Timeline

So far the Bill is still (just) pausing, but the changes to the NHS are still going ahead. The dates at the moment are:

July 2012
SHAs will be abolished. This is a new deadline announced after the "pause" was announced (previously it was April). This may now have changed (see below).

April 2013
PCTs will be abolished. According to HSJ the abolition of SHAs could be delayed until this date.

April 2014
NHS Trusts will be abolished. All hospital trusts will have to be Foundation Trusts by this date.

More on Warner

I posted last night about Lord Warner's business interests. The reason was that I remembered how he tried to scupper the attempt by the previous government to try and do something about the impending crisis in social care. It wasn't just that his action was nasty, it was because he was making his comments at just the wrong time politically - just before an election. he knew that his comments would be detrimental to Labour's image and the only result would be a Tory government. Yet Warner is always described as a Labour peer.

Basically the rather hapless Health Minister Andy Burnham was belatedly trying to sort out the issue of funding social care - then (and it is still the case) social care is means tested so those with savings of over £23,250 are excluded. The problem is that £23k does not go far when it comes to social care (last year the Audit Commission said that the average cost of residential care was £980 per week). Burnham wanted to make social care in people's homes free to a wider group of people and he claimed that the plans were costed. Warner tabled an amendment against the plans saying that he thought they weren't costed. The problem, politically, was that someone who was being described as "former Labour Health Minister" was in opposition to the current Health Minister's plans just months before the election. Government's lose elections because the electorate thinks they are no longer competent, and this calculated action from Warner was designed to make the public think that the labour government was not competent.

When you do an internet search on Warner, you come up with some interesting results. For example, earlier this month he was cavorting with 2020Health. These are the people who want us to pay for GP appointments. What is a Labour peer doing within 100 yards of such people?

Warner was also appointed an adviser to Deloitte in 2009:

Deloitte, the business advisory firm, is today announcing the appointment of Lord Warner as a strategic adviser to its public sector practice. Lord Warner will work with Deloitte’s clients enabling the successful delivery of health and social care policies.

The man has "privatise NHS" written all over him. Isn't it time Labour disowned him?

(Oh sorry, I forgot, Labour want to privatise the NHS too.)

Warner and NHS Reforms

Lord Norman Warner keeps turning up like a turd that will not flush away.

He keeps being brought up by the media as a "previous Labour Minister" that "supports Lansley's NHS policies". Why is it that he supports "the coalition's plans to reform the NHS"? Why, on BBC Westminster Hour did he tell Carolyn Quinn that he is "critical of Labour's opposition to proposals to increase competition within the NHS"?

Might it be because in 2008 he became "nonexecutive chairman of a company - UK Health Gateway - which promises to "open the door" for overseas businesses selling to the National Health Service"? In other words, he became part of a company that would benefit from competition in the NHS?

Might it also be because he also "works as an adviser to Xansa, a technology firm, and Byotrol, an antimicrobial company, which both sell services or products to the NHS" and was "paid by DLA Piper, which advised ministers on the £12 billion IT project for the NHS" projects that he was responsible for when he was a government minister?

Basically, when Lord Warner supports a Tory Government about a policy to introduce more private sector involvement into the NHS is is simply because Lord Warner will make a huge pile of cash from such policies.  This is why Lord Warner is "critical of Labour's opposition to proposals to increase competition within the NHS". A huge pile of cash will make you say anything, even if you are nominally, a Labour peer!

Debts Circling round and round

Ali Parsa, the Chief Executive of Circle Health, loves to call his organisation a "social enterprise". It isn't. He is either rather stupid, or he is deliberately trying to deceive. I think that Parsa is a clever man, so work out what I think about his integrity.


The Social Enterprise Coalition ("the voice of social enterprise") defines a social enterprise as:

Social enterprises are businesses driven by a social or environmental purpose. ... As with all businesses, they compete to deliver goods and services. The difference is that social purpose is at the very heart of what they do, and the profits they make are reinvested towards achieving that purpose.

There are two main criteria. First, the business has a social purpose, and second, any profits (or surpluses) are re-invested into the social enterprise. It is very important to remember these criteria.

Healthcare is often described as being a "social purpose", but clearly since there is a private healthcare sector where businesses treat healthcare as a profit-generating commodity, it means that healthcare can only be a "social purpose" when it is run not-for-profit (ie, healthcare is not treated as a commodity). If the company starts treating healthcare as a commodity (ie, it sells healthcare to private patients) then it is not a social enterprise.

At the same time we need to remember that not all for-profit companies have rentier shareholders, some for-profit companies are owned by the people who work for them and thus the workforce receives a profit hare. Such an organisation is a co-operative or mutual. The important point here is that they are for-profit and that the profit is shared between members. This is often quoted as the John Lewis model, but since such companies make a profit (it is shared with employees, but it is still a profit) such companies are not social enterprises.

So where does Circle fit in? This was taken from Circle's website in October 2010, curiously, it is no longer there:

Circle is structured as a partnership of clinicians and other professionals. Being a partner means you share in the ownership of Circle, with shareholder voting rights to help direct the company.

* 49.9% of Circle is owned by Circle Partnership Ltd, which is owned by everyone who works in clinical services, directly or indirectly and at every level.
* 50.1% is owned by Circle International plc. This is the investment vehicle that blue chip City institutional investors have subscribed to for shares by providing the capital for Circle. They ensure that any refinancing is achieved without diluting partners' 49.9% ownership.
* The investment needed to buy land and build hospitals, clinics and invest in infrastructure is raised by Health Properties Ltd, a separate business.

Every year from 2003-2015, up to ten million shares will be available for allocation to partners until 100 million shares have been issued.

There are several interesting things here. The first is that the majority of Circle (50.1%) is owned by City investors (Balderton Capital, Landsdowne Partners, Bluecrest and BlackRock). This means that less than half of the company is owned by the workforce. The share allocation policy of Circle is designed to keep it that way. There is no worker control of this company! The dividends for these shares are paid to their shareholders including the employees so the employees receive profit share. the company does not re-invest its profit into the company.

All of this means that Circle is a for-profit organisation where over a half of the dividends go to City investors. This means that Circle is not not-for-profit so it fails the first criteria to be a social enterprise (namely re-invest surpluses into the company). However, since Circle also sells healthcare as a commodity - it has private patients as well as NHS patients - it means that they fail the other criteria to be a social enterprise that they have a social purpose..

It is very clear that Circle Health is not a social enterprise.

As I said above, Ali Parsa calling Circle Health a "social enterprise" is an attempt to deliberately deceive.

Circle run two Independent Sector Treatment Centres under the Nations Healthcare brand. ISTCs are the rather dodgy way that New Labour tried to privatise the NHS. The ISTC They allowed private sector companies to provide healthcare to the NHS and to entice them the government paid then 11% over the national tariff (the payment for NHS hospitals). The then government also allowed the ISTC to reject any patient they did not want to treat, while still being paid for the patient ("take or pay"). It is estimated that this meant that ISTCs only completed 85% of their contracts, making them even more expensive. Finally, the last government provided a buyback guarantee so that when the ISTC contract was completed the NHS would buy back the ISTC properties at market rates (Residual Value agreement), so that the private company would bear no risk at all.


Now have a look again at the last point from the Circle website (that they have now deleted):

The investment needed to buy land and build hospitals, clinics and invest in infrastructure is raised by Health Properties Ltd, a separate business.

This basically says that Circle do not own their hospitals! Bear this in mind whenever you hear Ali Parsa speak about his hospitals. He always implies that Circle (registered company number 5042771) have built hospitals, but they haven't, Health Properties Management Ltd (registered company number 5811838) have built them. Isn't saying that you are doing one thing when someone else is doing it for you rather dodgy? Health Properties is a separate company to Circle Health. They have different owners (though, interestingly, they have the same CEO, Ali Parsa). This is very dodgy. (It is something that Norman Warner, the former Labour Health Minister can be accused of too: saying one thing and doing something else, as I'll explain in another blog).

Recently the Bureau of Investigative Journalism have taken a good look at Circle and they say that:

49.9% of Circle’s shares held in the British Virgin Islands, and the remaining 50.1% in Jersey, although Circle says the Jersey arm “has recently been re-domiciled as a UK tax resident company”.

This is even more dodgy. Remember that Circle want to take over as many as 30 NHS hospitals and make a profit from their NHS work. Rather than investing the surplus back into the hospitals (as is the case with Foundation Trusts and social enterprises) Circle will take these profits and give them to shareholders as dividends. If they gave them as taxable dividends, that would be bad enough. But squirrelling away these profits into tax havens is far worse! If the government give NHS money to Circle they are condoning tax avoidance while starving NHS facilities of this re-investment cash.

Where is the social purpose of putting profits into a tax haven and avoiding paying tax?

