Bill Committee

The Health and Social Care Bill Committee will sit next Tuesday for ten sessions to scrutinise the government's new amendments. The Committee is listed here and I have listed their party loyalties here:

Conservative

Mr Steve Brine
Mr Simon Burns
Dan Byles
Stephen Crabb
Nick de Bois
Margot James
Jeremy Lefroy
Nicky Morgan
Dr Daniel Poulter
Anna Soubry
Julian Sturdy

Labour

Debbie Abrahams
Mr Kevin Barron
Tom Blenkinsop
Liz Kendall
Grahame M. Morris
Fiona O'Donnell
Owen Smith
Emily Thornberry
Karl Turner
Phil Wilson

Liberal Democrat

Paul Burstow
John Pugh

DUP

Jim Shannon

Bill committees are made up in proportion to the number of MPs in the Commons so there are 11 Conservatives, 10 Labour two Lib Dems and one DUP. In addition there are four chairs, one from each of these four parties (Labour: Mr Jim Hood, Lib Dem: Mr Mike Hancock, Conservative: Mr Roger Gale and DUP: Dr William McCrea).

When the government's response to the Field Report was released it was reported that Dr Evan Harris was not happy and thought that the response did not completely address the motion passed at the Lib Dem spring conference. Today Nicholas Watt at the Guardian reports that Dr Harris is not happy with the bill amendments.

The plans remain bad for the NHS, go beyond the coalition agreement and we must insist on sovreignty (sic) of conference on major issues not in the CA [coalition agreement].

Further, he indicates that Shirley Williams broadly agrees with him.

So if the Liberal Democrats are not in favour of the amendments what will happen now? There are 11 Conservatives on the Committee and they will vote with the government. There is also the Liberal; Democrat Paul Burstow who is a minister and so has to vote with the government. So whatever happens the government's amendments will get 12 votes out of 24 and there will always be a majority over Labour's 10 votes. Crucial will be John Pugh and Jim Shannon, but even if they both vote against the government there will be no majority which would mean the casting vote of the Chair.

Will the Lib Dems table their own amendments to the Bill? If so, that will put Burstow in a quandary if the government's position is to vote against a Lib Dem amendment.

It seems to me that regardless of whether Dr Evan Harris thinks the amendment addresses the Lib Dem Spring Conference motion the amendments will be passed. And if Dr Harris is correct then this will continue to be a "bad bill" and one which grassroots Lib Dems will oppose.

But remember above that I said that "Shirley Williams broadly agrees with him"? The amended Bill will have a rocky ride in the Lords. perhaps this is why Nick Clegg is so keen on replacing the independent minded peers with a senate stuffed full of compliant politician clones?

Twitter

I disagree when people say Twitter is a "micro-blogging" site. Twitter allows you to post small messages to their web site, but the way you use it is very different to how you blog. While Twitter does allow people to interact, it is much too difficult to use conversations in the same way that you use comments on a blog as a review and modification mechanism (as I explained yesterday).

I use Twitter in four ways.

News Stream
In the olden days people had pagers and every now and then it would beep and a short message would show on its tiny screen. In more recent times SMS messages have filled this role. In both cases you pay for the benefit of these beeps and messages. This is a one way mechanism, the service provider sends the message and you read it. Twitter can be used in a similar way, but it does so without charge.

With Twitter you "follow" those accounts that you want to receive tweets from. When they tweet, the message will appear in your timeline: one message in a stream of tweets. A news item posted on twitter spreads very fast the source may have hundreds or thousands of followers, and many of them may re-tweet (ie copy the tweet to their followers) spreading the message to people who do not follow the source. It is no surprise that the newsmedia provide appropriate accounts (for example, @bbcnews, @skynews, @itn, @channel4news) for breaking news, and these usually link to an article to draw you into their website. Using Twitter like this effectively means that your timeline is a stream of news items, similar to the "tickertape" at the bottom of the screen on a TV news channel.

Some news tweets will have links to a complete article and I find that often it is easier to wait for an organisation to tweet a link rather than search for it myself (often websites have poor site maps and poor search engines). Some sites may tweet several times, others will tweet only when the site is updated. For example, I follow @DHgovuk because this account tweets whenever there are updates on the NHS statistics like waiting times. As soon as the statistics are released I get the tweet, read the page and then I can respond (re-tweet, or write a blog).

