Excuses for the Squeeze

Of course, the real reason for the squeeze is to push the majority of trusts into bankruptcy to justify cutting the NHS down to an emergency services only, but let's leave that for another post. How does Monitor justify its Draconian new rules about the "savings" that trusts must make?

This is from the letter sent to trusts.

We have decided to adjust both of these cases in light of the new information contained within the CSR, Operating Framework and OBR inflation forecasts. We recognise the scale of the productivity challenge that the revised financial assumptions imply; however it is important that the assumptions reflect the economic outlook and current policy framework.

The last sentence is important. Monitor says that it has to change its rules due to inflation and the change in policies outlined in the Operating Framework. In other  words, it is the government to blame. The letter then goes on to list the issues:

1. A health settlement that, while generous when compared to other departments, represents a substantial challenge to the NHS given expected demand growth;
2. Confirmation of the QIPP challenge to deliver £20bn efficiency savings by 2014/15;
3. Significant inflationary pressures as noted in the projections released by the Office for Budget Responsibility in its economic outlook published ahead of the 2011 Budget; and
4. The impact of specific tariff rules set out in the Operating Framework and the Payment by Results Guidance for 2011/12 that are expected to have a material effect on trust income.
5. (Implied in #4, cutting the national tariff by 1.5%.) 

So, first, there is not enough money (hardly "I'll not cut the NHS", eh?); second, even with not enough money, hospitals have to save more; third, the country is going to hell in a hand cart (rising inflation, with no chance of growth), so we have to cut the bottom line, welfare state, safety net; fourth, the government is cutting incomes to hospitals (changes in the tariff, hardly "I'll not cut the NHS", eh?); and finally, Lansley has set up Draconian rules about re-admissions which will be a financial drain on hospitals. Every single one of these is due to government policy.

It is worth categorising these points a little more exactly. First, the cuts. The increase in funding in the "health settlement" was a mere £24m. This is what Osborne has given us in exchange for believing Cameron when he said before the election that there would be "year-on-year, real terms increases". Twenty four million in a budget of over 100 billion is nothing. For example, yesterday I mentioned the cuts that Hull And East Yorkshire Hospitals NHS Trust will have to make over the next 5 years. This is to try and save £95m. That is just one trust, so £24m is paltry. As Monitor mentions, it is expected that there will be greater demands on the NHS in the next few years, since people are living longer and they need more expensive medical interventions. What Monitor does not mention is that as the economy gets worse, and more people are put out of work or forced into low pay jobs, their health will suffer; and it is the NHS that has to deal with that.

The mention in #2 of the "QIPP challenge" belittles its importance. Calling it a "challenge" is disgraceful since a challenge implies that the task is optional and that failure is acceptable, even honourable. The problem is that the £20bn "efficiency savings" are not optional, they must be achieved because it means that for £20bn of work that the NHS will do over the next 5 years there will be no money to pay for it. This is a cut.

In #5 I mention the tariff cut. Over half of procedures performed in hospitals are paid from a price list called Payments by Results, or the "tariff". The government intends to increase this price list so that it covers all but the most specialised care. How is the price determined? Well, up until now, the price was essentially the average cost of the procedure across all hospitals in England. Now, however, the government is moving to a fixed tariff determined by the bureaucrats in the National Commissioning Board (the new, unaccountable, quango that will do most of the work currently done by the Department of Health). As a foretaste of what is to come, Lansley cut all tariffs by 1.5% this year. Regardless of rising costs, regardless of inflation (#3), he arbitrarily cut the money hospitals are paid. This is a cut.

These three (and a contribution from the previous calculation of inflation) are the reasons for the 4% "cost savings" that hospitals are currently working towards.

Next, the non-cuts that may be cuts.

The world is currently volatile and commodity prices are increasing. This means that inflation is rising, and is expected to be more than the levels estimated in October last year. The problem is that Osborne determined in cash terms last year the amount of money the NHS would receive every year until the next election. Although Cameron pledged "real term increases" Osborne has given increases based on the optimistic estimates of inflation made last year. Now the estimates of inflation are higher, but Osborne has not provided any more money. Consequently, hospitals will have to make do with the cash they have. It may be that the OBR estimates of inflation are too pessimistic and that inflation will fall over the next few years; but since Osborne has not pledged to change the funding according to actual inflation rates we have to hope that this is the case. So if inflation continues as it is, we will see an addition cut in hospital funding, but if inflation goes down we will see a real terms rise in hospital funding.

The fourth point is a bit cryptic. Although Lansley abolished Labour's waiting times targets, he is keen on producing his own targets. In the Operating Framework 2011/12 Lansley produced a long list of fines. Basically, if a patient is re-admitted due to poor care, the hospital will not be paid for the additional work and will be fined. In #4 Monitor is saying that hospitals have to cut their costs to build up a warchest to pay for any possible fines. There is no implied irony, after all, if the hospital is making cuts in care, they are more likely to deliver poor care (this is what happened at Mid Staffs). The fines (and the lack of payment for remedial work) mean more cash (or less spending) for the government. This is a really cynical way to cut hospitals. So, if a hospital can avoid re-admitting patients then the "savings" they make to pay for fines become surpluses which they can re-invest (ie subsidise the services that they cannot do for the newly reduced tariff). If they end up re-admitting patients then they lose money and the government benefits.

Put together, the increase in inflation and the warchest to pay for fines account for the additional 2.5%.

It is quite clear that the actual reason for the huge hike in the "savings" hospitals have to make are due to the government and Monitor are merely acting as Lansley's henchmen. The worrying aspect, as I mentioned yesterday, is whether hospitals can manage to find another 2.5%.

The big squeeze

When you put someone in charge of Monitor who has said that he wants the NHS dismembered, you should expect something nasty from him. And here it is.

The NHS is expected to make 4% "savings" for each of every year for the next five years. This is extremely difficult, and finance directors of hospital trusts (acute and mental trusts) have been jumping through loops, trying to make the sums add up (for example, Hull And East Yorkshire Hospitals NHS Trust, has recently announced that it needs to cut 300 beds by closing 10 wards over the next 5 years).

Now the economic regulator has moved the goalposts.

Four per cent savings/cuts for 5 years was going to be difficult, but now Monitor says that Foundation Trusts must make efficiency savings of between 6.5 and 7.1% over the next five years. A value of 6.5% compounded over 5 years comes to a "saving" of 37%. This is frankly ludicrous. John Appleby, the chief economist for the Kings Fund is quoted in the Financial Times:

"I can see a hospital doing this for one or two years but not five years," Professor Appleby said. "It’s like the unit cost of a hip operation [around £6,000] has got to decrease by 37 per cent. How?"

How, indeed.

Monitor is deliberately pushing all hospitals towards bankruptcy and the government has said that it will not "bail out" any trust in the future.

Furthermore, there are still 85 trusts that are not yet Foundation Trust, and these trusts have to meet Monitor's tough financial criteria to be authorised.   Even at 4% the Department of Health was worried that 22 trusts would not become Foundation Trusts by the April 2014 drop down dead date forced on them by Lansley. If these trusts are not able to meet these initial 4% criteria by that date, then they will not achieve FT status and since the current NHS Trust status will no longer exist after that date, they will no longer be NHS hospital trusts. They will cease to exist.

Monitor has now made the criteria worse. Increasing the 4% annual "savings" to 6.5 to 7.1% annual "savings", means that all of the remaining 85 NHS Trusts are at risk of not being able to achieve FT status and hence not being allowed to be an NHS hospital trust after April 2014. The fact is, all of these trusts, covering over 100 hospitals are at risk.

This is how David Bennett expects the NHS to be "dismembered".

Here are the details in the letter from Monitor.

Here is a short video from the BBC explaining the issues in the simplest of terms.

Burning your bridges

Burning your bridges: the allusion is that you continue on regardless and remove any chance of reversal, or taking any other route. This is the NHS we are in.

It is well known that re-organisations are destabilising and costly and it is no wonder that the Conservatives - desperate to dupe anyone into voting for them - would promise "no more top-down re-organisation" before the last election. Yet we have one now. The most damaging, far reaching, re-organisation ever. A re-organisation that is untested. A re-organisation that may well fail. At the next election there will be a clamour for a re-organisation, one that will restore the service destroyed by Lansley.