BIJ also say:

Health Properties (Bath), a company on whose board Lehman Brothers have 50 per cent representation. ... Health Properties (Bath), the[ir] hospital’s landlord, is also part-owned by the Jersey arm of Circle and by Health Estates Fund.

If you are interested here is a link to the company information in Jersey for Health Properties Limited (company number 91705, registered 11 Nov 2005), Here's a link to more company information about Circle Health (company number 05042771, registered 12 February 2004).

A final interesting bit of information from the BIJ article, is this:

Circle Health Limited’s most recently published set of annual accounts, for the year ending 31 December 2009, show the group made a pre-tax loss of £28.3 million on an income £63 million.

Bear in mind that Circle do not own their hospitals, so they cannot use the excuse that many companies use that their property have lost value. These loses are due to the fact that Circle are simply incompetent at running a hospital. Yet they run two ISTCs where they paid 11% more than the NHS doing 85% of their contract! If an NHS hospital had such poor finances it would be in serious trouble and the Department of Health would now be looking at bringing in private management to replace the NHS management, just like the Department have done at Hinchingbrooke!

Oh Circle are the company who have been chosen to take over the management of Hinchingbrooke!

Circle make a loss and are brought in to "fix" an NHS hospital that is in debt... Hmm is this why they are called Circle, with the debts going round and round and round?

One Third

The Conservatives have some kind of attraction to the concept of a third. A third, the reciprocal of three. We know that three is a magical number, from the 1996 song from Blind Melon, but we do not know why a third has such a hold on Conservative politics. In this rather lengthy blog I will describe where it came from and how this value has morphed over the last couple of years.

The "third" first appeared in the Conservatives' party conference in 2009. The suggestion was that the Conservatives would remove all the extra administration that had been "introduced" into the NHS since 2003: the A&E targets, 18 week targets etc. Conservatives obsessed with the free market argued that targets were not necessary if you allow the market to close those providers that did not perform. This shows a complete misunderstanding of what the phrase "comprehensive and universal healthcare" means, and should have sounded klaxons in the minds of voters not to allow such people in control of the health service. 

The Conservatives reckoned that this extra administration cost £850m, and so if you removed this performance management then that would be an extra £850m that could be put into healthcare. Of course, it ignored the possibility that if performance managing was removed the NHS could become less productive and so the increase in costs may be more than that £850m. The Conservatives also reckoned that in 2003, NHS administration (ie other than the performance management) cost £750m more than it should, and so the uber efficient Lansley would cut that too. The total - around £1.5bn - would be a third of the estimated annual cost of administration at £4.5bn. This is where the magical third appears. A £4.5bn cost would be slashed to £3bn. All of this was extremely ambitious. But note that these were "efficiency savings": we were pledged that would get just as good a service, and it would simply (and probably, magically) cost less.

This pledge of a third made it's way into the Conservative Draft Manifesto, Chapter One (January 2010) which says:

"Our reforms will devolve decision-making closer to patients, removing the need for expensive layers of bureaucracy to oversee the NHS. As a result, we will be able to cut the cost of NHS administration by a third and transfer resources that Labour is currently wasting on bureaucracy to support doctors and nurses on the frontline."

The Draft Manifesto was a damp squib, and the Conservatives actually suffered a dip in the opinion polls when it was published. Consequently, "Chapter One" on Lansley's NHS policy was not followed by any other chapters. However, most of the policies survived, and the Conservatives 2010 election manifesto said:

"NHS staff will be properly accountable to patients for their performance, removing the need for expensive layers of bureaucracy to oversee the NHS. As a result, we will be able to cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the frontline."

There is that figure of one third again. Note what this is saying.  If administration at that point in time was, say, £3.9bn (and everything else in the NHS cost roughly £96bn) the implication is that after Lansley has made staff "properly accountable to patients" it would mean that administration would cost 67% of £3.9bn (or £2.6bn) and the "everything else in the NHS" would get that additional £1.3bn. This is illustrated here, where the grey box on the left and right is the cost of admin (£3.9bn and 2.6bn respectively, using these example figures) and the box in the middle illustrates the one third (£1.3bn) that is removed and "transferred to the frontline".

The implication is that everything else in the NHS would get more money. This is a typical politician's trick, you can never trust the term "re-invest". Right now we are seeing the effects of attempting to cut administration by one third, but are we seeing more, better quality healthcare? No, we are actually seeing cuts in healthcare where people are being denied treatments. Everything has been cut, not just admin.

The "properly accountable to patients for their performance" part is a bit of fantasy from the Tories. Basically their beef was with the NHS performance targets (things like the 4 hour A&E, or the 18 week referral to treatment targets; things that matter to patients but really piss off hospital managers). The Tories reckoned that if they replaced performance targets with the prospect of a public instigated tar and feathering* of hospital managers, the managers would make sure that they performed to avoid the aforementioned tarring and feathering*.

[* no, I don't mean real tarring and feathering, but the managerial equivalent: bankruptcy forced upon the hospital by the market through patients going to other hospitals.]

As yet we have heard very little about this "properly accountable to patients" aspect. In fact, the government seems to have forgotten about it entirely. The Conservative pre-election policy documents talked about detailed league tables of individual consultants, and even talked about hospitals taking out advertising in the local press to publish their performance figures. Very little of this has happened. Part of the reason is that the public does not like the idea of hospital bankruptcy. Patients do not like the faff of checking performance figures or choosing to go to another hospital to "punish" those hospitals with lower performance. Basically, the public do not like market forces in healthcare. This rather kills the whole idea of "properly accountable to patients" making sure that hospitals perform, and hence if the government cuts performance administration (which they are, by abolishing SHAs) the result will be under-performing hospitals rather than better performing hospitals.

Once in power Lansley put this policy into force. The Operating Framework is the NHS rule book for the coming year, and the Revised Operating Framework for 2010/11 (the first of the Lansley regime, published before the NHS White Paper was published) says:

"The overall ceiling for Management Costs in PCTs and SHAs will now be set at two thirds of the 2008/09 Management Costs (£1,509 million), the ceiling will therefore be £1,006 million" (23, p10)

This is the only mention of the magical one third in the Operating Framework. It does not say administration will be cut by one third, it says that management costs will be cut by one third (from £1.5bn to £1bn).  But hold on a minute! This says there will be a cut from £1.5bn to £1bn, it does not say a cut from £4.5bn to £3bn, the figure that was promised at the Conservative conference. What has happened to the rest of the money?

Well, once the Tories got into power they suddenly realised that the £4.5bn included £3bn worth of stuff that they had no direct control over. That £3bn was "administration" in hospitals. Lansley has said that by April 2014 all hospitals will be Foundation Trusts, and Foundation Trusts can spend their money on whatever they like. If an FT decided to increase the number of administrators it has, it can do this and there will be nothing that Lansley can do about it. The Operating Framework only talked about the administration that the Department of Health had direct control over: the Department itself, so-called Arms Length Bodies (regulators and bodies that monitor health), PCTs and SHAs.

In June 2010 Lansley announced:

"Management costs now stand at £1.85bn and it's our intention that during 2010/11 we will remove all the management costs that have been additionally incurred during 2009/10, to get back to the level of 2008/09. Then in subsequent years, we will go beyond that, with a further £350m reduction in 2011/12."

These cuts represented a total cut of £850m or 46% of the total, although it was unclear how SHAs and PCTs could withstand such a large cut. The answer, of course, is that they cannot. The NHS White Paper, published a month after the Operating Framework, announced the abolition of these bodies. If the bodies don't exist, their costs don't exist either, right?

The NHS White paper says:

"Over the next four years we will reduce the NHS’s management costs by more than 45%." (5.3, p43)

So whatever "good" management that SHAs and PCTs were doing (and, curiously, Lansley implies the stuff that they were doing in 2008/09 was worth paying for) would be done by someone else for 55% of the money. The third has been transformed into "45% management costs". This is reflected in the Initial Equality Impact Assessment document that accompanies the White Paper says:

"By streamlining and simplifying the infrastructure, administrative costs will be reduced by more than 45% freeing up resources to reinvest in front-line services." (5.32, p14)

This effectively says that the only way that the one third in savings can be achieved is by abolishing PCTs and SHAs altogether. These bodies will be abolished, so the cost will be cut, but there is no evidence that the work that these bodies carried out can be done for 45% less.

The Analytical strategy document (another document accompanying the NHS White paper) says:

"There are also costs associated with changing the system around loss of productivity within the transition period, and potentially relocation of staff. These short-term costs will be accompanied by reductions in bureaucracy spend in the longer term, with the aim being an overall cut by at least a third in real terms." (21, p5)

This warns that cutting management would have costs associated with it, but it is still optimistic that the third will be achieved.