Some users will live tweet events. This is not quite like being there because the user will only tweet statements that they think are relevant. If you follow a user whose opinions you trust, this is a far better than attending the event because you do not have to experience the boring bits in between the relevant information. The true masters of this genre will also tweet explanatory, complementary or contradictory links to put the meeting into context. Live tweeting is similar to a sports commentator describing the action on the field.

Broadcasting
I write blogs, when I write a blog I tweet a link to post. People who are interested in my blogs can follow me and when I tweet a blog post they will see this in their timeline and then they may choose to read my blog. If they like it, they can re-tweet my tweet (that is, copy my tweet to their followers) so that others can read it too. This is similar pamphleteering: you do not assume that people will buy a publication, and the only commitment you need is that people are willing to read your post.

Of course, this way of using Twitter is only useful if you have enough people following you, and the best way to achieve this is by tweeting interesting comments which will get re-tweeted. The followers of the people who re-tweeted you may decide to follow you and your followers list will increase. This means that communities are created, where people with similar interests follow each other. (You can monitor the people who follow you, through your followers list, and you can decide to "block" a follower, which means that they will be blocked from following you and will no longer see your tweets.)

Conversations
This is where Twitter gets very powerful, but to do so it means that you, and others, should not "protect" your tweets. When a user protects their tweets they can have conversations, but only with the people they know and they miss the opportunity to talk with people they don't know. Conversations occur when you mention another user (prefixed with the @ symbol). If you start the tweet with the user name then that user and the users that follow both you and that user will see that tweet in their timeline. The person mentioned in the tweet will see it in their mentions timeline. You can also mention a user (again, prefixed with an @) elsewhere in a tweet, in which case all your followers and the mentioned person will see the tweet (the former in their timeline, the latter in their mentioned timeline). This is why you sometimes see a tweet prefixed with a dot (for example ".@anotherperson you and all my followers will see this"), it merely means that the message is expected to be seen by all followers.

Twitter is one way, but if people who you mention choose to they can reply back to you. This way conversations can start. Such conversations are not limited to two people. If one of the people in the conversation follows you, you do not have to mention them (unless you have replied with a user at the beginning of the tweet who they do not follow), but it is useful to add people into a tweet since the message will appear in their mentions timeline which will be less busy than their timeline. You can "send" a tweet to any of the people you follow (by mentioning them in a tweet) but whether they will read the tweet, or even reply to it, is another issue. However, I have found that if you tweet interesting and intelligent responses people will engage with you and consequently I have been able to have conversations through Twitter with people who normally I would never dream of engaging with: politicians, journalists, campaigners, academics and policy makers.

But note that you do not have to contribute to be part of a conversation. If you follow the people who are in a Twitter conversation then you will see the tweets in your timeline and this is essentially eavesdropping their conversation.

Random Interactions
Twitter allows you to search for tweets with a specific phrase or with a contracted phrase called a hashtag. A hashtag is just a word or phrase (without spaces) prefixed with # (the name, I guess must be British who call the symbol # "hash" since Americans call it "pound"). Some Twitter clients give special treatment to hashtags so that, for example, if you click on the hashtag you'll see all current tweets which contains the hashtag.

Twitter search is not specific to hashtags, but it behaves differently depending on whether the search term is a hashtag or not. For example, if you are interested in NHS topics you can search for tweets with the #NHS hashtag. The result will only be tweets where the user has actually put the string #NHS in their tweet (they have consciously provided a hashtag rather than the word). You can also search for words other than hashtags, so if you search for NHS you will get tweets which contain NHS and tweets that contain #NHS and NHS, thus, you will get more results than simply searching for the hashtag.

If you are interested in a topic then you will have built up a community of people who you follow and people who follow you, all of whom are interested in the topic. You can widening this community through searches for a key phrase or hashtag. The result of the search will be tweets from people outside of your community and if you find that the tweets from one person are useful, you can follow them (to widen your community) and talk to them (through replies or mentions) and interact. Potentially, they will follow you, widening the community further.

Writing

In my day job I write technical articles and books. Well, no longer paper books, the royalty on each is small and internet pirating is rife which means that I do not get paid for the 6 months of solid writing, or the 18 months of research that goes into a 500 page book. You get a lot for your $50 (not least the picture of me in the book, or sometimes on the cover), but I get very little from it and so I have to sell a lot of books to make writing it worthwhile. These days I write for hire rather than for royalties, and consequently the client - who will be giving away my work via their website - usually likes to ensure that I am on message rather than (as I like to do) make up my own opinions about software. I have even ghost written for some people. That hurts a bit, not that my name isn't on the work, but that someone else claims they wrote it. At least I get paid to do it.