Health Service Journal reports:

A briefing on the first meeting of the NHS Future Forum last week, seen by HSJ, says there was “a strong mood in favour of the report recommending ‘no more top down reorganisations’”. 

This strong mood existed before the government started its latest re-organisation, even after promising that there would be no more re-organisations (perhaps Lansley and Cameron missed out the clause "after this one" in their pledge) . However, the Forum apparently believe:

proposing “no more top down reorganisations” was unlikely to stop the current changes. That is because they are already underway, and the group has been told to recommend “improvements” to current plans rather than suggest scrapping them. 

So rather than recognising the damage currently being inflicted on the NHS and recommending that they are stopped, Lansley's hand-picked, blinkered forum members are recommending that all bridges are burned as the re-organisation progresses:

National Voices chief executive Jeremy Taylor said it could still call for all political parties to commit to no further reorganisations in future. 

Taylor should stop and think. It is the people of this country who vote, and if the people of this country wants the NHS restored to a well-funded system, providing comprehensive universal healthcare then political parties (and I hope the Labour party) will find it hard to ignore that demand. It is called democracy.

If I were Miliband or Healey, I would not agree to any pledge of "no more top-down re-organisations", instead I would make the far stronger political point of pledging to maintain the NHS as a publicly funded, publicly accountable, comprehensive, universal system and to pledge to do everything necessary to achieve that. Taylor wants political parties to pledge to maintain the status quo after Lansley has ruined our NHS, there is little chance the public will want the system Lansley will leave, and so there is little chance that parties will to keep it.

Are UK private hospitals capable?

Recently Deloitte produced a document aimed at Americans who are considering "healthcare tourism" that is, going abroad for elective treatment. There are two things that struck me.

The first thing is Figure 5:

This says that the cost of surgery (and the stay in hospital) for a hip replacement is $43,000 in the US and $9,000 in India (there is no indication here of how this "average" figure is calculated, but clearly if the patient has other medical issues - co-morbidity - then the cost will be more). The document goes to great lengths to say that the foreign hospitals are to US standards, even to point out that they have "partnerships" with US hospitals where the clinicians are trained.

Most of the activity in NHS hospitals is paid through what is known as "payments by results" (this is actually, payment by activity because they are paid for what they do rather than for the outcome of the treatment). The tariff for hip operations are between £716 ("minor hip procedure") to £8,152 ("major hip procedure" involving a major complication or patient co-morbidity). Using an exchange rate of £1 = US$1.65 the NHS rates are $1,181 to $13,451, ie similar to the rate for India and far lower than the US rate.

The government says that in the new NHS market private providers will be paid the NHS tariff. Clearly this presumes that the private sector can do these procedures for the NHS tariff (and still make a profit!). So if the UK private hospitals are so cost effective, surely they would be the destination of choice for US healthcare tourists? After all, we speak the same language (well, we speak it better, jk), our cultures are similar (Friends is shown prime time in both countries) and our clinicians are trained as well, or better, than those in the US (notwithstanding Madonna's ignorance). Surely Americans should be chartering planes in their thousands to get a hip replaced and then do a coach tour of Olde Englande? They're not.

This is the second thing I noticed when reading the the Deloitte report. The document estimates that 6 million Americans went abroad for treatment in 2010. The report addresses the issue of safety and quality by mentioning the Joint Commission International accreditation and interestingly not a single UK hospital has JCI accreditation (but 24 Irish hospitals are listed). Consequently the Deloitte document does not even consider the UK as a destination for US healthcare tourism.

Six million patients and barely a single one of them comes to the UK for our incredibly cost effective, but high quality treatment, why is that? The Care Quality Council does not warn UK patients against using private hospitals, so one assumes that quality is good. So perhaps it is cost? Medical Care Direct is essentially a broker of private healthcare in the UK, their website gives a list of "guide prices" for common procedures and for hip operations they list:

Total hip replacement (Primary with or without cement) £6,800 to £10,450

Again, one assumes that this is without any major complications.* In US$ this range is $11,220 to $17,242. Again, it should be cost effective for an American to come to the UK for a hip operation (they're going to Singapore for the treatment at that price).

[*Since I am not a doctor, I cannot verify these figures. However, they do look a little odd since hip replacements are listed as being £6,800 to £10,450 yet knee replacement is listed as £9,300 to £14,600, ie knees are more costly than hips; the NHS tariffs are £696 to £3,222 for knee operations that is, less than half of hip costs. From this, I suspect the website has got the wrong cost for hip operations.]

There is one other possible reason why Americans are not queuing up to have their hip replacements in the UK: capacity. Capacity is determined by the numbers of surgeons, and if the limited number of surgeons are spending all their time clearing the 18 week NHS waiting lists they are not available for performing the same operation for bargain seeking Americans. It is interesting that the 18 week target is now effectively optional and hence the NHS waiting lists are growing.

All of this makes me wonder if the Lansley/Letwin healthcare market is possible. If the UK private healthcare providers are not already exploiting the droves of Americans seeking cheap, high quality elective healthcare, how can they be in any state to provide the NHS with much cheaper, equally high quality elective healthcare?

Is the Enquiry turning Toxic?

It has always been clear to anyone who's been willing to scratch below the surface that Mid Staffs is far more than the issues of poor care that have been reported in the Press. The problem is that the Press like salacious stories, they like something that they can amplify into a scandal. Indeed, if they can make a story into an international scandal, then that will sell far more newspapers. But Mid Staffs is more than that, there is a political aspect.

What is coming through from the evidence is that while Mid Staffs had poor care, it was not exceptionally poor. We are not talking about a hospital run by Harold Shipman. What appears to have happened is that there was poor care, but this was amplified by poor statistics and a poor statistical method that took garbage in, produced garbage out, and stamped it with the certification of Dr Foster Intelligence.

Then there was political interference, first locally, then nationally with a General Election. Politicians desperate to do anything to get elected allowed their judgement to slip. Suddenly, a local problem, that should have been corrected with proper oversight by regulators, got out of control and turned into an international scandal. (At the height of Obama's healthcare reform I got emails from US colleagues claiming that they did not want Obama's reforms because they were being told it would lead to "thousands dying like at Mid Staffs"!)

There are several things that the enquiry is telling us. These are two, which are distinctly bad news for the government:

1. A hospital trust attempting to attain Foundation Trust status too fast will put patients at risk
2. A reorganisation of the statutory regulatory bodies means that they cannot effectively monitor the quality in hospitals and care will suffer.

What do we have at the moment?

Yes, you have noticed it, hospital trusts are being forced into becoming FTs before they are ready while at the same time the bodies that monitor quality in those hospitals are being abolished.  

At possibly the worst time for Cameron (it was his fault, he did not have to have another enquiry) the Francis Enquiry will report just as the Health Bill pause ends, and it will give the message that what Lansley is doing is dangerous and puts patients at risk.

But there's more. Some of the people who are crucial to Lansley's dismantling of the NHS are implicated in Mid Staffs. Health Service Journal reports that

"national figures will give evidence to the enquiry in the next few weeks and are spending significant time with their lawyers in preparation"

The question is whether the legal advice is to cover their backs about their involvement at Mid Staffs, or whether they do not want to give evidence that will prove that Lansley's dismantling of the NHS is putting vulnerable people at risk. We will have to wait and see.

NHS OBR?

It is clear that the government will bend the truth to persuade people that only their policy for the NHS is the acceptable policy. Rather shamelessly health ministers (and the Prime Minister) trot out misleading "statistics" even when leading academics have proven that the "statistics" are either wrong or being used misleadingly.

This is not new in British politics. The Major government misused statistics to such an extent that the 1997 Labour manifesto pledged to make the Office of National Statistics independent (however, this did not happen until 2006). Similarly, creative use of Treasury statistics by Gordon Brown lead to a manifesto pledge by the Conservatives to set up the independent Office for Budgetary Responsibility. We now see politicians argue about the meaning of OBR statistics, rather than arguing over the veracity of the economic statistics. So why not a healthcare version of the OBR?

Such an organisation, independent of  government could collate all medical statistics, from the public sector and private sector so that meaningful comparisons could be made.

In the meantime, I suggest that government ministers restrain their use of dodgy stats because we have come to the point that any figure about the NHS when uttered from the mouth of a minister is treated as being untrue. That is not a good thing. A simple solution is at hand: the Chief Medical Officer. Ministers should only present statistics that have either been mentioned by the CMO or they have checked with her and therefore have her approval. The government is losing trust over the NHS, this is one small way that they can gain a lot of trust.