Two months after the NHS White Paper was published we had the Osborne spending review that outlined the money that the government would spend over the next five years. The Spending Review (October 2010) document has this general statement:

"the administrative budgets of central Whitehall and its Arms Length Bodies (ALBs) will be reduced by 34 per cent over the Spending Review period, saving £5.9 billion a year by 2014-15 so that resources can be focused on frontline services" (1.99, p38)

The magical third appears again, this time it will be applied to all administration across all government departments.

The Operating Framework 2011/12 covers the first full year of Lansley's regime. It says

"By 2014/15 the overall running costs of the new NHS superstructure, compared to the running costs of the current NHS superstructure, will decrease by one third. This decrease includes the over 45 per cent reduction in management costs detailed in Equity and excellence: Liberating the NHS, in relation to SHA and PCT non provider management costs." (5.14, p49)

This includes both the magical third and the 45% cut in management costs.

In January2011 the Health and Social Care Bill was published. The Impact Assessments document that accompanied the Health Bill alludes to the spending review when it says:

"The Comprehensive Spending Review set the admin baseline for 2011/12 onwards for the Department of Health, SHAs, PCTs (excluding provider arms) and Arms Length Bodies which is 33% lower in real terms (27% in cash or nominal terms) than 2010/11 baselines." (A45, p14)

Interestingly, this says the cut is 33% in real terms which is a 27% cut in cash terms. Note also that this statement excludes the administration in PCT provider arms. The reason was that from April 2011 PCTs no longer have provider arms (these are things like community hospitals, some GP practices and community health services), these services were mostly moved to Foundation Trusts which (as I have explained above) are completely out of the control of Lansley. Since the admin in these organisations cannot be cut, it means deeper cuts elsewhere.

The Impact Assessments document says that administration costs of SHAs and PCTs was £3.941bn in 2009/10 and so given that there is a pledge to reduce this by a third by 2014/15 this means that administration in that year (in real terms, 2009/10 prices) will be £2.627bn. So administration would cost £1.314bn less. Clearly this is a cut (the Department provides less money but demands the same work) but it is always quoted as a "saving". The document does not say how this money will be saved, it merely says that if the target is achieved then administration will cost £1.3bn less every year. Thus, in the figure above, the grey box on the left is £3.9bn, the grey box on the right is £2.6bn and the box in the centre is £1.3bn.


The government often says that the "reforms" will save £1.3bn a year. The Impact Assessments makes it very clear that this "saving" is a result of the pledge to cut administration by one third, it does not say how this "saving" will be made, it just says that it has to be made. A saving implies that you can get the same outcome for less money, yet we have no evidence to show that the outcome (effective commissioning) will be the same. Thus since this is merely a reduction in the money paid to commissioners, it is a cut not a "saving". The other thing to be wary about, is that this £1.3bn "saving" is quoted as if the Department of Health will be able to hand a cheque with £1.3bn back to the Treasury and this will buy some more healthcare (illustrated above, where the third in grey becomes part of the white box that represents resources for healthcare). This is not the case. The Department will merely be given less money, there will be no transfer to frontline care.

One final point to make, and it is rather interesting point, is that this pledge to cut management costs originates from Lansley. The last government commissioned the McKinsey report to recommend ways to improve efficiency in the NHS. This report said that there could be "£13 to £20bn efficiency savings, over the next 3 to 5 years" which became "£15 to £20bn efficiency savings by the end of 2013/14" under the last government and "£20bn efficiency savings by the end of 2014/15" under this government (do you see what they did there?). Nowhere at all does the The McKinsey report say that money could be saved in management. £1.3bn of savings is huge (6.5% of the "£20bn efficiency savings"), yet this is not mentioned at all in the McKinsey report.

This makes you wonder one of two things: an either/or case. First, are McKinsey incompetent; if they did not notice such a huge saving, can they be trusted on anything in their report? Or, second, if McKinsey can be trusted, then this means that administration cannot be cut by one third and so it is not possible to "save" £1.3bn a year.

The message you should take from this is that PCTs and SHAs will be abolished merely because they are the only parts of the NHS over which Lansley has any direct control. He cannot tell hospitals how much they can spend on administration, and so this means he has to make a bigger cut in the parts of the NHS he does control. This is why he has decided to cut management costs in commissioning by 45% and why he has decided to abolish PCTs and SHAs.

Social Care and the Lib Dems

The Health and Social Care Bill addresses social care on every page: because it is in the title that is on every page. The Bill does not address the huge issues in social care at the moment, it does not address the forthcoming crisis in social care.

The Liberal Democrat manifesto says this:

We will Integrate health and social care to create a seamless service, ending bureaucratic barriers and saving money to allow people to stay in their homes for longer rather than going into hospital or longterm residential care. 

Cue applause from yours truly.

Has the Health and Social Care Bill done this? No, not at all. It was never the intention of the bill. (The intention of the Bill has always been to create a healthcare market.) The House of Commons Library produced a research paper that accompanied the Bill (RP11-01) and in the summary it says:

Although the Bill deals primarily with health services, its title refers to social care because a number of measures would apply to bodies with joint functions and responsibilities; the Government intends to introduce legislation on social care reform later in the Parliament.

This says that the Bill is not about social care because there will be a social care bill later in the Parliament. It is essentially saying that the only place that social care has in the Bill is in the title. 

We hear that the great achievement of Paul Burstow, the Lib Dem Minister of State, was to get integration of social care with health into the Bill. Yet he has failed abysmally to do this.

It reminds me of the Spitting Image sketch where there was a discussion between David Steel, the leader of the Liberal Party, and David Owen, the leader of the Social Democratic Party, over the name of the party once they had merged. (From memory, anyone have a link online to the sketch?):

David Steel: what shall we call our new party?
David Owen: well, I thought we would take something from your party name, and something from our party name
David Steel: oh like the "Social Liberal Party", the Social from your party's name and Liberal from our party's name?
David Owen: Yes, something like that. But I thought that we would take the "Social Democrat" from our party's name.
David Steel: and from our party's name?
David Owen: I thought we would take "Party"

This sums up exactly how much influence the the Lib Dems have had in getting integration of social care in the Health and Social Care Bill: they merely got it in the Bill's name.

Competition

So now we know that Nick Clegg does not want Monitor to promote competiton:

"There must be no change in the way competition law operates in our NHS. No to establishing Monitor as an economic regulator as if health care was just like electricity or the telephone and no to giving anyone in the NHS a duty to promote competition above all else."

That is nice to know. I wonder why, if Nick Cleggis so much against competition, he did not notice that competition was one of the principle parts of the Bill?

We also know that Lansley (fingers crossed behind his back) says:

modernising the NHS is "about competition as a means to an end, not an end in itself"

and

the economic regulator should promote competition "where appropriate" and use regulation "where necessary"

Lansley's behaviour does not sound very liberating. So let's have a look at when the White Paper says.

GP consortia will need to have sufficient freedoms to use resources in ways that achieve the best and most cost-efficient outcomes for patients. Monitor and the NHS Commissioning Board will ensure that commissioning decisions are fair and transparent, and will promote competition. (4.6)

The and will promote competition is ominous. It certainly sounds like Monitor will not just regulate competition, or prevent unfair competition, as seems to be the narrative from Lansley at the moment. The section says quite blatantly that Monitor will make sure there is competition.

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

Again, this certainly reads like competition will be forced upon the system, because the section implies that innovation will not be possible without it.

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

Again, we read that Monitor will promote competition, although here the emphasis is on preventing anti-competitive behaviour (ie those providers who refuse to compete).

Monitor should have proactive, “ex ante” powers to protect essential services and help open the NHS social market up to competition, as well as being able to take “ex post” enforcement action reactively. Ex ante powers would enable Monitor, for instance, to protect essential assets; require monopoly providers to grant access to their facilities to third parties (4.28)

This is more concerning. The section specifically says that the intention is to open the NHS social market up to competition, ie to force competition on the NHS. The second highlighted phrase indicates that Monitor will allow private providers to use NHS hospital facilities. (For example, a MRI or CT scanner, Monitor will force NHS hospitals to allow private providers to have access to those facilities paid for out of NHS funds.)

All of this fits in with what Oliver Letwin said before the election:

"We will implement a very systematic and powerful change agenda where hospitals compete for patients, schools compete for pupils, welfare providers compete for results in getting people out of welfare and into work."

That certainly sounds like competition for competition's sake.

Creative accounting with public money

NHS budgets come in three parts:

• Department’s fixed resource budgets (Resource DEL)
• Department’s fixed capital Budget’s (Capital DEL) 
• Annually Managed Expenditure (AME) 

The Treasury say that Resource Departmental Expenditure Limit (DEL) is the basic expenditure, mostly on pay, but (for the NHS) it also includes things like the drug bill. Spending that cannot reasonably be subject to firm limits, or that relates to certain non-cash transactions, is called the AME. The Capital DEL includes the acquisition of assets such as land, buildings and machinery and capital grants.