Whether it is a book, or an online article the process is the same. First I have meetings (usually online: the client is often in the US, but I have worked with people in India too) to scope the article and after the meeting I will be sent the software. I then play with it for a while before writing an outline based on the discussions with the client and what I have learned from playing with the software. The client then reviews the outline and I make the changes and then inform the client how long the writing will take. Usually I will provide milestones - dates when each chapter is delivered.

Once everything is agreed, I start writing and as I approach each milestone I pass the article(s) to the client. At this point the article will be technically reviewed, usually by the client, but often it is done by both the client and a third party. The point is to check my code to make sure there are no obvious errors and to read through and see if my descriptions are correct. Once the technical review is completed, the article is passed to me and I make the changes. Usually they are minor (you get a quality service from me!).

Then I pass the article to a copy editor. Since I mostly write for US clients the chief purpose of the copy editor is to convert my English into American. Sometimes the copy editor introduces obscure grammar rules and I am happy to make the changes as long as they do not change the meaning of the text. I have had more passionate arguments with copy editors than I have had with technical editors, and these usually involve me complaining about some antiquated grammar rule that the copy editor thinks must to be followed or else the book must be spiked.

Once the article has been copy edited, it can go to production (printed on paper, or posted online).

You can see that there is a lot of interaction here. The client knows roughly what they want: as vague as "a book about this" or a detailed description describing the audience, the software and the scope. During the writing process I am constantly in touch with the client, asking questions, and sometimes pointing out bugs. Technical and copy editing makes sure that what I write is readable and correct. As a consequence I am willing to defend my technical writing to the hilt: it is not just me that is being criticised, it is the entire team who has contributed and all of us have gone to great lengths to produce a quality product.

So what about blogging?

I do not have a client, in fact, there may be no one at all reading this. And other than me doing some web searches, there is usually no checking of my blogs to ensure they are correct. So what you read is usually just a brain dump.

However, blogging is more than that. You know so because you are a seasoned blog reader and you know that you can comment below the line (that is, at the bottom where it says "Comments"). So although I try to make sure that what I write on this blog is correct, I rely on people who read the blog to correct me below the line. Sometimes (if I am very incorrect, and I have the time) I will even alter the blog to reflect the comments.

So to me, blogging must have comments. If there is no ability to comment then this is essentially the same as an article of being published without a technical review.Comments are an integral part of blogging and without the ability to make comments this is not a blog, it is merely a random article on the web. This is why there is a comment section on my blogs. If there are no comments on a blog post then I assume that no one has anything extra to add (which is a good thing).

Temple, moneychangers and dog food

I am not a believer, but I will allow a little bit of god in this blog today.

"And Jesus went into the temple of God, and cast out all them that sold and bought in the temple, and overthrew the tables of the moneychangers, and the seats of them that sold doves, And said unto them, It is written, My house shall be called the house of prayer; but ye have made it a den of thieves." (Matthew 21, 12-13)

It really is time to rid the Temple of the moneychangers. The Temple is the Department of Health, the moneychangers are the vast numbers of people on secondment from the private sector. There is a huge conflict of interest with people from the private sector "advising" the government on healthcare. We have to stop the revolving door between the department and the private sector.

Microsoft use a term: dogfooding. The term comes from the phrase "eat your own dog food" meaning that if a manufacturer thinks that their dog food is so nutritious and tasty they would be willing to eat it themselves. (Talk privately with Microsoft developers and they will tell you that Microsoft is somewhat selective about dogfooding when it comes to their own developing tools.) I think the Department of Health should have a dog food policy. Make it a sackable offence to use a private healthcare provider. The justification is clear: how can someone formulating NHS policy do it effectively if they do not use the NHS themselves? How can the public be at all confident in NHS services if the civil servants designing them do not use the NHS themselves?

These two policies: cleansing the Temple and dogfooding will do wonders for NHS policy.

Localism and centralising

Localism gets a very good press. People regard it as being a good thing that policies and services are tailored for the locality rather than a one-size-fits all. This works if the localism gives better services, but it can give worse services, in which case localism becomes a postcode lottery. There is a lot to be said for a hybrid where basic standards are applied everywhere, and localism is applied on top, but the issue is where to draw the dividing line.

