pay "top-ups" in 2008 (how times have changed). Once Lansley sanctions co-pay, health insurance will follow.

Paul's article, like most people, ignores the policy of Any Willing Provider, and the effect this will have on NHS hospitals. This is the most significant part of Lansley policy and GP commissioning is minor compared to it. Lansley sells the policy as patient choice, but it is clear that it really is commissioner's choice: patients will not get to choose. Further, it has become apparent that the privatisation will be imposed top down. Yesterday Pulse magazine reported that the SHA in the East of England was designing integrated care pathways that used private companies. The SHA is a level above PCTs and their work in future will be provided by the soon to be constituted National Commissioning Board. It is clear to me that the NCB will impose privatisation top down onto GP commissioners through AWP.

Prof Chris Ham from the Kings Fund writing in the BMJ says:

"Although many organisations have focused their attention on plans to give general practices a major role in commissioning health services and to require all NHS providers to become foundation trusts, these changes are of secondary importance compared with the radical extension of competition in healthcare."

It is clear to me that the main focus of any opposition to the Health Bill should be focussed on the policy of Any Willing Provider.

Paul's article is announced as the first of two parts, and

"If I get round to a part 2, I’ll cover some things the Left and Labour still can do, but this will be with a mind to strategy, not pointless posturing (so I don’t suppose anyone will take any notice)."

Well, I have already covered what Labour should do in an article on Liberal Conspiracy and on this blog:

And one final point. Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned. Drop the "mutuals" idea because this is too close to Lansley's "social enterprises" idea. NHS hospitals should be publicly owned, publicly run and publicly accountable. Is that a simple enough message for Ed to understand

The battle in the future will be about keeping our hospitals publicly owned. I hope that Paul gets round to his part 2, and I hope that he follows my lead.

"GPs up against private firms in NHS sell-off of entire care pathways"

Pulse magazine issue an exclusive today that the intention of the government's "Any Willing Provider" policy is designed to privatise care pathways. So far Lansley has been careful to say that AWP is about "patient choice", but the Pulse article shows that the intention is actually to exclude patients and to offer only "integrated pathway hubs" that have been competitively tendered to private contractors.

Dr Steven Laitner, a GP in St Albans and associate medical director at [NHS East of England] SHA, said the plans could deliver 'transformational change' to the NHS. Dr Laitner is shared decision making lead at QIPP Right Care, a Government-backed unit set up to spearhead the NHS’s £20bn savings drive. He told Pulse: "We’ve got support from the Department of Health and are looking to test this model across the country."

This shows that the government intends that the Any Willing Provider policy to be about wholesale privatisation of care pathways. Pulse report:

Ms Parbinder Kaur, project lead for the hubs, said: "The push has come from GPs. They are open to the market coming in with new ideas."  She said a string of meetings with GPs and private providers had shown both had "appetite" for the idea, with the next stage a bidding process for contracts, which are due to go live in April 2012 to fit with the Government's ambitious transition timetable: "It will involve a competitive tender. We expect this to involve a combination of third-sector, independent-sector and NHS providers."

This is completely opposite to the briefing that the government is providing to their MPs which says:

Our plans for 'any willing provider' are precisely the opposite. Competitive tendering means identifying a single provider to offer a service exclusively. 'Any willing provider' means being clear that a service needs to meet NHS standards and NHS costs, and then allowing patients to choose themselves wherever they want to be treated. 

In other words, the government is telling their MPs that there will be no competitive tendering, but Pulse are reporting that in practice the policy is to competitive tender entire "integrated pathway hubs". This is wholesale privatisation of the NHS.

Cameron as Royalty

A new government will always want to go through some kind of re-branding, they want to be seen to be different to the last lot. I'm not a graphics designer, and I do not know the reasons behind the imagery, nor the subliminal messages they convey, but I have noticed a change in the symbols that Cameron uses. I started by doing some simple image searches on the internet for images of Cameron and Brown in front of a lectern at Number 10, since I know that the lectern is often adorned. These two images are typical.