Dodgy Figures

When the government (Number 10, not the Department of Health) produced their "listening" exercise leaflet Working Together For a Stronger NHS there was a lot of cynical responses, particularly over the "statistics" it contains.

The first response in the Press came from John McTernan in the Telegraph. McTernan said that the leaflet broke the Civil Service Code of Conduct ("you must set out the facts and relevant issues truthfully" and "You must not deceive or knowingly mislead Ministers, Parliament or others"). He also pointed out that if the leaflet was an advertising flyer (it isn't, and so is exempt) then it would break the Advertising Standards Authority code ("must not materially mislead or be likely to do so" and "objective claims must be backed by evidence"). McTernan pointed out that the "statistics" in the leaflet were misleading and were intended to mislead.

More recently, Ben Goldacre wrote a piece about the leaflet in the Guardian. Goldacre rips apart the "facts" and then concludes:

This stuff matters, and the facts in this plainly political pamphlet should be clean, correct, transparent, and justified. As the government defies all reason by claiming that NHS staff support their reforms, I can only fear the results of their listening exercise. 

It appears to me that the article has suffered a little in editing, and the figures need a bit more explanation, which I will do here. Goldacre covers three "statistics" presented in the leaflet:

1. "If the NHS was performing at truly world-class levels we would save an extra 5,000 lives from cancer every year."
2. "Since May 2010 the NHS has gained 2,550 more doctors and has 3,000 fewer managers."
3. "95% want more choice over their healthcare"

The first "statistic" references an academic paper that analyses cancer figures over the period 1985 to 1999 and asks the question "if cancer survival in Britain were the same as in Europe: how many deaths are avoidable?" over that period. (The answer is that if the Thatcher and Major governments had taken action to reduce cancer deaths to European levels there would have been 7000, not 5000, fewer deaths). The paper does not make a comment on cancer survival now, it makes a comment on cancer survival during the last Conservative administration. This figure is clearly irrelevant.

The second statistic uses figures from the NHS Information Centre. However, it presents the information in a misleading fashion. We know that year-on-year the NHS has to do more work, and the number of clinicians will increase accordingly (hopefully). It is the trend that is important: how does the change in the number of doctors compare with previous years? The following graph is data from the NHS Information Centre where I have plotting the numbers of all doctors (not GPs) expressed as Full Time Equivalent from 1995 to 2010:

The graph shows basically two trends, 1995 to 2001 where the count was increasing but shallower than the second trend, 2001 to 2009. These two trends are approximately linear.

If I fit a linear trend line to this graph between 2001 and 2009 it yields a gradient (and therefore, an average increase of) 4,859 doctor per year. The increase of 2,600 quoted in the Cameron leaflet is hardly something to crow over. The plot of FTE shows clearly the drop off in the increase in the numbers of doctors.

What about the number of managers? Well, here is the graph using data from the NHS Information Centre (again, FTE):

Again the leaflet is correct, the figures shows a downturn, but look at the trend over time. The change in the number of managers is quite complex, but it is clear that the figure is not increasing every year. In 2006 and 2007 there were falls in the number of managers, and the drop in the last year is equivalent to the large fall in 2006. If you think that the fall in the number of managers is a good thing (which itself is contentious) you cannot deny that it is a new trend. Why hasn't the government said that the fall in 2010 is equivalent to the 2006 fall?

The last figure the government gives is bizarre. As Goldacre points out, there are no figures about the "choice" that patients want, in fact most evidence shows that patients want to go to their nearest provider (hospital, GP) rather than making any other choice. The government has taken the results from the British Attitudes Survey and Mark Hawker has given a possible explanation of where the government gets a 95% figure from given that they never asked anyone how much choice they wanted. It appears that they have aggregated several responses together and say that those who want choice are not those that do not want choice. This is rather disingenious at best.

The Department of Health's Cooperation [sic] and Competition Panel say that

40% of patients have access to at least three NHS Trusts within less than 20km, and around 80% of patients have access to at least three NHS Trusts within 40km. On average, patients travel around 12km to their chosen provider.

This indicates that most patients choose their local hospital.




The Kings Fund's have also researched this area and have found that of those patients who were given a choice of provider (a right since 2006 that will not change under the Health Bill), 69% chose their local provider: a figure greater than that found by the CCP.

However, it is significant that the CCP point out that when there is bad Press coverage of their local hospital patients choose to go elsewhere (they use the example of adverse publicity over quality standards at Basildon & Thurrock NHS Foundation Trust). This does not mean that people want to go elsewhere, just that they usually choose their local hospital, but only go elsewhere when they see a reason not to choose their local hospital. It's clear that choice is not the important thing, the important issue is ensuring that your local hospital is of a high quality.

Tax the sick for being sick

It is instructive every now and again to read what the right wing free marketeers are thinking about, if only simply to "know your enemy".

Today, Andrew Burns posted an article on the 2020Health website. In it he trots out the usual excuses for the reasons for the current government's policy: we are living too long, using too much healthcare and there isn't any money to pay for it. He says:

Patients will have to start taking some responsibility for their health and long-term care. The Dilnot Commission, examining the funding of long-term care and support, which is proposed to be a partnership between the state, individual and families, is due to report in July. It is probable that it will introduce the concept of patients having to take a degree of responsibility for funding arrangements for their post-retirement care, whether this is a lump sum paid at retirement or contribution towards a fund while working. In time, it is likely that a future government will extend this ‘partnership’ concept towards healthcare such as requiring patients to make top-up payments to their treatment, paying for low clinical value treatments and eventually having some form of insurance (a ‘dirty’ word at present) scheme, but with premiums weighted to encourage healthier living such as participation in weight reduction programmes if obese, smoking cessation, regular attendance at diabetic clinics if diabetic, etc

Well, first, I think that the Dilnot Commission will suggest something close to the Burnham solution (the so-called "death tax" that, prior to the 2010 election, Lansley used to distract the public from questioning his NHS policy in detail). What the Dilnot Commission will not suggest is that the government should move to the eventual abolishment of the principles of "free at the point of delivery" and "care according to need" (it is not in their terms of reference), but nice try to give you an opportunity to spout your right wing views.

But more importantly are to give these suggestions in the context of what Burns says justifies them. First he says:

Of course, the underlying reason is money; there simply isn’t enough of it. Yes, improvements in organisation and efficiency are also crucial, but even with these, funding solely through general taxation will never be sufficient to meet the projected demands and maintain high standards of care. 

Then he says:

such as requiring patients to make top-up payments to their treatment, paying for low clinical value treatments and eventually having some form of insurance scheme

Hold on, I thought that he said that there was no money? But then he identifies another source of money: ask people for some more! Hallelujah! He's got the solution, you just need to tax people more, then the cost is spread across everyone, including those that can afford to pay!

Oh no he isn't saying that. He is actually saying that we should ask the sick to pay more than the healthy. He says that if you are ill, you should pay for it twice: first in the discomfort and pain of being ill, and secondly from your pocket. Andrew Burns wants to tax the sick for being sick.

Remember what I wrote yesterday about how ill health can affect your employability and compound the problem of your illness? Yet here is the right wing saying that is a good thing. My compassion for humanity is why I will never associate with such right-wing views.

Two livers, two healthcare systems

I have a career in computer technology and so came to the internet earlier than most. As a result I have a group of friends/colleagues across the globe with whom I speak regularly albeit online. The nature of online forums mean that people who have a shared interest in one area (in this case computer technology) may well have diametrically opposed opinions in other areas. For many years I have conducted some vociferous arguments with Americans who regard the NHS as communist and hence all that is evil. The years of such discussions has enabled me to build up arguments in favour of the NHS, which, in my wildest nightmares, I never thought I would have to use with my own countrymen. How times change.

One such person is Len (I've changed his name). Many times over the 15 years I have known him I have had to put him in my Bozo Bin (block responses from him) because of his extreme right-wing views on healthcare and his attitude that if you simply do not have the money then you do not deserve the treatment. Here, is a forum post from a year ago when he told the group about the condition he was suffering (I have edited it slightly to put the facts in context).