The NHS reforms were initially sold as localism. The whole "put GPs in control" message was designed for patients to look at the doctor they trust and think "you should be determining my care, not that faceless bureaucrat miles away". Of course, it was never that simple. Some policies, like public health, can only be applied to large groups of people (in the reforms, this is moving from the 152 PCTs to the 50 or so county/unitary councils). In the case of rare conditions - organ transplants, rare cancers - most GPs do not come across such patients, so it makes sense to centralise the care in a few specialist centres where every patient will get expert care and to centralise the commissioning. This is the case at the moment, specialist commissioning is carried out by the Department of Health.

However, as details of the policy started to appear, it became more obvious that the government's policy is actually centralising decision-making, rather than devolving it.

There are 152 PCTs covering, on average, 330,000 people (there are a few PCTs that cover over three times that many). A GP practice will cover, on average 6,000 people. GPs have to be commissioned, and this is currently done by PCTs. Similarly, dentists, opticians and pharmacists are also commissioned by PCTs. This is the case of local knowledge being used to design the care for a local population.

The government is creating a new super-quango called the NHS Commissioning Board. (Know anything about that? Despite all their bluster about quangos during the election last year, the Tories kept quiet about the NCB.) This is essentially the Department of Health, SHAs and a quarter of PCTs all rolled into one. This quango will do the specialist commissioning that the Department of Health currently does, and it will also oversee the commissioning work done by the new GP-based clinical commissioning groups and set guidelines. Since the NHS White Paper was published a year ago the figure "80% of the NHS budget" was constantly thrown around. This figure refers to PCT spending and most people assumed that the GP consortia (now renamed clinical commissioning groups) would take over that budget. However, at the health select committee a couple of months ago, the Secretary of State mentioned a figure of £60bn (roughly 60% of the NHS budget). He pointed out that primary care commissioning (GPs, opticians, dentists, pharmacists etc) would be carried out by the new super-quango.

Over the last few months the government has been forced to re-think the artificial deadline they set for when PCTs will be abolished. The government has now agreed that GP commissioning groups will only do commissioning "when they are ready", but the April 2013 deadline for PCTs still remains. Currently 90% of England is covered by "pathfinder" consortia, many of which are far too small to provide effective commissioning. Under the government's previous plans such consortia could buy in commissioning from private companies, however, yesterday the Secretary of State confirmed that the new clinical commissioning groups would be statutory bodies and would have a responsibility to do the commissioning themselves. When pushed, he confirmed that they would not be allowed to buy-in the commissioning. This is significant because it will mean that there will have to be a re-think about the smaller pathfinders. Further, the Secretary of State confirmed that (unless there was an important reason otherwise) the commissioning groups would be expected to share borders with local authorities. The original Pathfinders were set up with no regard to local authorities boundaries. This means that the figure of 90% of the population covered by Pathfinders will surely change.

So who will do the commissioning in the areas where the local GPs are "not yet ready"? The PCTs will be abolished in 2013. The government says that this commissioning will be carried out by the new super-quango the National Commissioning Board.

However, it goes further. In response to demands that there is more clinical involvement in commissioning, the government has decided to set up new organisations called clinical senates. (When the government says that they are reducing the number of administration tiers in the NHS, point out that with the NCB and clinical senates they are simply replacing tiers, not removing them.) The senates will oversee the work of the local commissioning groups but will be part of the NCB rather than be locally based.

Further, local authority Health and Wellbeing Boards will oversee the commissioning decisions made by commissioning groups. These boards will be part of county or unitary councils and hence there will be fewer of these than there are currently PCTs. Yet again, this is centralising this responsibility.

So rather than localising decision making in the NHS the Bill will be centralising: centralising primary care commissioning and centralising oversight of commissioning. This is not a government of devolution it is a government of centralising.

Hospital doctors and commissioning

One of the complaints about GP commissioning was that it lacked the collaboration with secondary care doctors in hospitals. One solution was to put a hospital doctor on the commissioning boards. However, Andrew Lansley, quite rightly, objected to this. Commissioning groups are purchasers of healthcare, hospitals are providers and putting a hospital doctor on a commissioning board means that a provider could be involved in purchasing healthcare from themselves: a conflict of interest.