For comparison, here are the figures for 2010/2011 for NHS England

Resource DEL £98.7bn
Capital DEL £5.1bn
Resource AME £-2.0bn

The Spending Review gives the following figures for Capital DEL. The government decided to transfer part of the Capital DEL to local authorities to pay for social care (PSS - Personal Social Services grant).

	2010/11	2011/12	2012/13	2013/14	2014/15
Capital DEL	£5.1bn	£4.4bn	£4.4bn	£4.4bn	£4.6bn
Transfer to PSS	£0.0bn	£0.8bn	£0.0bn	£1.1bn	£1.0bn

So what is Capital DEL spent on? Well the best evidence I can find (I haven't searched far) is NHS Budgetary Information for 2006/07 and this suggests (Table 3.4) that the majority of the DEL is spent on hospitals and PCTs. This makes sense because hospitals have large capital projects like hospital buildings and expensive equipment like MRI and CT scanners; and PCTs also fund capital projects like community hospitals and clinics.

In July last year Andrew Lansley announced that FTs would no longer have access to public sector capital. The intention was to take FTs entirely off the public sector balance sheet. Lansley told FTs that if they need capital then they would have to borrow it at commercial rates from commercial lenders. So FTs do not have access to the NHS Capital DEL. Significantly, all hospitals have to be Foundation Trusts by April 2014. The Health Bill will abolish PCTs in April 2013, and since PCTs will not exist, PCTs will not use the Capital DEL after April 2013.

This produces an odd situation. There will be £3.6bn of NHS Capital DEL in 2014/15 (£4.6bn - £1.0bn to take into account the transfer to PSS) yet there will be nothing to spend it on.

Why did Osborne allocate money for a budget that will not be spent? Perhaps there is a clue in the fact that it will not be spent. The last government, in the Darling Budget of March 2010, said that they would reduce capital spending by one half by 2014/15, so under the last government the NHS Capital DEL would be £2.25bn in 2014/15 (compared to £4.5bn Darling budgeted for in 2010/11). Labour actually intended to spend this money. However, it looks mean compared to the £4.6bn that Osborne allocated in his 2010 Spending Review. Osborne actually only intended to spend £1.0bn of that money (the PSS transfer), but that would look mean compared to Labour's £2.25bn.

When it comes to who would cut more, it is important for Cameron to be seen to be spending more on the NHS than Labour would. The phantom Capital DEL makes Cameron look generous because it looks like he would be spending more than twice than Labour, when in actual fact the Conservative government will be spending less than a half. Creative accounting with public money.

Observation on NHS satisfaction survey

Every six months the Department of Health commissions Ipsos MORI to conduct a survey on the public perception of the NHS. The latest survey is from December 2010. This was at the end of the public consultation period of the White Paper and before the Bill was published. It was clear to those who followed health policy that there was a lot of opposition to details in the White Paper, but since the Bill had not been published it was not clear whether the Government would take such opposition into account (they didn't).

The survey summary starts by saying:

Public satisfaction with the NHS remains high (70%) but is drifting downwards. Most of the fall is due to non-users becoming more critical – perhaps in response to media coverage, as they have no direct recent experience. In contrast, users of the service remain very positive (73% satisfaction rating versus 61% of non-users).

The media attention is important. Cameron and Lansley knew that public satisfaction with the NHS was high and consequently it would be difficult to persuade the public that changes must be made. The result was a long stream of press releases telling the public how "bad" the NHS is. People who use the NHS knew from their own experience that this was not the case, but such press releases did have an effect on the people who do not use the NHS. In particular, I suspect those that use the NHS are grateful for an effective service, but those who do not use it resent paying for it, particularly as we go into a period of austerity with the relentless (and untrue) message from the Government that the NHS is "protected" whereas other areas of government spending is not.

Private Healthcare Touts For Business

My local freebee newspaper has this advert for a local private hospital:

It says:

"with increasing NHS cutbacks and fewer operations being available, if you are struggling to get the treatment you need and you don't have private insurance, another option is to go private and pay for treatment yourself".

Remember "I'll cut the deficit; not the NHS"? BMI didn't get that message.

Here is the price list they give, compared to the national tariff (the payment NHS hospitals receive).

Procedure	BMI Price	NHS National Tariff	Notes
Cataract	£1,900	£741	Phacoemulsification cataract extraction and lens implant
Hip Replacement	£8,500	£5,522	Major, non-trauma, category 2, without CC
Varicose Veins Unilateral	£2,200	£1,098	Primary Unilateral Varicose Vein without CC
Inguinal Hernia	£1,900	£1,205	Inguinal Umbilical or Femoral Hernia Repairs 19 years and over without CC

It is interesting that one of the local PCTs (NHS Warwickshire) has been operating a Stop-Slow-Go policy since last October. The items on this price list are either on the Stop list (varicose veins) or on the Slow list.

Lansley's Fantasy Figures

Over the weekend some people tweeted an article from Fraser Nelson of the Spectator about some bizarre figures that Lansley had published via a press release. Unfortunately the press release is not available online, so I have had to try and piece things together. Nelson gives part of the PR:

Lansley: Ed Miliband and Ed Balls would cut our NHS by almost £30 billion
New analysis of Labour’s NHS spending plans shows that Labour would have cut the NHS by £28 billion over the current Parliament. This is a cut of over £520 for every man, woman and child in the country.

This is a bit bizarre because as I have proven elsewhere Labour had planned to fund the NHS more or less the same as Osborne. That is, the Darling budget of 2010 pledged that the NHS funding for 2011/12 and 2012/13 would rise with inflation, which is what Osborne has promised. In addition, Labour said that there would have to be £15-20bn "efficiency savings" over four years and Lansley has said there will be £20bn "efficiency savings" over five years, so at best Labour would expect slightly less "efficiency savings" at £3.75bn per year than the Conservatives at £4bn per year. So the Tory claim that Labour would cut the NHS is a big fat lie.

So where does Lansley get this bizarre £28bn (rounded up to £30bn in the title, woohoo it must be great to have the power to round up by £2bn!) from? I spent some of yesterday and this morning trying to either get hold of the Press Release (no luck) or find out what the figure was calculated from. I struck lucky when a persistent Tory Troll on Twitter was making incoherent statements about NHS management (he calls the Health and Social Care Bill "a fantastic piece of legislation" so you can imagine that I don't pull my punches when I tweet with him). I asked him if he knew where the £28bn came from. He replied that it's "based upon Labour's actions in Wales".

OK, so here are the figures. In 2009/10 the Welsh NHS budget was £5.2bn and it cut £430m (note that in Labour Wales this is called a cut, in Tory England there has to be £4bn "efficiency savings"). The Welsh Labour administration say that they have to cut/save £435m per year for each of the next three years. That is, 8% cuts/savings. This is contrast to the 4% savings/cuts that the NHS has to bear in England (although Monitor says that hospitals have to endure at least 6.5% savings/cuts).

So this is what Lansley has done. He says that because Labour in Wales are making 8% cuts to the NHS, if Labour were in power now in the UK it would be making 8% cuts to the NHS in England. Errr, no, Labour would be implementing the £15bn-20bn "efficiency savings" just like Lansley is. I am not quite sure how Lansley gets £28bn from an 8% cut each year for four years, but frankly I do not care because it is totally made up. It is thoroughly dishonest for Lansley to extrapolate the Welsh NHS budget to England. The two systems are very different (Wales have free prescriptions, for a start!) and England already has its own cuts/savings programme.

So, on Wednesday, during PMQs, what are the bets that Cameron will raise this made up figure of £28bn? And more to the point, what are the bets that Labour will look clueless at Cameron and be unable to understand what he's talking about or how to respond?

UPDATE:
It appears that the Guardian have already analysed the Lansley figures and it appears that my Tory Troll was not correct. However, the Lansley figures are still dodgy.

What Lansley has done is taken Darling's settlement for the NHS and then extrapolated in a dishonest way. Here is what Darling said last year in his final budget:

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;

Lansley has produced a table assuming that Darling would increase funding in line with inflation right up to 2014/15. I have no issue with that. However, note that Darling said that 95% would be "protected" this way, what would happen to the other 5% (non-frontline, presumably administration and management)? Lansley assumes it would disappear! Yes, because Darling did not say how he would fund non-frontline spending, Lansley assumed that he wouldn't fund it at all. So there is a 5% cut every year for 4 years. Dishonest or what?

Here is the table from the Guardian website and note that the total is the 95% figure added to the Capital DEL discounting the other 5% completely.

Lansley also says that Labour pledged to half capital funding by 2014/15, but Osborne would maintain it (well, not quite). You can see the fall in Capital DEL in the table above. So this accounts for a total of £6bn less under Labour by 2014/15 than Osborne's settlement (but there is a catch).