Len has liver failure, which he blames on anti-depressants he was described when his wife died:

Most of you know I lost my wife to Atherosclerosis. That was a bit over 3 1/2 years now. In the first 6-8 weeks after she passed, I lost over 50 pounds because I  simply gave up trying to survive. Then I let my "less than perfect" (saying it nicely) doctor talk me into taking several anti-depressants. The worst of the bunch was called Cymbalta and that's what I blame for my liver problems. The list of side-effects is almost ridiculous. One side effect says "in rare cases, may cause liver failure and possibly death"... well, it didn't kill me outright, but tried very hard.

So a year ago I developed the symptoms of liver failure and I get tired easily due to poor liver functions and get a lot of fluid buildup. Last summer, I spent 5 days in the hospital because this fluid became infected. Over that 5 day period, they drained 20 liters of fluid from my body. That's 10-2 liter bottles of Pepsi! Right now, I have /some/ fluid... not much. I eat a handful  of water pills every day and watch my salt intake, so that, pretty much,  takes care of the fluid problem.

The first day in the hospital was the worst. Since it was the first time I'd ever been in the hospital, for any reason, I was extremely nervous and hated every minute. Days 2-5 weren't so bad because I had a great team of nurses. My morning nurse brought me coffee from Starbucks every morning! Can't beat  that! I was in USC hospital and... no matter what anyone says.... their hospital food was *great*.

When I had all of that fluid in my abdomen and legs/feet, I literally looked pregnant (the extreme pressure caused my 'belly button' to rip and protrude -  very painful) and my legs/feet looked like something a cartoonist would draw  - felt like they were going to "pop" any minute.... I always said I  had "Fred  Flintstone Feet" because they were so puffy I couldn't even bend  my toes. Needless to say, I couldn't wear shoes. Even "diabetic shoes" were too tight.  I /did/ have one pair of shoes that "fit".... Nike Air's with super long  laces that would expand far enough to let me put my feet in them.

I suffered through well over a dozen tests to see if I would be healthy enough to survive a liver transplant. I passed all tests with "flying colors". My heart, lungs, circulatory system, intestinal tract, etc, etc, etc, passed without any problems at all. I had several EKG's, an Echo Cardiogram and Pulmonary Function Test (breathing) and the doctors were almost amazed at how healthy my heart and lungs are, considering I've been a smoker for years and have had such a devastating decade. My heart is "as healthy as a horse", so they say and my lungs work better than quite a few people much younger, who've never smoked a day in their lives.

I had to quit smoking, though. Insurance wouldn't pay for the transplant if I were still a smoker.

I have AB+ blood (a bit on the rare side) and my step son, who has O+ blood (universal donor), volunteered to be a living donor for me and let me have 1/2 of his liver. He went through several tests and we were ready to make a decision to wait for an entire liver or go with the living donor program...

This is all very concerning and I recognise the symptoms since my wife's stepfather - an alcoholic - developed the same symptoms over a decade ago. He is a small wirey man who, over a period of a couple of months, ballooned through the fluid build up. The toxins that build up in the blood also have an effect on your mental processes and my wife's stepfather's thought processes slowed down and at times he hallucinated. Liver failure is not pleasant.

As Len describes, patients with liver failure go through a whole series of tests to see if they are suitable for a transplant. My wife's stepfather went through these too and was found to be suitable. Decades of liquid lunches had luckily not affected the rest of his body and unlike Len, he had given up smoking in the 70s so his heart and lungs were in a great condition for a man in his 60s. In addition to the medical tests, transplant candidates have to go through psychological tests, particularly if they are alcoholic. My wife's stepfather passed these tests, assured the hospital that he would not drink again, and was put on the waiting list.

Then the door developed a squeak. They found 3 tumors in my liver and assumed  they were liver cancer. To the transplant staff, that was almost "good news",  since it placed me much higher on the list, as far as transplant priority  goes.

This too, I recognise. My wife's stepfather was told that the operation is complicated and lengthy and the aftercare is far from straightforward (as we have found out since). He was told that to get the transplant he had to be ill enough to need it, but strong enough to withstand the operation. He was certainly strong enough to survive the operation (liver failure was his only medical condition). When it was discovered that he had liver cancer it meant that he was prioritised to have the transplant.

So now there was another complication, along with liver failure he had cancer and the possibility of it spreading. Notwithstanding the effects of his liver failure, my mother-in-law could cope with his care, but with the diagnosis of cancer she enquired about additional help at home and through her GP she was put in touch with MacMillans. They never did need the help of MacMillans, but it was reassuring that the help was available.

They were just going to keep the tumors from spreading by using a drug that doesn't try and kill or shrink them... just stop new ones from developing... well... one final MRI shows a 4th tumor. Now they had to do a biopsy (not a fun thing, take my word for it)...

They found this newly discovered tumor was in my bile duct, right outside of my liver... the particular type of cancer is called cholangiocarcinoma... a rare type of cancer, of course... just my luck. Now, everything has changed. I can no longer get a transplant... most likely never, ever... and they said that, in most cases, people with this type of cancer survive from 4-36 months, depending on how they respond to treatment.

They can't use surgery or strong chemo-therapy/radiation because of my existing liver damage. That means they can only use "low dose" chemo (for now) and try to slow down the process (which is where the 36 months comes in)

The good news (if there is any) is that I don't feel "bad" at this point.

This is devastating news. The final hope for Len had gone, there was no chance of a transplant, and no chance of attempting to treat the cancer through surgery, chemotherapy or radiation. It was just a matter of how long he could be kept alive.

In the case of my wife's stepfather, his liver cancer had not spread by the time he had his liver transplant. That was a decade ago. It was successful, and now he has a fully functioning liver, but the treatment does not stop there. The anti-rejection drugs have significant other effects and he has had a decade of low white blood counts, which means that any infection affects him badly. He has regular consultant appointments - travelling 50 miles each way to one of the brand new super-hospitals that were built in the last decade. He has regular appointments with his GP, who monitors his general health. The last few years there have been several scares and several interventions: he has had many blood transfusions.

As you can imagine he takes a bucket-load of pills every day, and he has regular blood tests to ensure that the combination is correct. Last year it was clear that the drug combination was not effective and his consultant was concerned since he had tried all the available alternatives. There was one drug, but this was not on the NICE approved list. Note that this is not a cancer drug so Cameron's ludicrous cancer drug fund would not help him. So he had to go through the process of persuading his local PCT to fund an expensive drug. They agreed. Whether the new GP consortia will pay for that drug (or more to the point, will pay for it for a new patient who needs that drug) is another question.

Before his liver troubles my wife's stepfather would always complain about how much tax he paid, and often complain about the NHS, it took one sixth of all taxes and since he had never used it he felt it was a waste of his taxes. After his liver problems he realised the benefit of a social insurance system that gave people the treatment they needed (even extremely expensive treatment) regardless of their personal wealth. He has easily had more treatment than he has ever paid in taxes.

So back to Len:

Most of you also know I was laid off in November of 2005. I had an excellent chance of getting a job that was easy but without any loss in pay and much, much closer to my house...  then I got sick and that fell apart. Since then, I've had several job opportunities that fell apart due to my health (1-5 doctor visits per week)

What many people in the UK do not realise, is how significant medical insurance is in the US. Many employers provide health insurance as a benefit, and, particularly for people with families, this kills job mobility. If your employer provides a good insurance plan then you are willing to put up with a less than perfect job rather than move to a better job with the risk that the insurance plan will not be as good. Young people are more mobile because they do not think they will ever have to use healthcare ("indestructibles") but I've seen marked shifts in the attitudes of US friends at the point of the birth of their first child. The huge cost of childbirth jolts them into understanding how important their insurance premiums are. As for people with chronic conditions, well, their condition defines their life, it becomes their life. They work to pay for their treatment, rather than to be a productive and contributing member of society.

The problem with health insurance is that it shifts much of the decision making from clinicians to bureaucrats. One friend's husband had an accident at work and needed an operation on his leg, but the wrangling between the various insurance companies delayed the operation which complicated the condition. Months later, when he finally had the operation, the condition had worsened and the operation was more complicated and more expensive. I hear terrible stories about patient choice: to keep costs low insurance companies restrict where you can have treatment. Another friend has to travel to another city 20 miles away because their insurance will not pay for any of the primary care practitioners (GPs) in her town. This affects not just her and her husband, but her children too. Imagine having to take your sick child 20 miles to see a GP. Similarly with hospitals. Sure, if you can slap a pile of dollar bills on the desk you can get treated anywhere, but most people, even middle class people, do not have an available wad of dollar bills.