However, the government has now accepted this idea as long as the doctor is not from a local provider. So how can this work in practice: is it possible for doctors from the other end of the country to sit on a commissioning board? Pulse reports on Lansley's new plan:

Mr Lansley said it was imperative that conflicts of interest were avoided, but said the problem could resolved by appointing specialists doing tertiary work, hospital doctors who had recently retired, or consultants who lived in the local area but worked elsewhere.

Patient choice means that patients can go to any hospital and the limit is usually the distance that the patient will travel. One would assume that patients are willing to travel further for treatment than a consultant would travel to get to work, so the third criteria "consultants who lived in the local area but worked elsewhere" would present some conflicts of interest. Tertiary care is commissioned by the new super-quango, the National Commissioning Board, so there will be no conflicts of interest. It seems that the new hospital doctors on commissioning boards will be either tertiary or retired consultants.

Wouldn't it be simpler just to change to a collaborative model? This would get rid of any concept of conflicts of interest since local GPs will commission the local hospital and so local hospital doctors can work with them to design services.

Two tiers

The Prime Minister is reported to be making five pledges on the NHS, but he is also reported to saying that the 2013 deadline for GP consortia will be scrapped so that consortia only go ahead when 'GPs are good and ready'. The reason for the deadline has been explained quite clearly by the Secretary of state. Fundholding was optional and lead to about half of GPs taking part, the result, as the White paper says:

Fundholding led to a two-tier NHS

More recently Lansley has said that he does not want the deadline removed:

The health secretary has consistently argued that to allow GPs to opt in or out would create a “two-tier” health service, as what happened with GP fundholding in the 1990s. He believes two systems would hurt care and efficiency.

Get ready for the two tier NHS. The only question for patients is whether you are better registered to a GP practice out or in a GP consortium.

District General Hospitals

There is a view that the NHS costs too much because too many treatments are performed in hospital. The theory is that we have to move treatment out "into the community" and most likely that means to your GP. This is not suggesting that your GP (a "generalist") will be performing kidney transplants or brain surgery: there will still be specialist hospitals for that. Instead, minor surgery and some clinics will be moved to the GP who will be paid less than the hospital. The services that cannot be moved are those provided by specialist hospitals. The services that can be moved are those provided by District General Hospitals (DGH). This means that there is a distinct possibility that some DGHs will close.

There is a lot of faith that moving care into the community will cut costs. Indeed, the McKinsey report estimates that it could save £800m to £1.6bn by moving treatments out of hospitals (the phrase they use is "shifting care to lower cost settings"). McKinsey further estimate that by better management of chronic conditions fewer patients will be referred to hospital for treatment and this could save £1.9bn to £2.5bn. Finally they estimate that further savings can be made by not performing treatments that are ineffective or which has limited effectiveness (£800m to £1.5bn, generally known as the "Croydon List"). DGH are paid to treat patients, if there are fewer patients, they will be paid less; if hospital incomes fall, they will close clinics and wards and may become financially non-viable and eventually close completely.

The British love the NHS and in particular, they love hospitals. When I give a talk about the government's NHS policy I often start by asking people to say what most embodies what they think is "the NHS". It is not GPs; it is always hospitals. Politicians know this and they are careful when it comes to suggesting that a hospital has to be downgraded or even closed. In some cases politicians even campaign against their own party's Secretary of State because they know that however ineffectual the campaign is to prevent the final outcome, it will help shore up their vote.

A wise Secretary of State, recognising how sensitive the subject is, would get together all the cleverest people in the NHS and ask them to review hospital provision. These clever people could look at which areas have too many hospitals and identify which of the hospitals should go. It is then the responsibility of the wise Secretary of State (as a professional politician) to include the stakeholders and the public in the locality in the review and convince them that services would need to be changed. The wise Secretary of State may even argue that such a review is not be a bad thing since closing one hospital could result in more investment in a neighbouring hospital resulting in a better service for all. The important point is that a wise Secretary of State would make a strategic decision based on the collective advice of people who know the local area.

The last government attempted such a review in 2007, there were a series of Acute Services Reviews around the country and recommendations were made to re-configure services. These recommendations were sent out for consultation, so that service providers and service users could comment. The result was protests around the country wherever a hospital was to lose a service. The leader of the opposition, one David Cameron, campaigned against the re-configuration saying on the Today programme:

"I can promise what I've called a bare-knuckle fight with the government over the future of district general hospitals. We believe in them, we want to save them and we want them enhanced, and we will fight the government all the way."