But it does not stop there. One of Osborne's tricks was double counting. In the spending review he awarded a "real terms increase" to the NHS and then took roughly a billion away every year from the settlement to pay for social care (normally social care is paid for through the local authority budget). Guess which figure Lansley uses to show the "greater funding" by the Tories? Before, or after the £1bn has been taken off? Yup, before, so Lansley's figures are roughly £1bn per year more than they should be. This transfer of money from the NHS capital budget to social care amounts to £4bn cumulative by 2014. So rather than Labour's capital budget receiving £6bn less over the five years, it would receive £2bn less.

So in summary Lansley's figures are wrong in two aspects. First they do not include the transfer from the NHS capital budget to social care so this knocks £4bn off the extra £6bn that Osborne's capital budget would have over Darling's (assuming Darling would have halved the capital budget). So that means that Osborne would have given £2bn more in the capital settlement. The other place where Lansley is wrong is that he assumes that Labour would reduce spending by 5% every year for no reason whatsoever. We do not know how Darling would have funded the 5% non-protected budget, but he would not have cut it completely. If we assume a rise with inflation for the 5% then the total difference between Darling and Osborne would have been £3.7bn to Osborne's favour (total over 5 years). So not a £28bn difference but a £3.7bn difference. yet another Tory Lie!

Can we trust Clegg on the NHS?

Imagine it, a 20's Billy Bunter type public school.

The school matron has decided that, for their own good, every pupil has to have a large dose of cod liver oil. She approaches the headmaster and asks his approval, in loco parentis. He is not interested and blithely grants his approval. He has far more important things to do. He winds up the gramophone, puts on a disc of Puccini and informs the school secretary that he is reading poetry before firmly closing his study door.

The matron is efficient. She lines up all the pupils in the school yard and quickly moves from one to another giving each one a tablespoon of the foul tasting oil. As each one is given the spoonful they retch noisily, and this agitates the other pupils waiting. As the matron progresses the opposition grows, not only from those waiting, but also from those who have had their spoonful who are keen that others are not inflicted. The matron knows that she must get to everyone in as short a time as possible.

The opposition reaches a crescendo when nine tenths of the pupils have had their medicine. But the noise of the retching was loud and it caught the attention of the headmaster; and then one boy knocked on his study door - something no one does when the headmaster is reading poetry - and pleaded for clemency for those who have not yet had the oil.

Swiftly, the headmaster trotted down to the school yard and ordered that the process must stop. Using his famed wisdom of Solomon he said that only those who want to have the medicine should have it. There is one tenth of the school yet to have the cod liver oil, and one tenth decide that they do not want it. The school matron stomps off to her room in a suppressed rage.

It's hardly a solution is it? While one tenth is not inflicted, the other nine tenths have been and are still retching from the foul oil. The matron has had her way with nine tenths of the school and although she is a stickler for getting a job done, she can feel that she almost completed this one.

This is what we have got with GP commissioning, only far worse. GPs were effectively bullied into becoming "Pathfinders" because they were told that in April 2013 no GP could practice in the NHS if they were not part of a consortium and that any debts run up by PCTs from April 2011 would be inherited by the consortia covered by that PCT. GPs knew that if they wanted to start commissioning with a healthy balance sheet they would have to start commissioning early. Other GPs have seen their local PCT disintegrate, as Lansley's diktat to shed staff and the demoralisation of being part of a doomed organisation sinks in, and GPs, as responsible clinicians, felt they had no option other than to do commissioning to ensure that vital services are maintained.

Furthermore, there is evidence from Pulse that the applications for Pathfinder status have not been a result of the enthusiasm of GPs, rather, they have been reluctantly and apathetically pushed into the process. At this point 88% of the population is covered by Pathfinder consortia, Lansley and Cameron say that this is a "success".

Now Clegg (who gave his approval to the Health and Social Care Bill without understanding the implications, and like the headmaster in our story, moved onto something that interested him) says that "'alternative arrangements' would be made if GP practices were not ready by April 2013". In other words, he is signalling one of two things. The first interpretation is that he is saying that the deadline will be extended, but eventually every GP must take part in commissioning. (So the remaining one tenth of the Greyfriars-like public school will still have to have their cod liver oil, they will just have to wait until tomorrow.) The other possibility is that Clegg is saying that those GPs who do not want to take part in commissioning will not have to (they will not have to take their cod liver oil) and a PCT-like organisation will do it instead. Of course, Clegg is not saying what will happen to those who have been forced to become Pathfinders, can they renege on their original application? Will GP commissioning be changed to make it more palatable? (Will the headmaster give all pupils a jam doughnut to make up for what has happened to them?)

This really does not solve anything. If we have one tenth with PCT commissionign and nine tenths GP commissioning then we will have a two tier NHS, the very criticism that Lansley has used to justify making GP commissioning compulsory. The last time the Tories tried this idea, with the optional GP fundholding half of GPs chose not to take part. If one tenth are allowed to delay their involvement in GP commissioning it merely means that Lansley's unpopular plan will still be implemented. And what about those that have been bullied into signing up early, who now feel that they would prefer the extra delay, or the choice not to take part at all? Will they be allowed to withdraw their application? No.

Yet again, Clegg shows that he is implementing Tory policies. Clegg the human shield fails to deliver yet again.

LibDems get tough

Is it possible for the LibDems to get tough?

The Sunday Express (yeah, stop laughing, but honestly there is nothing in the article about Princess Diana) reports that Simon Hughes saying that the LibDems are now going to get tough with the Tories and insist only on policies mentioned in the Coalition Agreement. (For politicians who are supposed to be experts at coalitions - it is, after all, their only chance of power - they do seem to have made a complete mess of keeping the Tories to the Coalition Agreement, but I digress...)

The Express reports that Hughes is upset that the No2AV campaign fought a

"fundamentally fallacious campaign" which would affect the way the coalition partners behaved in Government.

"The effect on the coalition is it will reduce trust in the Tory party among our members and amongst colleagues. The coalition is a five-year deal. That won't change, because that is in the national interest. We did a deal and we will keep to that deal. But it will mean, from now on, we are very clear that we will keep to what the coalition has agreed in the Coalition Agreement - that other stuff will not be allowed in as policy unless our party has agreed to it, and I guess that the same will apply for the Tory party."

GP online are rather optimistic about this, saying

Much of the Health Bill could now be rejected by Liberal Democrat MPs, including the plans to abolish PCTs and SHAs.  The Coalition Agreement, released in May last year, did however moot plans for GP commissioning and the development of Monitor to oversee ‘competition and price-setting in the NHS’. It also said an ‘independent NHS Board’ will be created to allocate resources and provide commissioning guidelines.

Such a pick and mix approach to the Health Bill will be completely bonkers: you simply cannot pick which parts you want and drop the rest. However, if the LibDems do get tought, and do stick to the word of the Coalition Agreement it should affectively kill the Health and Social Care Bill because the types of amendments it would suggest would be too wide scale for the Bill to be workable.

Coalition Agreement

It is interesting to see what the Coalition Agreement says, so here are the important points:

1. Real terms increase in health spending
2. Stop top-down re-organisations of the NHS.
3. Significantly cut the number of health quangos. 
4. Stop centrally dictated closures of A&E and maternity wards
5. Enable GPs to commission care.
6. Directly elected boards to PCTs, PCTs to "champion patients" and do the commissioning not done by GPs. PCTs will be responsible for public health.
7. Right to a choice of GP.
8. 24/7 urgent care service
9. Develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS. 
10. Create NHS Board to allocate resources and provide commissioning guidelines
11. "reform" NICE and move to value based pricing
12. Allow patients to choose any healthcare provider that meets NHS standards, within NHS prices (independent, voluntary and community sector providers) 
13. Cut the cost of NHS administration by one third. Various stuff about "reducing duplication and administration". 

What is in the Bill?

So what has been delivered? "Real terms increases" is specious. There are still Tories who will argue until the cows come home that Osborne gave the NHS a generous settlement, and there are even some Tories who believe in the virtual money that will be created as "efficiency savings" (here's the clue, the money will not be there, the efficiencies have to be made to make up for the lack of funding, in any other government department such changes in funding would be called cuts).

The number of health quangos has been cut (this is also a LibDem manifesto pledge) and the health bill does give patients the right to choose a GP (even if it is a daft idea), another LibDem manifesto pledge. The 24/7 urgent care service is the 111 service and is a consequence of allowing patients to register with any GP (otherwise, how do you get home visits if your GP is in another part of the country?). NICE has been neutered (the Daily Mail will be happy) and VBP will be implemented. Although Lansley has pledged to stop the central closure of A&E and Maternity units, in practice he has gone ahead and closed some (for example, Maidstone's maternity unit), so it is debatable whether he can be said to have implemented that part of the agreement.