Can you see the difference? Firstly Brown's lectern is dark oak and Cameron's is light ash. I am not sure what that means design-wise, probably nothing. Secondly, and I think more importantly, Brown's lectern (if it had any adornment) had the URL of Number 10. Cameron's has a crest. In other images it is clear that the crest that Cameron uses is the royal coat of arms.

(In my opinion, the URL looks more modern, the crest is too detailed with the effect that you cannot quite see what it is: from a distance it is just a blob.)


The items on a coat of arms have a lot of significance and in particular, coats of arms usually have a helmet of some kind that indicate the status of the family. The crest Cameron uses clearly shows that it has a crown as the crest, furthermore, the supporters (the lion and unicorn) have crowns. This is clearly the Queen's coat of arms, and the Queen (or institutions that represent her, like courts) is the only person who is allowed to use it. So why is Cameron using it?

The Queen is the head of state as the constitutional monarch, but the executive (and Cameron is the head of the executive) is separate. Indeed, the country fought a civil war to assert that Parliament and the monarch were separate. Parliament uses the crowned portcullis as its emblem (as used on the old style 1p piece before the Royal Mint gave us the horrible jigsaw puzzle piece that newer coins show) - and the crown is used for the House of Lords. Should Cameron, as Prime Minister, use the Parliamentary coat of arms? Perhaps not, but constitutionally he is closer to Parliament than the monarch.

I cannot find a single case of the previous government using the royal coat of arms as the symbol for the UK government, yet I find the coat of arms everywhere on the current government's websites.  This logo is used throughout:

A little more searching  gives me a civil service web page which explains the re-branding:

"The identity embodies integrity, trust, impartiality, quality of service, and professionalism – values thatare an integral part of the civil and public service. Its use should be governed by similiar values and be honest, effective, impartial and accountable."

I am not sure that Cameron (a politician who owes his status to the fact that he is the leader of a political party) can be described as impartial. This reinforces my question of why he uses the royal crest. The branding documents (irritatingly, there are several, each with a handful of pages, why couldn't they have been put together as one document?) further say:

"the Royal Coat of Arms can only be used by organisations that have Crown immunity from prosecution"

Does this mean that Cameron is immune from prosecution? I certainly hope not!

I think the reason Cameron uses the royal crest is quite simple: it is an indication of his inflated opinion of his own importance. He has royal blood in him, so he he thinks he is royalty.

Lies, damned lies and Lansley's utterances

The most bizarre thing about the government's NHS policy is that there is no evidence to support it, yet Lansley and his weird bunch of henchpeople keep telling us "evidence" that is verifiably untrue.

First we have the nonsense of Cameron's "myths" about outcomes on heart attacks and cancer which  were expertly debunked by the world re-known health economist Prof John Appleby in the BMJ. Then Ben Goldacre entered the fray questioning Lansley's lack of evidence. And, as if he has lost the ability to read (or comprehension), the Lib Dem human shield Minister of State, Paul Burstow, decided to take on the redoubtable Goldacre, quoting even more dodgy figures, and promptly lost the bout when Goldacre pointed out that Burstow was not telling the whole truth.

The BMJ published a survey about doctors opinions of the Health Bill, which effectively says that most do not want it, and Lansley's henchpeople respond (according to the BMA Tavistock blog)

with a statement calling it “unscientific” and “self selecting”.  They say, with a great deal of certainty, that the survey “does not represent the views of doctors in this country.”

Tavistock respond that the survey was conducted by "one of the UK’s leading market research companies" and it further goes on to debunk the government's irritatingly constant untruth that GPs are "voting with their actions" and showing that they are enthusiastic about the re-organisation by becoming consortia. Tavistock point out that GPs have formed consortia because:

"Many GPs have little choice but to get involved as primary care trusts become ineffective as they prepare for their abolition."

Yet Lansley's henchpeople still won't give up. Today the Guardian published an article from an NHS consultant Dr Mark Porter (no, not the BBC celeb doctor, a more eminent doctor) where Dr Porter says that Lansley's re-organisation will return the NHS "to the 1930s". This solicited a response by the soporific Minister of State, Simon Burns (in the first of his popular "Simon Says" tweets) who yet again stated Lansley's dodgy figures:

"Our cancer survival rates are amongst the worst in Europe so doing nothing is not an option"

As Prof Appleby says in his BMJ article this is not the case, the UK's cancer figures are not "the worst in Europe", quite the opposite in some cases.