That is unequivocal: David Cameron supports District General Hospitals. Note that there was not even a tinge of mentioning the huge swathes of waste that he has since claimed are infesting the NHS right now. No, in 2007 he expressed his great love for DGHs and even produced a list of 29 hospitals that he claimed were "at risk":

Chase Farm (London), Frenchay (Bristol), Grantham (Lincolnshire), Horton (Oxford), Huddersfield Royal Infirmary, King George (Essex), Princess Royal (Telford), Royal Surrey County, St Richard's (West Sussex), Worthing and Southlands, Princess Royal (Haywards Heath), Eastbourne, Conquest (East Sussex), University Hospital (Hartlepool), University Hospital Lewisham (London), Queen Mary's (Sidcup), Queen Elizabeth (Woolwich, London), Scarborough General, Trafford General, Hemel Hempstead, Queen Elizabeth (Hertfordshire), Lister Hospital (Hertfordshire), George Elliot (Nuneaton), Hospital of St Cross (Rugby), Warwick Hospital (Warwickshire), Epsom General (Surrey), West Cumberland (Cumbria), Queen Elizabeth (King's Lynn), City Hospital (Birmingham)

Altrincham General was included in the original list, but the Conservatives later said this was an error. They replaced it with Trafford General.

It is easy to argue that if the reconfiguration had been carried out in 2007 these trusts would be more efficient, their local PCTs would have more money, and there would be less need to close hospitals now. However, Cameron campaigned against A&E and maternity ward closures and made it an election issue so that the Conservative manifesto in 2010 said:

"We will stop the forced closure of A&E and maternity wards, so that people have better access to local services"

Then after the election the new Secretary of State, Andrew Lansley outline four criteria that had to be met before a service would be closed:

First, there must be clarity about the clinical evidence base underpinning the proposals.

Second, they must have the support of the GP commissioners involved.

Third, they must genuinely promote choice for their patients.

Fourth, the process must have genuinely engaged the public, patients and local authorities.

Health Policy Insight points out that only the second of these is actually measurable, the others are merely opinions. (And as I have mentioned before, when Lansley was first tested on these four criteria he failed: 97% of local GPs in Maidstone did not want their local maternity unit downgraded, but Lansley chose to do it anyway.)

The word wise is not often associated with the current Secretary of State, and I will not make the association here. In place of wisdom we have a Secretary of State with a blind faith in the free market. His theory is that if there are too many hospitals and not enough money, the best hospitals will survive and the weaker, poor quality hospitals will naturally wither away and die. The problem is that hospitals take a long time to die and so to help them along Lansley has created an artificial deadline: 1 April 2014. This date is when NHS Trusts will be abolished. All trusts that are NHS Trusts at the moment must become Foundation Trusts by that date. The problem is that the criteria for becoming an FT includes financial governance - being able to at least break even, being able to make 6.5 to 7.1% cost improvements every year, and not to be saddled with debt.

Private Finance Initiative is a large drain on some (not all) hospital trusts and in April HSJ published a list of 22 trusts where the "private finance deals that are 'an obstacle to them achieving FT status by April 2014'". It has since come to light that the Department of Health have contracted McKinsey to investigate how to alleviate the challenges of PFI. HSJ lists the 22 trusts (the HSJ-22) as:

Mid Yorkshire Hospitals, North Cumbria University Hospitals, St Helens and Knowsley, Sandwell and West Birmingham, University Hospitals Coventry and Warwickshire, Hereford Hospitals, Walsall Hospitals, University Hospital of North Staffordshire, Worcester Acute Hospitals, Mid Essex Hospital, Barts and the London, Barking, Havering and Redbridge University Hospitals, South London Healthcare, West Middlesex University Hospital, North Middlesex, Royal National Orthopaedic Hospital, Dartford and Gravesham, Maidstone and Tunbridge Wells, Buckinghamshire Hospitals, Portsmouth Hospitals, Oxford Radcliffe (and Nuffield Orthopaedic Centre), North Bristol

Interestingly, there is no overlap with the 29 hospitals that Cameron gave. The reason is that many of these are large hospitals with PFI, and not DGHs. It has since been suggested that the Treasury may even provide extra funds for these hospitals so that they achieve FT status since it would be too costly to allow these hospitals to close:

"The Department of Health and the Treasury between them are going to have to twist arms as much as they can, but you have to assume that some money is going to have to be involved. [One] way to do it is to try and make a one-off bullet payment to bring down the ongoing costs. That clearly does require some money and my expectation is there’s likely to be a few of those needed."

