I'll cut the NHS and raise the deficit

It was inevitable, but now the figures are out: Cameron has cut the NHS. The Financial Times reports:

"Treasury figures show the NHS spent £102bn from April 2010-April 2011, almost all of which took place when the coalition took power. This marked a £750m real-term fall from the previous year, something Mr Cameron repeatedly promised would not happen. ... Treasury officials pointed out that this spending had taken place under plans originally put in place by Labour. But under those plans, spending should have risen in real terms by £150m."

On the other hand the Conservative government is borrowing even more than the previous Labour government:

"A fall in tax receipts got the new fiscal year off to a disappointing start with public sector net borrowing hitting £7.7bn compared with £5.3bn in April last year."

Remember that poster: I'll cut the deficit not the NHS. Well he got it the wrong way round, in practice he cut the NHS and raised the deficit.

When it comes to hypocrisy, Lib Dems are the Masters

Unless, of course, you are a Minister. The government was adamant during the white paper: all NHS Trusts have to become a Foundation Trust by April 2014, to do this each Trust had to match the tight financial criteria that Monitor sets and any Trust that failed to become a Foundation Trust would close. The Health and Social Care Bill reinforces this market-based way of reconfiguring services. The drop-down-dead date was brought up in the Pause and the government has relinquished saying (in their response to the Future Forum):

We strongly expect that the majority of remaining NHS trusts will be authorised as foundation trusts by April 2014. ... It will not be an option to stay as an NHS trust, but there will no longer be a blanket deadline in the Bill for abolishing NHS trusts as legal entities. All NHS trusts will be required to become foundation trusts as soon as clinically feasible, with an agreed deadline for every trust. (7.17)

Note that an NHS Trust cannot remain as such (ie be treated as part of the public system of healthcare provision), under this government the only option is for a Trust to become an autonomous Foundation Trust over which the government will admit no responsibility.

Further, the government says:

To enable time for foundation trusts’ governors to build capability in holding their boards to account, we will further extend, to 2016, the transitional period where Monitor retains specific oversight powers over foundation trusts. Monitor’s oversight will last until two years after a foundation trust is authorised, if that is later. To provide continuity during a challenging period, and in recognition of concerns about the readiness of foundation trusts’ governors, these powers will initially apply to all foundation trusts, and they will be reviewed in 2016. (7.18)

This says that after 2016 (or two years after a trust becomes a Foundation Trust, whichever is the later) Foundation Trusts will be completely autonomous of the government or any government agency (including Monitor). This is the "level field" that Lansley keeps talking about because Monitor (as the economic regulator, rather than the Foundation Trust regulator) will treat FTs exactly the same as private and voluntary sector hospitals.

The point of quoting these paragraphs is to show you that the government is intent on allowing hospitals to close - and to use the market to close them. There are many reasons why a hospital loses money, and poor management is just one (and most likely not the most important reason). The hospital could be in an area of high deprivation or some other demographic with a high healthcare cost. The hospital could be in a rural area and consequently serve a population that is not large enough to be economic, but nevertheless be vital for that community.

It makes no sense at all simply to look at the balance sheet and close those hospitals in the red and allow those in the black to continue, the other criteria - the health inequalities in the community being one of the most important - should be taken into account. However, this requires a strategic and planned approach and this government does not do that.

Consequently, the government's market-led approach creates hypocrites of ministers. For example (from the Evening Standard),

In a startling admission, the Work and Pensions Secretary [Iain Duncan Smith] said waiting lists are already growing as he led a campaign against shutting the A&E and maternity units at King George Hospital, Ilford. The ex-Tory leader warned that thousands of patients in his constituency will suffer if the closures go ahead.

The last sentence actually explains his worry. It is not thousands of patients he is worried about, it is thousands of voters. However, Duncan Smith, if true to his ideology would do what politicians are supposed to do, and show leadership and explain to the voters why the hospital should suffer the closures that are the bedrock of his government's policy. He doesn't. He's a hypocrite.

However, hypocrisy is not the sole domain of the Conservative party: the Liberal Democrats are hypocrites too. HSJ reports that health minister, Paul Burstow says "services could be put “at risk” by a hospital merger proposed near his constituency on the Surrey-London borders". Burstow says

Any merger that could result in the loss of services, which local residents rely on, will not be tolerated. It is essential that we show local NHS bosses this.

Well, Mr Burstow, these market-based reconfigurations are your government's policy. If you are against them, then stop them all. It is pure and utter hypocrisy to say that they should happen everywhere else in the country but should not happen in his backyard where they will affect him electorally (majority 1,608 over Cons).

Vote for Public Services?

This is from the Open Public Services white paper:

Read the whole paragraph.

"We want to open up existing provision to competition from new providers with different ways of doing things. ...  in other areas it will mean people competing against one another through the democratic process to gain citizens’ votes."  

Doesn't the highlighted sentence describe the process of electing councillors and MPs? In which case, why is it in a paragraph about the provision of public services? Was this a cut 'n' paste error? Or does it mean that we will vote for who provides the public services in an area?

What do you really mean, Mr Clegg?

After all the hoo-ha over the Health and Social Care Bill and Lib Dems finally realising that it is just a plan to privatise the NHS we had a series of speeches from the Deputy Prime Minister where he told his supporters that he would protect the NHS.

For example (26 May):

"That’s why I have been absolutely clear: there will be no privatisation of the NHS."

And (14 June):

"You told us you were worried about privatisation through the back door. So we have made that impossible."

Yet in the Open Public Services white paper, it says

"In the services amenable to commissioning, the principles of open public services will switch the default from one where the state provides the service itself to one where the state commissions the service from a range of diverse providers." (5.2)

It is very clear here. There will be no state provision in the NHS. How can Clegg say that this is not privatisation? Who is he trying to fool?