A substantial part of the Health Bill is about changing the role of Monitor and its role in promoting competition. This part of the Bill has upset a lot of LibDems because they do not like the idea of competition being forced upon hospitals (particularly the cherry-picking of services). They should have made their concerns more explicit during the Coalition Agreement negotiations, because points 9 and 12 certainly indicate that competition will be king. Indeed, the policy of patients being allowed to "choose any healthcare provider" was named Any Willing Provider in the white paper and is now called Any Qualified Provider, and will still go ahead.

Commissioning

That then leaves commissioning. The Coalition Agreement does not describe the type of commissioning that is introduced in the Bill. The version in the coalition agreement is:

We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf. 

This is very different to handing over £60bn of NHS funds to GP consortia and telling them to go ahead and do it. Indeed, the implication of the agreement pledge is that GPs will have only some commissioning responsibilities and only in the context of a patients' expert guide. The white paper makes it perfectly clear that GP commissioning is not about patient care, it is about raw, hard-nosed, cost cutting:

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

Nowt in there about commissioning care as a patient's expert guide.

Further, the Coalition Agreement says that some of the PCTs board should be directly elected (with the remaining members appointed by local authorities and the Secretary of State). Of course, this assumes that PCTs will exist! But the current Bill abolishes them. The level of GP commissioning suggested in the Coalition Agreement would allow a role for PCTs and it specifically says that they will "act as a champion for patients". There is no patients' champion in the Health Bill. Further, the Coalition Agreement says that PCTs will be responsible for public health (as they are now) but the Health Bill has given this to local authorities to the disdain of public health experts.

The agreement also says that PCTs will "commission those residual services that are best undertaken at a wider level, rather than directly by GPs" and presumably this means that they would commission GPs as primary care practitioners. In the Bill, both of these actions (specialist commissioning, and commissioning GPs) will be carried out by the NHS Commissioning Board. So rather than merely producing commissioning guidelines the NHS Commissioning Board will actually perform 40% of all NHS commissioning (twice as much commissioning as is carried out by the Department of Health!) This is a huge change because it centralises a lot of power and does a lot of commissioning (GPs, opticians, dentists etc) that should be commissioned locally.

What Does the Bill Add?

So what does the Health Bill do that is not in the Coalition Agreement? There is no mention in the agreement about abolishing SHAs (this is, however, a LibDem manifesto pledge) and the agreement explicitly says that PCTs should exist and that GP commissioning would be a very different to what has been offered. Significantly, the Coalition Agreement does not say that the Secretary of State for Health will no longer be responsible for the universal and comprehensive healthcare provision in England, yet clause 1 of the Health Bill repeals that responsibility.

But the most important bit is that the Coalition Agreement says

We will stop the top-down reorganisations of the NHS that have got in the way of patient care. 

This is not a throw-away remark. It is meant to be a significant tenet of the new government's health plans, and it is a pledge that has been completely, and utterly ignored.

Conclusion

If the LibDems get their way, and only the NHS policies mentioned in the Coalition Agreement will be implemented, the Bill will effectively be killed. The changes to the Bill will be to substantial and the type of commissioning (and the LibDem approach to competition) is very different to that proposed in the Bill.

If the LibDems stick to the spirit of the agreement, then the Pathfinder consortia will have to be re-configured, not least because they will have to work with the directly elected PCTs and thus the GP consortia will have to be aligned to PCT boundaries.

So will the LibDems act tough? Let's hope so, because the very existence of the NHS is depending on this Bill being killed.

GP Commissioning

Anyone got an idea what it is about?

If commissioning is about the purchaser/provider split, where the people who USE healthcare are separate from the people who PROVIDE the healthcare, how does that fit in with GP commissioning?

GPs provide something like half of NHS healthcare contacts (NHS daily contacts: 51% with GPs; 24% with total community care; 7% outpatient attendances; 6% in bed emergency; 3% A&E emergency; 2% in bed elective).

So who is buying healthcare, and who is providing it?

Phantom Listening Events

After my post about Lansley's phantom listening events, Joe Farrington-Douglas (@joefd on Twitter) points me to the following Commons order paper where John Healey asks for a written reply to the following questions:

101 To ask the Secretary of State for Health, pursuant to the oral Answer to the right hon. Member for Bermondsey and Old Southwark of 26 April 2011, Official Report, columns 3-4, on NHS reform, how many of the 119 events organised centrally had been organised prior to the announcement of the NHS Future Forum. (54868)

102 To ask the Secretary of State for Health, pursuant to the oral Answer to the right hon. Member for Bermondsey and Old Southwark of 26 April 2011, Official Report, columns 3-4, on NHS reform, what the (a) date, (b) location and (c) attendance list was of each of the 119 events. (54869)

Question 101 is important because it ensures that Lansley isn't just re-badging normal, scheduled staff meetings as "listening events". If they are to be serious events they have to be separate and scheduled as such. Question 102 is important because we will be able to see who are being listened to and how easy it is for them to get to the event. If events are scheduled in a way that people cannot attend then they cannot be regarded as true listening events. For example, have a look at this tweet from Richard Caulfield (Voluntary Sector North West):

If you are keen to get as many people as possible to comment, then you must make sure that you don't put obstacles in their way, like scheduling the meeting at a time that would involve a peak time rail ticket, or an overnight stay.

To AV or Not to AV?

Don't care either way. Here's why.

No2AV

On the anti side we hear that:

1. It will produce more coalitions. No, see below. AV is not proportional and studies have shown that it is more likely to reinforce a result (give the winning party more seats if they are popular, give them fewer seats if the result is more marginal) than dilute it. The studies show that the only coalition under AV in the last 20 years would have been in 2010, and get what FPTP delivered?
2. It is only used by three other countries in the world. Spurious. We are the only country in the world to have a House of Lords, are they suggesting that we get rid of that? No, in the case of the Lords, they say it makes us "unique", so why can't we be unique in other ways? Are the No2AV campaign suggesting that we have to be blandly like everyone else?
3. It allows second or third placed candidates to win. Only if there is a three way race, ie very little between the top three candidates. In this case, under the current system, irrelevant issues like celebrity endorsements or the candidate's sex life will swing the vote. It is much better that the vote is swung by people's preference than by irrelevant issues, or worse, dirty tactics.
4. It will cost £250m. Well, when you employ the guy who ran the Taxpayers Alliance to run the No2AV campaign, you should expect totally made up figures. This is a totally made up figure. It includes the cost of the referendum (£100m) so that is unfair, and it also includes the cost of counting machines that will not be used.
5. It will mean that someone's fifth preference is worth the same as your first. It is unlikely that someone's fifth preference will ever be counted, but if it does get to a fifth round, then there is some truth in this. If you support one of the top two candidates then your first preference will be counted in each round (remember, each round is different, so your vote is counted again) and if it gets to a fifth round then your first preference will be counted along side someone's fifth preference. So what?
6. It will mean that the supporters of the BNP and fringe parties will decide who wins. The argument is that fringe parties will be knocked out first so their preferences will swing the vote. Well here's the clue: fringe candidates (by definition) will be small in number, the winning candidate has to have 50% of the vote, and the only way to get this is to be popular and get as many first preference votes as possible. So it is the first preference votes that really decide. Studies have shown that even second preference votes are unlikely to change a vote: they are more likely to reinforce the first preference majority.

The No2AV campaign go under the banner of "One Person, One Vote". This is still the case under AV because the counting is done in rounds, and in each round you still only get one vote.

Yes2AV

On the pro side we hear that:

1. Make all MPs work hard. How an MP is elected does not affect how hard they work once they get into the House of Commons. This is a spurious argument. But let's just imagine that Yes2AV are right, and MPs will have to keep canvassing you in the time between the elections. Do you really want that, an MP whose only purpose in life is to get elected? Surely you want an MP who will work hard representing you in Parliament. I think (hope) that most MPs agree. The way they are elected will not affect how "hard" they work.
2. Give you a stronger voice. Do I have to repeat this? AV is not proportional. The Yes2AV say that "you will still get a say even if your favourite doesn't win", well yes, but by definition, you do not get the candidate you wanted, the candidate who wins will do so mostly on first preference votes. Only a proportional system will give you more say, and AV is not proportional.
3. Stop MPs "Jobs for life". In a third of constituencies at the last election, the candidate won with 50% of the vote, so AV will have no effect there. Even if AV could stop "jobs for life" (which I doubt) it will not affect one third of MPs.

The Yes2AV campaign says that it is a "fairer voting system". Fair is subjective, of course. It certainly gives you an opportunity to give your preferences, but it will still mean that votes for minority parties have no effect and so are "wasted".

Last year, the British Election Survey found that the proportion of people who gave a minority party their first preference vote was (9%) the same as the the proportion who actually voted for a minority party at last year's General Election. YouGov also found the same result. This shows that AV has no effect in increasing minority party support.