When you talk to Americans what you learn is that it is not healthcare that is the problem, but insurance and Obama's reforms were actually more about reforming insurance than healthcare. Bizarre as it may sound, when I have travelled to the US on business (which I used to do 5 times a year) I had better coverage than many of the people I worked with, particularly if I was attending a conference and there were many people out of state, since their insurance would not cover them for out-of-state treatment and my travel insurance would covere me wherever I was in the US.

Len was middle class. He was a software engineer and had quite a comfortable life in Southern California. But as the quote above shows, when his health problems started he could not get a job. No insurance company would want to take on the responsibility. Neither personal, nor through an employer. And no employer would take on the liability of an uninsured employee. Even though Len was good at his job and very employable when he was well, after he developed medical issues he became unemployable.

I've been on State Disability since that time and not doing too terribly bad, financially. SDI pays nearly as much as my former employer because my final quarter included my severance/vacation and sick pay... which brought the total up quite a bit for that quarter. I know SDI won't pay forever and I've gone through the steps required to get Social Security based disability... problem with that is, it's only about 1/2 of the amount I get from SDI, which means I'll probably lose just about everything I own.

I'm pretty sure I have a place to go... so I won't be homeless, or anything like that (whew)... these days, it almost seems like California would rather let someone go homeless than have to pay them "for nothing" or deal with the paperwork. The people who work at the government offices are a bunch of a-holes, if you ask me. They're "full of cheer" when they apply for the job and quickly turn into heartless robots after a few weeks. Same goes for medical staff.

Essentially, the state welfare benefits were initially good, but time limited. He's applied for other benefits, but when you consider what he has to pay for his treatment (remember, he is not employed, and does not have medical insurance) the last few months of his life are a financial nightmare. He will lose his home to pay for his treatment, but friends have offered to give him a place to live.

My wife's stepfather was close to retirement when his liver troubles started. He was self employed, so the time off work did have financial implications, but the money he had to find was for the normal costs of living. He did not have to pay for the medical treatment. He had paid off his mortgage and had some savings. If he had not got this financial buffer the welfare state would have stepped in. Benefits are not generous (and they are being cut by this government) but no one has to sell their home to pay for medical treatment. Consequently, his primary concern was his medical condition.

Coincidentally, at 50 my father was seriously ill, he neither smoked nor drunk and was generally quite fit, his problem was that his genes were against him. He was ill for several months and I remember when he moved to sickness benefit (if I recall correctly, about half his salary) it had quite an effect on the family finances. Dad recovered from that illness and went back to work. Unlike Len, his ill health did not affect his employability because the costs of his ill health would not affect his employer (and to be fair, he was very much valued by his employer, who would have found it difficult to replace him). Len was a financial liability on any employer, my Dad was not because the NHS (and the welfare state) would absorb that cost.

(As I said, my Dad's genes were against him: he died at 68. My wife's stepfather's genes are very much in his favour, he is in his mid-70s still alive with someone else's liver.)

Len finishes his missive with a caution, but as far as I know, still clinging onto his belief that commercialised healthcare is the right solution, regardless of his experiences.

Well... that's my story.

No matter what... NEVER take your health for granted. People are *far* more fragile than most would assume. No matter how young or old, tomorrow is promised to no man. Heck... Even the "super healthy" can get slammed in a car  accident... Just be careful, watch the side effects of any meds you're taking  and try your very best to make each day count.

I have just learned that Len has died.

I had some very heated arguments with Len and we hurled great abuse at each other (and in every argument I was right, naturally). But the end of his life was quite sad, and just at the time that he was at his very worst, the system rejected him. No insurance, no chance of a job and a bureaucratic welfare system to which he had to go cap-in-hand to get the care he needed. He had to sell his home and rely on the charity of his friends and family for the last few months of his life.

Insurance is not wrong: the NHS is essentially funded by an insurance system where we all have to pay. The problem comes from insurance run as a business and hence, as any business, when it rejects custom from those from whom it cannot make a profit. In the case of health insurance, this means that sick, vulnerable people are rejected just at the time when they need it most.

Healthcare should never be about profits. Len would never accept the NHS as a legitimate system, but when you compare his story with that of my wife's stepfather, you will see exactly why we need the NHS and why we need to ensure that it is never comercialised.

Ed Miliband "gets it"

Today, Labour have shown that they understand the effect the Lansley Bill will have on the public and how to make the public aware.

The government has been rather clever by focussing on GP commissioning. The contact most people have with the NHS is through their GP and if they have a good experience (88% of people do, compared with 72% satisfied with the NHS overall) then they put their confidence in their GP. The message that the Conservatives used during the 2010 election, and since, is that they would put GPs "in control". The problem is that when the Bill appeared it became clear that GPs would not be "in control", instead Consortia would be in control, and the Bill does not even mandate that they are run by GPs. The plan was a clever one, but it was sunk by the facts.

However, when you ask anyone to identify what they think most embodies the NHS they will not say their GP, instead, most will point to their local hospital. The NHS ensures that there is an acute hospital covering all of the population: the Secretary of State must provide this (the Bill, of course, removes this compulsion). Threaten a hospital and people get upset; very upset.

Today, Ed Miliband shows that he realises this. In today's press conference it is reported:

Mr Miliband said, under the plans, hospital could face huge fines for breaching competition law, could "go bust" as they would be subject to insolvency laws, health service decisions could end up being "made in the courts" and hospitals could convert whole wards to become private wards only.

This is important. What he is saying is that the Lansley plan will affect our local NHS hospitals: competition law imposed by a large national organisation (or a supra-national organisation if EU competition law applies) could close cherished local NHS hospitals. Labour have learned, far too late, that decisions made by a distant power (however right they may be) are not popular if they affect local hospitals. Under Labour the "distant power" was the Department of Health (the Conservatives and Liberal Democrats have tried to paint PCTs as such malevolent "distant powers" as a way to justify their demise, but this argument has not worked with the public), now Miliband is identifying another unaccountable "distant power", Monitor. The more that Labour maligns Monitor, the less the public can justify its powers. To the public Monitor will be seen as enforcing competition law that will close their local hospital: all negative aspects. The government will find it difficult to persuade the public that there are any "good" aspects to Monitor.

Miliband also makes an interesting allusion to the policy of removing the private patient income cap (PPI). He says "hospitals could convert whole wards to become private wards only". The PPI cap means that NHS Foundation Trust hospitals are restricted to the proportion of private income they can generate: this does not prevent them from doing private work, but it does mean that if a trust does more private work it has to do proportionally more NHS work. Removing the PPI cap means that hospitals (and particularly those in big cities, principally London) could increase their private work and squeeze NHS patients out.

The phrase "whole wards to become private wards only" is important because it heralds a two-tier system. Miliband has tapped into the inherent decency of the NHS: when it comes to ill health we are all equal; your access to treatment should not be dependent on your wealth. The government has gone to great lengths (sometimes inappropriately) to emphasise that the NHS will still remain "free at the point of use", but they avoid the issue of a two tier system. Miliband explaining that the Lansley Plan will lead to wealth determining a different, perhaps even better, care is political dynamite.

After floundering for months for a narrative it now appears that Ed Miliband has found the right combination to attack the government. Ed Miliband gets it.

PCTs and Lib Dems

Yesterday Matthew D'Ancona wrote an excoriating article in the Sunday Telegraph berating how badly Lansley and Cameron had sold their re-organisation of the NHS. Make no mistake, D'Ancona is not defending the NHS, he says "As it happens, I agree with just about every detail of the Lansley plan" but then again, he is not a health policy expert, he is a political commentator. D'Ancona was commenting on the politics and on this he said:

The clear impression before the election was that there would be no more "structural upheaval" ... it is stretching credulity to claim that the electorate voted for this, or expected it even when the Coalition was being formed.

He then goes on to say:

The trouble is that this has now become a trust issue for the PM, just as tuition fees are for Clegg: you said one thing, and did another.

This is very worrying for the Prime Minister, but it is worse for the Deputy Prime Minister who seems set to push the Lansley Bill through Parliament intact, even though his grassroots (and the majority of the country) are against it.