Please could someone ask Lansley and his henchpeople to stop trying to justify their re-organisation with dodgy figures? All they have to do is be honest and say that they are changing the NHS because they know best and we just have to put up with it. Indeed, they could even justify that the changes have to be done because "Simon says..."

Private Healthcare

According to the Office Of Fair Trading:

PMI [private medical insurance], which is often provided by employers, is the main funding source for the provision of PH [private healthcare] by private hospitals and clinics (61 per cent), followed by NHS-funded patients (23 per cent) and then self-pay patients (15 per cent).

So most of private healthcare insurance is paid by employers. This is backed up by anecdotal evidence - those friends and neighbours who have had care in a private hospital always say "the company pays for private insurance, so I thought I would use it". I don't know anyone who actually admits to paying private health insurance themselves, but maybe that is because they don't want to admit it to me.



In the post today I got a letter from Aviva. Well, I didn't really get a letter since it was not addressed to me, it was simply a sales sheet in an envelope and every house in the street was delivered one. This "letter" reminds me that private medical treatment is available at a BMI hospital 30 miles away. Well whoopido, there's a private hospital that does private medical treatment, who would have thought that would be the case? The letter was the usual drivel: how the treatment is world class, rapid and affordable. Indeed, it even suggests that "the healthier you are, the wealthier you could be" which is rather bizarre since you are paying them, so you are slowly getting less wealthy with each premium payment. It indicates that they do not know how insurance works: if I am healthy I will not claim, but I will still contribute premiums, so surely it should be "the healthier I am, the wealthier Aviva will be".

Anyway, the reason I mention this is that I have not had a letter like this before. Why are private health insurers going on a sales drive? Surely if Any Willing Provider is the success that Lansley hopes it to be then private hospitals will not have the capacity with all of the NHS work they are doing, to be able to fit in any private patients with private health insurance? Or maybe the private health insurers know something that Lansley is not telling us? Like, for example, that the changes he will make to the NHS will deteriorate their care. Aviva say that the BMI hospital provides "rapid treatment, excellent care and comfortable surroundings" perhaps Aviva are actually saying that under Lansley the NHS will provide "long waiting lists, poor care and dilapidated hospitals", like, um, the situation after 18 years of Conservative government?

Spin

Can you imagine that, as a patient, the tick of a pen in Whitehall can give you more personalised care, and do this instantly? No? The lack of understanding of this fact shows how out of touch Lansley's Department of Health team are. The latest round of GP Commissioning "pathfinder" consortia was announced with a press release that had the following title:


Two thirds of the country now benefit from more personalised care

This refers to  the fact that commissioning consortia now cover 2/3 of the population. However, they are exactly the same GP practices as before (so no change there). This is just propagandist spin from one of the legions of spin doctors in the Department of Health. I thought civil servants weren't supposed to take a political line.

Ch...Ch...Changes

Perhaps things are changing. I have six-monthly diabetic check-ups at my local GP. The check-up is usually carried out by the practice nurse. The drill for the last decade and a half has been for me have a blood test and then two weeks later make an appointment with the practice nurse who weighs me, tests my urine sample, examines my feet and tests my reflexes. I also have an opportunity to discuss my diabetic control. Since I have had diabetes longer than the practice nurse has been alive, I rarely need advice on my care. But the regular monitoring is vital. How will I know if I have lost the feeling in my toes? I mean, I won't be able to feel it! The practice nurse tests for this.

This has now changed. I have just been asked to have a blood test for the diabetic clinic, and the letter informed me that I will only have an appointment with the practice nurse if there is a problem highlighted by the blood test results. Of course, this means that my urine (kidney function) now will only be tested once a year, rather than twice a year. Similarly with the monitoring of the nerves in my feet.Will this make a difference to my diabetic care? I don't know, but it is definitely a change in the amount of care my GP provides.

One less appointment a year is a saving for the GP, but I am not sure what contribution that will make towards the £5bn that the NHS has to "save" in the coming financial year.