Since 1983 the British Election Survey have conducted a survey at all the General Elections asking the representative group to fill in an AV ballot paper. Academics simulating AV from these surveys show that the Liberal Democrats would have gained very little from AV, only a figure of 20 or 30 seats will be affected. The New Economics Foundation show that using 2010 election results, under AV no candidate would have "won" from third place and a mere 41 would have "won" from second place, so that's one No2AV myth busted. They also found that for the last seven elections the result (in terms of the winning party) would have been the same. The 1997 election would have produced marginally more Labour MPs and all others the winning party would still have won, outright, but with fewer seats. Other studies even suggest AV would have increased the majority of the winning party. The studies agree that AV would not have delivered a coalition in six out of the seven elections. The 2010 election result would have been the same: a hung parliament. The results from the British Election Survey shows that second preference votes would not swing many seats in an election and so the Yes2AV claim that it would make MPs "work harder" or stop "jobs for life" are not based on evidence.

Undoubtedly, giving people more preferences, even if they have little effect, is a good thing. It is a good thing because in a few cases they may have an effect. So AV is only a minor change in the electoral system. Both No2AV and Yes2AV are making a mountain out of a mole hill.

However, I am really angry about the referendum. It is reputed to cost £100m and the polls suggest that the country will vote against it. Hence we will have wasted £100m on keeping the status quo. Even if the Yes vote succeeds we will have wasted £100m on a minor change to the electoral system that will deliver the same government at elections as FPTP. Let's put £100m in context. It is half the annual funding of Cameron's Cancer Drug Fund. It is about the same amount of money (£95m) that Hull and East Yorkshire Hospitals NHS Trust has to save by 2015. £100m is a large amount of money. Regardless of the No2AV claims, wouldn't you have preferred that money to have been spent on something we need rather than a referendum that will be unpopular and maintains the status quo?

I am especially angry with Nick Clegg who should have demanded AV as part of the Coalition Agreement and if he asked for a referendum it should have been on proportional representation (ie, something that would make a difference and about which there are passionate divergent opinions). Nick Clegg was in a position where he could have demanded the moon on a stick, yet he agreed on a referendum on something he described as a "miserable compromise". That is pathetic.

So today I will vote this way:

Coulson and the NHS

Many people complain that the Tories did not tell us during the election that they were planning to tear the NHS apart if they were elected. In fact the Tories did tell us, but very quietly. Basically most of the stuff in the Health and Social Care Bill was in the Tory manifesto, their draft manifesto or the Tories' NHS Autonomy and Accountability policy document (abolishing PCTs and SHAs are the only parts that were not part of their published policy). The issue is that the Tories did not talk about these policies during the election because they knew that if the details were discussed the public would not like them.

Interestingly, Nicholas Watt at the Guardian tells us why. In an article about Lansley's possible future Watt says:

If Lansley leaves the cabinet he might be tempted to point out that he was keen to explain his reforms which were included in the Tory manifesto. He was, however, blocked by Andy Coulson who feared unsettling voters on the NHS ahead of the election.

Coulson was a tabloid editor, he knew what the public wanted to hear, and he knew that Lansley talking in detail about his plans would be disastrous for the Tories' election plans. Considering that Cameron could not get a majority at the 2010 election, it is likely that talk of Lansley breaking up the NHS would have lost him seats. Ironically, it would have been the Lib Dems who would have gained, possibly giving them more seats than they have had for a century.

A lost opportunity for the Lib Dems.

Lansley's Phantom Listening Meetings

NHS Future Forum Listening Events

The "pause" was announced on the 4th April, it was announced as a two month pause in some papers (Guardian) and three months in others (Independent). So that means the pause will last until 4th June or the 4th of July.  If we take the "pause" to be the Whitsun Recess then that means it will end on the 2nd June, so that is 19 working days. If we have a "three month pause" then that is 43 working days.
 On the 26 April Lansley said in Parliament that "a total of 119 events have already been organised centrally, and the regional and local NHS will organise many more".

I know of just two public events and a third private event. The first was the launch of the "pause" at Frimley Park (5 April) and the other was at Chelsea and Westminster Hospital (27 April). A third event with the Foundation Trust Network was held in Downing Street (19 April) and can hardly be regarded as a public event. If Lansley has arranged 199 events, then that leaves 116 other events between now, 4th May, and either the 2nd June or 4th July. If we have a "three month pause" then that is 43 working days so that means three events per day for each of the days during the "three month pause".

Surely we should be inundated by reports from these events?


Or maybe the Department of Health (and Lansley) is counting events other than those that can be attended by the public and NHS staff, like, the meetings of the Future Forum themselves? Even assuming they meet every day until the end of May (see below) and you treat the morning and afternoon meetings as two meetings (giving a total of 38), that means there are still 78 other meetings not accounted for. The 119 events clearly contains many phantom meetings.


The Summer Recess starts on the 27 July, so if there is a " three month pause" there will only be 17 days from the end of the "pause" until the House rises. During this time the Bill will have to be re-written (well, they have been doing a lot of listening, right?) and reprinted. The next stage of the Bill is the Report Stage during which the amendments to the Bill will be debated. The Report Stage often takes several days, but in the case of the Health and Social Care Bill Lansley has ensured that there have been few amendments made during the Committee Stage. The LibDems are demanding substantial amendments, but we have yet to see whether Lansley will agree to change the Bill accordingly, So either the Report Stage will be short (Lansley sticks to his guns), or long (he capitulates). The Report Stage is usually followed by the Third Reading with a debate typically on the same day as the last debate of the Report Stage. This will conclude the passage of the Bill in the Commons and it will then be passed to the Lords, where Lord Owen has promised to delay the Bill.


Will there be time for the Bill to actually make the House of Lords before they rise for the Summer Recess on the 28th July?

 On the subject of the Future Forum, according to the Department of Health website:

Following its initial report, which will be submitted by the end of May, the NHS Future Forum will continue to listen and advise on other non-legislative aspects of the modernisation plans, implementation of the changes, and the design of any secondary legislation.

So the Forum will only sit for a month (not the whole "pause" period") and will publish a report (no doubt congratulating Lansley on a wonderful Bill) at the end of May. After that, the Forum will not be concerned at all about the Bill so although they are supposed to be "listening" they won't be able to hear about anything concerning the Bill (so basically, don't bother saying anything to them). That's a bit fishy, don't you think?

The article on the Department of Health linked above, was written on the 13 April, three weeks ago. It promised to post a schedule of listening events. The list is still not published. The likelihood is that we will not see the list.

I have written to my MP asking for information about listening events in my area, I suggest that everyone does the same, and let's get the Department of Health to confess whether these events are real or not.

UPDATE:
After writing this I found out that Roy Lilley has written his expected schedule of the "pause". Have a read of it here.

UPDATE #2:
So now we hear that there are 150 listening exercises, but Simon Burns won't list them. What is he afraid of? Burns said, in response to a written question asking him to list the events:

The NHS Future Forum is participating in a number of meetings and events throughout the listening period. There will be in excess of 150 events over the eight week period, involving a wide range of participants from across the national health service, local government, third sector and beyond. The location of these events will largely be determined by the host organisation and as such, they will be held all over the country.

Incidentally, I am still waiting for a response from my (Tory) MP.

U-turn on Public Services Sell Off

In February David Cameron wrote a bold article for the Daily Telegraph entitled "How we will release the grip of state control". In this article Cameron announces that the government will allow any private provider (the voluntary and community providers have been dropped) to take over a public service.

We will create a new presumption ... that public services should be open to a range of providers competing to offer a better service. ... But everywhere else should be open to diversity; open to everyone who gets and values the importance of our public service ethos. This is a transformation: instead of having to justify why it makes sense to introduce competition in some public services ... the state will have to justify why it should ever operate a monopoly.

This is not competitive tendering, this is simply the case of a private company saying "we want to provide that service" and they will be handed the contract.

This is Letwin's big plan for the NHS, something that he first wrote about for the right wing Centre for Policy Studies in 1988 (together with John Redwood).

"establishing the NHS as an independent trust and of increasing co-operation between the NHS and the private sector. It should have an open agenda on health credits, insurance schemes and any other serious radical suggestions." 

Thankfully, we did not get that then, but there is still a chance that we could have that now. After all, Lansley's plans are to make sure that he is not in control of, nor responsible for, the NHS ("independent trust") and he wants the private sector providing much or all of the NHS health care ("increasing co-operation between the NHS and the private sector").

This is a huge political minefield, it is quite clear that most people are happy with the way that the NHS is funded, who controls it, and who provides the care. Changing all of that is difficult, and unpopular, which is why these ideas were not spelled out in last years election manifestos, nor openly discussed in public. Now that Cameron is able to get the plan moving, he is still in danger of losing the policy, particularly if the policy becomes deeply unpopular and there is a chance of a vote of no confidence over the policy. This is why it is so important for Cameron to get a full 5 year term, and why Cameron was so much in favour of fixed term parliaments (long parliaments) it lets him off the hook for five whole years.