The government is expecting a tough fight in the House of Lords. Lord Owen has said that him, and many other Lords, are opposed to the Bill and will make substantial changes to it. On his website, Lord Owen has published a pamphlet called Fatally Flawed, in this he says:

There was no mention in either the Conservative or Liberal Democrat party manifestos at the 2010 General Election of an intention to carry forward anything like this revolutionary change. Under the Salisbury Convention the House of Lords is entitled therefore to make substantial amendments to this Health and Social Care Bill.

This is very important because the Salisbury Convention says that if the Commons have a clear mandate then the Lords should not block the Bill, that is, although amendments may be suggested, they should not be designed to wreck the Bill. Owen is suggesting changes that would change the Bill into something very different. The government clearly wants to make sure that they can convince the Lords that they have a mandate for these changes. D'Ancona alludes to this:

It is perfectly true that you can find sentences in this or that pre-election Tory document which, when aggregated, come close to the Lansley plan.

In other words you can cobble together this policy from the manifestos, but it certainly is not a policy that the public will think they were sold (hence the trust issue).

The big problem is Primary Care Trusts (PCTs). Neither the Conservative manifesto, nor the Lib Dem manifesto say that they wanted to abolish PCTs. The Conservative manifesto does not mention PCTs at all, but in their earlier policy document NHS Autonomy and Accountability, Proposals for legislation published in 2007, they say (4.28 – 4.30):

PCTs will remain local commissioning bodies.

Further:

PCTs will also remain, as now, the areas to which NHS resources are allocated, although almost all of these resources will be cascaded down by the PCT to its primary care commissioners.

The Coalition Agreement says the same thing:

We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.

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. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations.

This says that PCTs will remain. But when the NHS White paper was published  (and now the Bill) it became apparent that Lansley will abolish PCTs. The Secretary of State for Health was asked on the Marr program about this change in policy:

ANDREW MARR: When did you decide that the primary care trusts were going to have to go entirely?


ANDREW LANSLEY: We decided that in late May, early June.


ANDREW MARR: So quite …


ANDREW LANSLEY: After the coalition.


ANDREW MARR: After the coalition agreement?


ANDREW LANSLEY: Yeah, we did. And for a very simple…

The change occurred a few weeks after the election and after the Coalition Agreement. Remember that the Liberal Democrats had a conference to decide whether to accept the Coalition Agreement, and they voted for it. Clearly they voted for the policies outlined in the Agreement document, and not for Lansley to make major changes without their agreement. Yet a few weeks afterwards Lansley produced policy that was in deliberate conflict with the Agreement.

D'Ancona, however, is either not aware of this or is deliberately acting as a mouthpiece for the government's spin machine. In his Sunday Telegraph article he says:

Conservative sources point out that the Lib Dems were explicitly in favour of abolishing Primary Care Trusts – effectively pointing a finger at Nick Clegg and shouting: "It was the crybaby! Blame him!"

This is not true. The Liberal Democrats never said they wanted PCTs to be abolished. The Liberal Democrat 2010 manifesto says this:

Empowering local communities to improve health services through elected Local Health Boards, which will take over the role of Primary Care Trust boards in commissioning care for local people, working in co-operation with local councils. Over time, Local Health Boards should be able to take on greater responsibility for revenue and resources to allow local people to fund local services which need extra money.

This does not say that PCTs will be abolished, it says that they will be replaced, in other words the same layer of management would exist but the boards would be elected rather than appointed. This morphed into the Coalition Agreement's phrase "directly elected individuals on the boards of their local primary care trust".

In Norman Lamb's health policy document The NHS: a liberal blueprint he says:

The commissioning of local health services should be democratically accountable. Boards of PCTs – which should be renamed local health boards – should be elected, not appointed, so that they can be held to account at a local level.

It is very clear that Lamb was not suggesting abolishing PCTs, just renaming them local health boards.

Yet, we hear from D'Ancona that Conservative sources are trying to make it appear that the Lib Dems said something different to what they actually said. Is this the right way to treat a coalition partner?

Tories' deliberate deception on the NHS

Read this:

The Tories' deception about their plans for the NHS (and make no mistake – it was a deliberate deception) was a blunder of stupendous proportions. Rarely has a party connived so neatly to get the worst of all worlds. They appeared incoherent in opposition – when they seemed to be taking precisely opposite approaches on health and education policy – and then dishonest and untrustworthy in government.

 I didn't write it. It was the right-winger Janet Daley in the Sunday Telegraph. Looks like a great slogan for an election poster.

Any Qualified Provider

The rather bizarrely titled policy document "Making Quality Your Business: A guide to the right to provide" the government outlines the "Right to Provide (R2P)" and "Any Qualified Provider (AQP)" policies.

The idea behind R2P is:

"the right is to present to your board your proposal for a staff-led enterprise and to seek approval to develop a full business case to test your proposal. If the business plan is then approved, you will be able to set up a staff-led enterprise"

So basically you and your colleagues get together and then demand that you can provide the same work as you are doing now either as a mutual (profit-share) or as a social enterprise (not-for-profit). The board are supposed to say "yes, you can".

Except there are problems. First, this does not apply to existing Foundation Trusts (who the government admit are outside the scope of R2P) and half of hospital trusts are already FTs. Second, they say that even if you present your business plan to the board of an NHS Trust, they may turn you down if they think that it may affect their bid to become a Foundation Trust. If the service you intend to supply is one of the surplus generating services in the trust then, yes, it will affect the trust's application to be an FT: they will need the surplus to be able to show that they have sound financial governance. The last thing they would want to do is allow you any your mates to share that surplus between yourselves as a mutual.

If the board agrees (and there will be political pressure for some to agree), it may not be in the best interest of either the trust or the new organisation. The trust will lose control of the service and will only be able to work through a new layer of management - the new R2P organisation's management. If a trust contracts to several such organisations then there will inevitably be fragmentation of service and collaboration will be threatened. The R2P employees will initially get NHS terms and conditions, but will lose them if they change jobs or get promoted within their organisation. They will also be on a fixed term contract, which means that ultimately they could lose the contract.


The R2P policy appears rather dead in the water. The last government had a similar programme called "Right to Request" for community health services. Out of 152 PCTs the first two waves of "Right to Request" yielded just 29 requests. In the third wave under the current government, another 32 were added to the list. Thus just over a third of community health services took up the option.

The "Any Qualified Provider" policy is presented to us as "patient choice". (The previous name, "Any Willing Provider", was replaced presumably because people thought it sounded too much like privatisation.)

First a provider (and it may be an R2P provider) has to "qualify" to be a provider:

"to show that they can meet the conditions of their licence with CQC and/or Monitor (if necessary), provide safe quality services to the contractual standards set by the NHS Commissioning Board and meet NHS prices – either set nationally or locally"

Then, apparently, patients choose them. But will they? Although AQP is being sold as "patient choice" it is quite clear that they will more likely be "commissioners' choice":

"It will be for commissioners to decide which services are best delivered through an AQP approach or tendering but the presumption will be that for most services patients will have a choice of Any Qualified Provider. Subject to Parliamentary Approval, the NHS Commissioning Board will have a duty to promote patient choice, having agreed its scope with the Secretary of State for Health, introducing AQP and holding consortia to account for delivering choice."

The presumption seems to be rather ambitious. If a commissioner is designing integrated care, an AQP aspect to the care pathway will complicate the process, make the commissioning more bureaucratic and more costly. We are now in an age of financial constraints and a pledge to cut bureaucracy, it seems bizarre to add more cost and red-tape.

Further, the government says:

"Once qualified, providers will register locally with commissioners (PCTs, clusters and consortia) for payment purposes. There will be no volume or payment guarantees for providers – their income will be wholly dependent on patients choosing to use their services."

The block contracts that are mentioned here are common in the NHS and help to keep costs down. A commissioner working under the tight finances of the new McKinsey'ed NHS ("£20bn efficiency savings") a responsibility to break even and no chance of a bail out from government, is likely to offset "patient choice" AQP with being able to keep the balance sheet in the black.

Four Simple Changes

In a letter to the Indy Prof Martin McKee, from London School of of Hygiene and Tropical Medicine lists four changes that must be made to the Health and Social Care Bill:

1. Restore the duty of the Health Secretary to secure or provide a comprehensive service and be the only person, subject to Parliament, who can impose extra charges for NHS treatment.
2. Commissioning bodies must be public authorities responsible for a geographically defined population, ideally coterminous with local authorities. 
3. Commissioning bodies must have a statutory responsibility to ensure that their decisions do not threaten the viability of existing NHS services, unless there has been an explicit decision to close them.
4. Foundation Trusts must not act in any way that leads them to be considered "undertakings" under competition law.