These trusts are clearly too expensive to fail.

Today, the Financial Times produced its own list (the FT-17):

Financial Times research that suggests up to 17 NHS hospital trusts are so cash-strapped they will have to impose deep cuts in services if they are to survive.

The interesting thing is that there is little overlap (7 trusts) with the HSJ-22:

Mid Yorkshire Hospitals, North Cumbria University Hospitals, Barking, Havering and Redbridge University Hospitals, South London Healthcare, West Middlesex University Hospital, Buckinghamshire Hospitals, North Bristol, Trafford Healthcare, Hinchingbrooke Healthcare, Royal United Hospital Bath, Winchester and Eastleigh Healthcare, Royal Cornwall Hospitals, Heatherwood and Wexham Park Hospitals, Surrey and Sussex Healthcare, North West London Hospitals, St Georges Healthcare, Whipps Cross University Hospital

These trusts are mostly DGHs and the type of work they do is the reason why they are at risk:

The root of the hospitals’ problems vary and in many cases are multiple. All but three of the 17 are classified as “district general hospitals” – organisations that do not specialise in any particular area and are being squeezed from all sides as specialist care is moved to regional centres of excellence, NHS commissioners place some restrictions on more routine procedures and technology allows some care to be provided more cheaply in GP surgeries and patients’ homes.

These "restrictions" on treatments are the McKinsey "efficiency savings" mentioned above. The FT-17 are hospital trusts that have generated large debts over the last 6 years:

But in the past six years 17 NHS trusts, named by the FT today, have needed to be bailed out with £625m in as yet unreturned loans and other forms of cash support ... Much of that money was paid over soon after 2005 when the NHS ran a financial deficit. But between them the 17 clocked up another £287m in fresh bail-outs over the past two years, when the rest of the NHS reported surpluses.

But note the following point made by the FT:

The impending financial meltdown at the trusts means local communities could lose their accident and emergency departments and maternity services, forcing patients to travel further for certain treatments.

Does this remind you of something? Yes, right at the top of this post I mentioned the Acute Services Review, Cameron's "bare-knuckle fight" and the Conservative manifesto's pledge to "stop the forced closure of A&E and maternity wards". The difference is that the Acute Services Review was planned and backed by evidence, but any closures due to Lansley's unnecessary 2014 FT deadline are not planned. In fact, they can involve otherwise well run hospitals because, as the FT points out, if one of these hospitals is a DGH with PFI it is likely to be spared by transferring work from neighbouring hospitals who themselves may have to close services:

Paradoxically, however, some hospitals with large PFIs may find their biggest problem is also their saving grace. The Treasury and the department of health will not want these new facilities to go to waste. So services at neighbouring hospitals which may not themselves be in financial difficulties are more likely to close to ensure that best use is made of the PFI unit.

The free market when it comes to re-configuring local health services is neither strategic, thought out, nor fair. But then the free market never is.

Choice

I was looking for some evidence about healthcare commissioning in the US and as a consequence re-read the evidence given to the Health Select Committee last November. The following is interesting because it addresses the issue of whether competition or choice will raise quality:

Professor Gwyn Bevan: There are systematic reviews in the United States for putting information out on a hospital's performance. They consistently find that people do not switch from poor to high-performing hospitals. One of the paradoxes about the New York study where they issued data on risk-adjusted mortality rates for cardiac surgery is that patients continued to go to hospitals with high mortality rates. But by publishing the information, the hospitals got better. The most famous case is Bill Clinton, who had his quadruple bypass in a hospital that the information said at the time was one of the two worst outliers in the whole of New York State he could have gone to. 

What Prof Bevan is saying here is that publishing hospital performance, even poor results, will not affect the number patients using the hospital. Patients presumably see themselves as individuals rather than part of an aggregated statistic. Bill Clinton used the hospital he did because he thought that the performance data would not include him. Isn't that what we all think? The interesting part is that publishing the performance data improved the hospital because hospital management were effectively shamed into doing so. They do think in terms of aggregated figures: the hospital's reputation.

The government's faith is that competition and choice will raise standards, whereas it seems that choice will not do that.