Even so, it appears that the privatisation plan is going off the rails. It is just so unpopular that the government is losing bottle. Today the BBC report:

Leaked documents suggest ministers have decided the "wholesale outsourcing" of public services to the private sector would be politically "unpalatable". Ministers instead want to use more charities, social enterprises and employee-owned "mutual" organisations.

The question, of course, should be why is it any more palatable to outsource to charities, social enterprises or employee-owned "mutual" organisations? Further the BBC say:

The shift in policy will raise questions about whether the government can make the savings it has promised - or deliver the services it is committed to - just by using charities and mutuals.

Why is it assumed that public provision is always assumed to be more expensive and that only private provision (which by definition must include a profit to provide a shareholder dividend) is always cheaper? The government document indicates that privatisation is about ideology rather than efficiency:

The government was not prepared to run the political risk of fully transferring services to the private sector with the result that they could be accused of being naive or allowing excess profit making by private sector firms.

The private outsourcing industry are not pleased with the u-turn which effectively freezes them out:

"This is a bit surprising. Francis Maude gave the impression when we got called in last year that we would be very much needed. There was every expectation that the private sector would be needed to help get the deficit down. This goes the other way. It seems to be different to what the government was committed to a year ago."

Instead, the BBC report indicates that the

Government is very open to ideas for services currently provided within the public sector to be delivered under a private/government joint venture. Government is committed to new models of partnership, and private sector organisations need to offer joint ventures - joint ventures between a new mutualised public sector organisation and a 'for profit' organisation would be very attractive.

So the future is that the government will partner (pimping?) with private outsourcing companies. In the BBC's report the NHS is listed as one of the public services that will be affected by this new policy. Presumably the new Any Qualified Provider policy will be influenced.

Telemedicine

Let me say that I am not a technophobe - I cannot be since my income comes from writing about new computer technology. However, in my day job I tell people how best to use the new technology, rather than simply fawning over the latest offering from big software or hardware manufacturers. My approach, which is to tell my readers when a product is not worth using (or how to get the inferior product to work), has not always made life easy for me - a few years back I was told by a product manager at Microsoft that I would never again be invited to test a Microsoft product, but in spite of that, I have.

I do think that technology has a role to play in managing chronic conditions, (in particular, in my own case with type 1 diabetes) but we have to be careful about what we use technology for, and don't simply replace common sense with a new gadget. As a born cynic, I usually regard the introduction of a new gadget to be simply a way for a company to make profits from the sick, so the gadget manufacturer has to try hard to convince me otherwise. Here are a few thoughts about telemedicine in our new NHS.

The first thing we have to bear in mind is that any telemedicine solution should be available to all. There is no point in choosing an extremely expensive piece of kit - even if it has all of the bells and whistles on it - because few people will be able to own the kit and benefit from the technology. There is an argument that the price of the kit will come down eventually, but you have to make sure that the starting point is low enough to get enough people initially using the kit. For this reason I reject solutions like the iPhone, iPad (and other tablets), Windows phones and Android phones. Smartphones in the region of £300 or more are simply too expensive: people won't buy them, and if the NHS buys them then there is the problem of patients losing them (or worse) generating a black market in "mislaid" smartphones.

If the device is to be used all the time then it has to be one which you, personally, can afford to lose. I have an £80 Samsung touch screen phone, I can afford to lose this, so I am happy to have it in my pocket all the time; I cannot afford to lose a £400 HTC Windows phone or a £600 iPhone, so I do not carry one. If the device is so expensive that I have to leave it in a padded case at home, then it will not be used regularly. Even the bargain basement phones available now are significantly more powerful than the first generation PCs, and yet without the first PCs we would not be where we are now.

The application should only be regarded as useful if the patient finds it difficult to live without it, but this also means that the application (and the device) must be freely available so that if they need to get a replacement they can. For example, a few years back I forgot to take my blood testing kit on holiday. These days blood sugar testing is a vital part of controlling diabetes, so a week away (and one when I was expecting to do a lot of hiking, as well as eating out in country pubs) from my blood sugar meter would be catastrophic. So, as soon as I could, I went into a local chemist where there was a display of meters and bought one for about £25. Blood sugar meters are usually sold at a loss (in fact, most are given away) because the manufacturers make their money from the test strips (in my case, each strip costs about 30p), so in this situation I chose the meter that came with the most number of "free" strips. Similarly, if I lose my insulin pen, I can go into any chemist and purchase disposable insulin syringes. The extra cost on me is acceptable - I don't want to have to pay for syringes or blood test strips all the time, but it is important that the cost is low enough (disposable syringes, a meter with "free" strips) for a one-off purchase, if necessary. So a device used for telemedicine must be freely available, and simple to set up.

The next thing to consider is features. The device has to be usable by as many people as possible. We are talking about telemedicine here, so the people using the device will be patients and many will have poor eyesight, poor co-ordination or impaired touch. A diminutive phone may fit nicely in your shirt pocket, but it is useless if a patient consistently presses the wrong button because they are too small.

I'm in my mid-forties and I have had cataract replacement, so that means that I have less than perfect eyes. I get extremely irritated when I am asked to evaluate some software written by a 20somthing with perfect eyes who's chosen to use 6pt light grey text on a slightly darker grey background. I get even more irritated when I find that there is no way I can change the colours or text size. I am not unusual, and whenever I bring up such complaints with colleagues who do similar work, they always agree with me. Yet the software vendors still seem to insist on only employing 20somthings with perfect eyesight who write software with small text and low contrast.

As far as I am concerned LCD displays are useless, the contrast is too low, but in the past all blood sugar meters have had LCD displays so I have always chosen the ones with the largest display to give me some change of reading what it says. Recently I bought a Bayer Contour USB, not because I can plug it into my computer, but because it has an OLED display. It is the most readable of any meter I have ever used, but even it has its faults. When the meter first displays the results it uses the full height of the display,  shown here (more or less life size):

This is readable, but this figure only shows for a few seconds before the device quickly zooms the figure down to half height because, well because some trendy 20somthing thought that it is "cool" to do that. Well fine, you be "cool" if you like, but please give me the option of only displaying results in the large font. The smaller display is shown here, and this is the size of the font when displaying stored results:

The extra data at the top of the display (and at the bottom when viewing stored results) may be useful, but surely I should be given the option to only display it when I press one of the buttons? So my perfect device is only perfect for the few seconds that it shows the large figure. This is an example of a device with a great feature that has been spoiled by over-egging that feature (adding the extra info on the display) or by not allowing me to choose how I want the display to work.

The final thing I should mention is development. Developers should recognise that although they may have one good idea, they do not have a monopoly on them and that others may have better ideas. Windows became an important platform for business not just because of the way that Microsoft sold the operating system, but because it was so easy to write applications with Visual Basic (and to a lesser extent, with C++ and MFC). Not only could you write applications in a matter of minutes, but you could also access the features of other applications (like Word or Excel) and use them in your application. The result was a large number of hobbyists developing applications, which resulted in a large number of free applications and a large pool of people from which the commercial software houses could employ, at a relatively low rate.

It is important, then to target a platform which has the largest number of users, and also to make your application and its data as open as possible. So if you develop some innovative way of presenting data, or using the hardware of the device, provide that through an open library so that other developers can use the library and provide additional features that you do not.

In terms of smartphones the most closed is the iPhone/iPad. Apps for these are written in Objective C which is not the most widely used language, it also uses an expensive SDK (software development kit) which will only run on a Mac (another expensive piece of kit) and can only be distributed through the Apple App Store. All of this reduces the available number of developers and makes the development expensive. Microsoft Windows Phones are relatively open compared to iPhones. The latest phones use .NET and the development tools, which run on Windows machines, are free. The .NET languages are C# and VB.NET and there are millions of such developers globally. Windows phones also run Javascript widgets, which brings in millions more Javascript developers. Android phones are also relatively open, with applications written using Java and there are millions of Java developers globally (although probably fewer in number than .NET developers). Java development tools run on any machine that runs Java: Windows, Macs, Linux etc.

However, I have already discounted smartphones because they are too expensive. These days most phones will run Java in some form or another. Thus it makes sense to develop a telemedicine application using Java. Java allows you to develop libraries that can be distributed compiled (so you can allow others to use your functionality without disclosing how you do it).

So in summary. A telemedicine application should target a cheap, freely available device, one that can be used by as many patients as possible. The application should be configurable, and allow patients to change the screen fonts, colours and even the buttons that are used. It should also be as open as possible, allowing other applications to use the data your application generates, and use your functionality through an open library.