Remember them, and when Conservatives tell you that the Bill simply needs clarifications, challenge them on these four points.

Notes:

The first clause of the Bill replaces the phrase "The Secretary of State must for that purpose provide or secure the provision of services" in all previous NHS Acts of Parliament with "The Secretary of State must act with a view to securing the provision of services". This is recognised as abolishing the duty of the Secretary of State to provide a comprehensive health service. (Bad Medicine shows how this amendment is made.) The Bill (clause 22) allows GP consortia to charge for some services, and clause 150 allows Foundation Trusts to charge for accommodation.

Lansley's policy is sloppy, he has no idea about how big consortia should be or what populations they should cover. (A consortium could, for example, cover a city, including the wealthy suburbs, but exclude the practices in the inner city deprived areas.)

The Any Qualified Provider policy is designed to bring in the private sector at the expense of existing NHS services, Lansley expects this to create a market and he expects market forces to provide the services we need. But we all know that market forces work on profit, not need, and such a healthcare market will result in those with the need for healthcare taking a poor second place to profits.

In the future all hospital trusts will be Foundation Trusts, and if they "engage in economic activity", that is, they offer of goods or services on an economic market, with the potential to make a profit, then they are treated as "undertakings" and are subject to EU competition law. Lansley tries to reassure us that hospitals will not be subject to competition law, but others (Health Policy Insight have an excellent overview here) disagree.

UPDATE:
Liz Kendal MP (@LeicesterLiz) points out that the simplest way to achieve these changes is to delete section 3 ("Economic Regulation of Health and Adult Social Care Services") of the Health and Social Care Bill. This section sets out the responsibilities of Monitor, explains how providers (NHS and Any Qualified Providers) are licensed so that they can bid for NHS work, defines how prices are determined and introduces competition law into the NHS.

Public Health delocalised

Under the Health and Social Care Bill the responsibility of public health will move from PCTs to local authorities.

First, a definition of "local authorities", this is from clause 8 of the Bill which inserts a new clause (2B) into the National Health Service Act 2006:

(5) In this section, “local authority” means—
   (a) a county council in England;
   (b) a district council in England, other than a council for a district in a county for which there is a county council;
   (c) a London borough council;
   (d) the Council of the Isles of Scilly;
   (e) the Common Council of the City of London.”

In effect this is saying that public health is the responsibility of county councils. This link is to a spreadsheet of all local authorities in England (county, unitary and district authorities). The source is ONS and it was collated by the Guardian.

From this spreadsheet we can see that the populations of the 33 counties vary between 404k and 2.6m (median size 760k). The interesting thing is that there are 152 PCTs varying between 90k and 1.3m (median 282k).

This means that public health is currently being carried out by authorities much smaller (around a third) than the authorities who will get the responsibility under the Bill. This is not localism, this is centralising power.

If mutuals are the solution, what's the problem?

The title is my response to Ed Miliband's speech to Labour's National Policy conference at the end of last year:

What are the solutions for the future that I am interested in? I am interested in mutual solutions to some of the issues we face in our public services. To community ownership of our public services. To public services where people don’t feel, both users and those working in them, like cogs in the machine which to often they do. And also we have to be the people who stand up for local democracy and local control over public services as well.

First, before you come up with a solution, please examine the problem. Don't put the cart before the horse. Second, what the hell does "community ownership of our public services" mean? If they are public services then we, the public, the community, already own them!

In September I attended one of the Labour leadership events where Ed Miliband came to my area and gave a talk and then took questions. I asked:

If you become leader will you pledge to take back into public ownership those NHS hospitals and community health services that Lansley has taken out of public ownership as Social Enterprises?

Ed Miliband merely heard NHS and not the rest of the question and although the meeting was run under the execrable "we will take three questions and then answer them all in one go" system (a system designed to stop the questioner intervening) he did not understand the question and so asked me to clarify:

Are you talking about GP Commissioning...?

I wasn't and told him so, explaining:

Lansley has said that he wants all our hospitals and community health services to be run by Social Enterprises, which are not publicly owned. Will you pledge that the next Labour government will take these back into public ownership?

His answer was surprising:

I don't know about that policy.

At the time I didn't realise the significance of this reply. A few days later when I was researching his career in government I discovered that Ed Miliband was the first Minister of the Third Sector in 2006. Ed Miliband created the "Third sector" as we know it, where social enterprises and charities take over public services. The NHS Confederation's NHS Handbook 2010/11 says:

DH research into the third sector's potential contribution in 2007 found 35,000 third sector organisations provided health or social care, and another 1,600 planned to do so. Total funding for these services amounted to £12bn a year, with just over half of that from the public sector - 36% of which was for healthcare and 62% for social care.

That is, currently about £2bn of NHS care is provided by the Third Sector. This is a huge contribution, surely Ed Miliband knew that? And surely Ed Miliband had been advised that Lansley wanted to expand this much, much further?

Well, after the NHS White Paper consultation the Department of Health dropped the idea of entire NHS hospitals becoming social enterprises. It may have been because of a bit of clear thinking from the Treasury: there just isn't enough money. Social enterprises are private companies, they are not public entities. They differ from the private sector because they ensure that all surpluses are re-invested into the service. These are not-for-profit organisations. (For comparison, half of US hospitals are nonprofit, that is, they are social enterprises.) If a hospital becomes a social enterprise it has to purchase the asset (you seriously did not think that they would have been given the hospital for free, do you? Seriously?) and that would mean a lot of organisations, making very small surpluses (if at all) taking out loans and having to service those loans.

The Department of Health estimates that our hospital trusts are worth £24bn. Can you imagine what it would do to the money markets if all the hospital trusts tried to get that amount of money in the run up to April 2014 (the dropdown dead date for NHS Trusts)? With such competition for money, the government would find it just that little bit more expensive to re-finance gilts. Not a great idea.

So the idea now is Any Qualified Provider under a programme called Right to Provide. The idea is that groups of NHS workers should get together as a mutual (profit share) or social enterprise (profit re-invested in the service) and they request that they provide that service for the hospital or community health service. If the service is an NHS Trust (ie does not have FT status) then it must consider the request.There are several issues.

Fragmentation is mentioned by Dr Mark Porter chair of the BMA's consultants committee:

"Doctors and other healthcare professionals are qualified to provide excellent care, but we believe the NHS should remain in the hands of the public. It is hard to see how the NHS can operate effectively if lots of bits of it are in private hands – even if they are those of former employees. New mutuals could quickly find themselves in conflict with each other, and at risk of being out-competed by private healthcare giants. The consequence could be financial and operational chaos."

Under the scheme an NHS hospital will be like a department store. When you walk through a House of Fraser store you walk past departments franchised to many different suppliers. Each department sell just their own branded goods. Imagine your local hospital run like that: different wards run by different organisations. Think of the paperwork when you are passed from one to another! This is in stark contrast to Marks and Spenser where every square inch of the shop is run by M&S and every item is an M&S branded goods. At the moment we have a (more or less) M&S model, but Lansley wants a House of Fraser model.

The problem with the franchised system is that it could get unwieldy. Rather than one bloc of employees to negotiate with, to lead and empower, a hospital chief executive would have to work with many disparate groups. Instead of the top management being able to intervene and address any employee, under the franchise system the employees of the mutuals/soc ents will be employed by a separate organisation and so there will always be a layer of management between the chief executive and any employee, possibly an impenetrable layer.

For the employees, forming a mutual may appear attractive initially, especially since the assets they will use will largely be leased from the NHS provider so there will not be large investments required. And the government may encourage such mutuals initially by awarding them sweetheart deals. (We already know that such mutuals will be handed the contract without tendering since this is a Right to Provide.) But the attraction rapidly wears off. Such employees will initially have TUPEd NHS terms and conditions, but new employee would have non-NHS T&C. And when an employee gets promoted, they will leave their NHS T&C behind when they sign their new employment contract. Further, the hospital will have no responsibilities over the employees of such organisations: if the mutual goes bankrupt the hospital will be under no obligation to employee the staff. Indeed, after the initial contract has expired, the hospital could choose another provider since the mutual is one of many possible providers: Any Qualified Provider.

Finally, it is worth pointing out that all hospital trusts have to become Foundation Trusts by April 2014. The Department of Health is quite clear about this. In its policy document on Right to Provide it says:

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.

In other words, this says that FTs are exempt from Right to Provide. As more and more NHS Trusts become FTs there will be fewer possibilities for the cosseted-mutuals explained above to be created.

But I return back to the initial question, and as Labour formulate their policies for the next election I need Ed Miliband to answer it: if mutuals are the solution, what is the problem? I think that if we find out what the problem is, we may well conclude that there are other, less disruptive, ways to fix it, other than breaking up the workforce into many disparate mutuals.

Anyone Listening?

In September the Liberal Democrats had a conference in Liverpool when they spent five days congratulating themselves that the Tories had failed to get a majority and that they had lost 5 seats but not too many to allow them to put a right-wing Conservative government in power.

However, a few Lib Dems (just ten of them) realised that being in government was more than just propping up Conservatives who could not get the country's support, and they expressed their worry over the government's policy on the NHS. The conference was just under two months after the NHS White paper had been published, but this was enough time to read the policy document, yet it appears that only ten did. They proposed the following Emergency Motion (22 September 2010):

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 points out problems in the white paper of conflicts of interest in commissioning, problems arising from using the private sector, highlights that the white paper proposals may increase health inequalities and provide worse care for people with complicated health needs, and it points out that training was at risk. This was a warning, but was anyone listening?

It seems not. The Lib Dems then passed a motion at their Spring Conference (12 March 2011) expressing concerns about the Bill (bear in mind that this motion was a toady motion proposed by Paul Burstow the Minister of State and then amended to change its tone from congratulatory to condemnation):

Conference believes that the NHS is an integral part of a liberal society, reflecting the social solidarity of shared access to collective healthcare, and a shared responsibility to use resources effectively to deliver better health.

Conference welcomes our Coalition Government’s commitment to the founding principles of the NHS: available to all, free at the point of use, and based on need, not the ability to pay.

Conference welcomes much of the vision for the NHS set out in the Government’s White Paper, Equity and Excellence: Liberating the NHS which commits the Government to an NHS that:

i) Is genuinely centred on patients and carers.

ii) Achieves quality and outcomes that are among the best in the world.

iii) Refuses to tolerate unsafe and substandard care.

iv) Puts clinicians in the driving seat and sets hospitals and providers free to innovate, with stronger incentives to adopt best practice.

v) Is more transparent, with clearer accountabilities for quality and results.

vi) Is more efficient and dynamic, with a radically smaller national, regional and local bureaucracy.

vii) Gives citizens a greater say in how the NHS is run.

Conference particularly welcomes the proposals to introduce real democratic legitimacy and local accountability into the NHS for the first time in almost forty years by:

a) Extending the powers of local authorities to enable effective scrutiny of any provider of any taxpayer funded health services.

b) Giving local authorities the role of leading on improving the strategic coordination of commissioning across the NHS, social care, and related childrens’ and public health services through councillor led Health and Wellbeing Boards.

c) Creating Health Watch to act as a local consumer champion for patients and to ensure that local patients are heard on a national level.

d) Returning public health duty to local government by ensuring that the majority of public health services will now be commissioned by Local Authorities from their ring-fenced public health budget.

Conference recognises however that all of the above policies and aspirations can be achieved without adopting the damaging and unjustified market-based approach that is proposed.

Conference regrets that some of the proposed reforms have never been Liberal Democrat policy, did not feature in our manifesto or in the agreed Coalition Programme, which instead called for an end to large-scale top-down reorganisations.

Conference therefore calls on Liberal Democrats in Parliament to amend the Health Bill to provide for:

I) More democratically accountable commissioning.

II) A much greater degree of co-terminously between local authorities and commissioning areas.

III) No decision about the spending of NHS funds to be made in private and without proper consultation, as can take place by the proposed GP consortia.

IV) The complete ruling out of any competition based on price to prevent loss-leading corporate providers under-cutting NHS tariffs, and to ensure that healthcare providers ‘compete’ on quality of care.

V) New private providers to be allowed only where there is no risk of ‘cherry picking’ which would destabilise or undermine the existing NHS service relied upon for emergencies and complex cases, and where the needs of equity, research and training are met.

VI) NHS commissioning being retained as a public function in full compliance with the Human Rights Act and Freedom of Information laws, using the skills and experience of existing NHS staff rather than the sub-contracting of commissioning to private companies.

VII) The continued separation of the commissioning and provision of services to prevent conflicts of interests.

VIII) An NHS, responsive to patients’ needs, based on co-operation rather than competition, and which promotes quality and equity not the market.

Conferences calls:

1. On the Government to uphold the NHS Constitution and publish an audit of how well organisations are living by its letter and spirit.

2. On Liberal Democrats in local government to establish local Health and Wellbeing Boards and make progress developing the new collaborative ways of working necessary to provide joined up services that are personalised and local.

3. The government to seize fully the opportunity to reverse the scandalous lack of accountability of publicly-funded local health services which has grown up under decades of Conservative and Labour governments, by:

a) Ensuring full scrutiny, including the power to require attendance, by elected local authorities of all organisations in the local health economy funded by public money, including Foundation Trusts and any external support for commissioning consortia; ensuring that all such organisations are subject to Freedom of Information requirements.

b) Ensuring Health and Wellbeing Boards (HWBs) are a strong voice for accountable local people in setting the strategic direction for and co-ordinating provision of health and social care services locally by containing substantial representation from elected local councillors; and by requiring GP Commissioning Boards to construct their Annual Plans in conjunction with the HWBs; to monitor their implementation at meetings with the HWBs not less than once each quarter; and to review the implementation of the Annual Plan with the HWBs at the end of the year prior to the construction of the Annual Plan for the forthcoming year.

c) Ensuring commissioning of health services has some degree of accountability by requiring about half of the members of the board of commissioning consortia, alongside GPs, to be local councillors appointed as non-executive directors.

d) Offering additional freedoms only to Foundation Trusts that successfully engage substantial proportions of their local populations as active members.

Applicability: England.

It does not appear that the government (nor Paul Burstow) listened to the Lib Dem conference in September 2010. The Lib Dem Spring conference were still complaining about issues that they highlighted in their Autumn conference.

Now the Social Liberal Forum have launched a petition to demand changes to the Bill.

Liberal Democrat members and activists – Demanding changes to the Health and Social Care Bill
Our Federal Party Conference last month overwhelmingly backed a call from Shirley Williams, Dr Evan Harris and 150 others, calling for Andrew Lansley’s health reforms to be significantly amended to bring the policy back in line with the agreed Coalition Agreement and with Lib Dem principles.

Specifically we seek amendments to:

a) ensure the Health Secretary has a duty to provide a fully comprehensive and free health service, with no gaps and no new charges
b) provide more local democratic accountability for the health service
c) curb the market obsession of the proposed reforms to prevent quality being relegated behind price and prevent the cherry-picking of profitable services by the private sector undermining and fragmenting existing provision
d) slow down the pace of change so that the NHS, facing its toughest settlement for decades, does not implode from the stress of another massive reorganisation

The changes to the health bill required by conference are set out in full here. They do not preclude other changes that may be needed but which were not covered by the conference motion as amended.

We are calling on our party’s leadership to fully respect the declared view of the Party on this matter and insist on all these changes in the health policy in any discussions with the Conservatives.

We believe it would be unacceptable for Liberal Democrat MPs and peers to be whipped to vote against conference policy and to vote in support of Tory policies that were not included the coalition agreement and that we have democratically rejected.

The Spring conference was during the time that the Bill was passing through the committee stage in the House of Commons, with ample time for the Liberal Democrat minister, Paul Burstow to amend the Bill according to his party's wishes. Did he? No, this is why the Social Liberal Forum had to launch their petition (and the pointed statement at the end about whipping Lib Dem MPs to vote contrary to Lib Dem policy).

Now the Bill has been  delayed (Lansley: "during the natural break"; Clegg: "for two months"; HSJ: "for one month"; in other words for very little time at all). Is it likely that the Bill will be changed "substantively" as Clegg suggests? Well, judging on past performance, the answer is No.