QIPP

The NHS "efficiency savings" is frequently misreported, journalists, MPs and the public don't really know what it is or how big it is. Mistakes are easy to make when reporting it, although you would have thought that an MP would check before talking about the cuts in Parliament (like Nahdim Zahawi who thought that the cuts would occur all in one year).

However, the one organisation you would expect to actually know what the "efficiency savings" cuts are, is the Department of Health. Apparently not.

The page for the documents on QIPP says:

"The quality, innovation, productivity and prevention (QIPP) challenge is our opportunity to prepare the NHS to defend and promote high quality care in a tighter economic climate. We know we have one more year of guaranteed growth in 2010/11, but the NHS needs to be making efficiency savings of £15-£20 billion per year by 2013/14."

Nope. This is a Zahawi error. The £15-£20bn is to total over the period, not the annual "saving".

Of course, this document has now been superseded so that the "efficiency savings" are £20bn over the period 2011/12 to 2014/15. That is, Labour wanted a minimum of £15bn over 3 years and the Conservatives want a minimum of £20bn over 4 years.

A poor show from Miliband

It was a poor show from Ed Miliband at Prime Minister's Questions today. The last few weeks should have been clear to Miliband that when you press the Prime Minister on details he falls to pieces and then starts saying things that he wished he hadn't. Today the schedule was clear: the Prime Minister would make a lengthy statement on the BSkyB takeover and there would be a debate, then later in the afternoon there would be an opposition day debate on the BSkyB takeover. Clearly Cameron would be well briefed on the BSkyB takeover. So what did Miliband choose to ask at PMQs? Yes, the BSkyB takeover!

There was also an orchestrated attempt by Labour MPs to only ask questions on the BSkyB takeover (or Murdoch). From a political point of view this was a daft approach because all it resulted in was a repeat of the same replies. If I had been Miliband I would have asked:

Will the Prime Minister apologise for insulting all the GPs in this country when he suggested that they are corrupt by implying that the only way that patients can get emergency treatment is if they have dined with their GP?

The Open Public Services white paper is a threat to our public services, and it deserved a mention today. Five questions targeted at the details of this policy would have wrong footed Cameron and highlighted the danger of this policy to the public. Today was a wasted opportunity from Ed Miliband.

Pathetic, pathetic, pathetic

... Labour, that is.

Yesterday Cameron put a huge For Sale sign on our public services. So what was Labour's response? The pathetic Tessa Jowell said:

This White Paper contains few new ideas and even fewer new proposals. Having promised radical change, the Tory-led Government are lagging behind their earlier rhetoric and are yet to catch up with the last Labour Government.

Does she really think that Cameron's plan to privatise everything is "yet to catch up with" Labour? If so, then Labour's privatisation policies are truly incredible. This is totally unacceptable.

If I were to be kind to Jowell I would say that this statement was made out of complete ignorance of Cameron's policy, and that is also unacceptable.

Labour, you have to up your game.

A Labour Manifesto on the NHS

Labour have to do something about their policies over the NHS. Here's how I think they should start.

Funding. Labour must do something to stop Cameron's charge that "Labour would have cut the NHS but the Tories are increasing funding". The evidence - from the last Darling budget - was that Labour would have given flat real terms increases (ie increases that match inflation, but no more) for two years, as opposed to Osborne's flat real terms increases for four years. There are other differences (for example, the size of the planned capital budgets) but most of these lacked detail and can be addressed. Labour needs to be clear about what its plans were and what its plans for the future will be. This is a vital issue and too long Cameron has been allowed to avoid answering an NHS policy question by repeating his trite and untrue statement that Labour would have cut whereas the Tories have increased funding.

Blairism. Labour must draw a line under the Blairite reforms. They must spell out once and for all the purpose of introducing ISTCs, the CCP, FTs, PbR etc, and they must point out which of these succeeded and which failed. If Labour does a mea culpa on ISTC funding it would kill the Tory attack that "Labour paid the private sector more than the NHS". Labour did pay ISTCs more than the NHS, and admitting that they did, and importantly, saying that they would not repeat this if re-elected, would make the Tory argument pointless.

What the public want. Labour have to be seen to be ahead of the government on the issues that matter to the public. The three main issues are: access, waiting times and accountability:

1. Access: the postcode lottery and health inequalities. These will get much worse under the new Bill and Labour must take every opportunity to point this out. While health inequalities are important, it is the postcode lottery that will get the most publicity and so Labour concentrate on this. Every time a Tory NHS policy is discussed, Labour must point out the potential for a postcode lottery. (And any policy that has the word localism in it will be a source of regional variations, and a postcode lottery.) If people think that they will be rationed simply because of where they live, then they are likely to oppose the policy because it is simply unfair. The public have a deep emotional attachment for fairness, Labour have to point out how unfair the Tory policies will be and how Labour will bring fairness back.
2. Waiting Times. Labour have tried to make an issue of waiting lists, but in my opinion they are looking at the wrong thing. The big scandal in the next few years will be Referral Management Systems, in other words, GPs' referrals rejected by "faceless bureaucrats". In many areas of the country only urgent treatment is offered without review and for non-urgent treatment (like hip replacement or cataract removals) GPs are being told to delay referrals, with the referral management system in place to ensure a GP sticks to the rules. Crucially, since it is the GP referral that is delayed, they do not appear on the RTT waiting times (since the RTT stopwatch only starts once the referral is made). This is why Cameron and Lansley can say waiting times are not affected: if care is denied the patient is not waiting for it. This rationing of healthcare will increase the business of the private sector as people decide to pay for the treatment denied by the NHS. (IMO, this is how the NHS will be "privatised".) Labour must attack this policy on every front. If the government says that GPs are in control of care, then Labour should question why Referral Management Systems (that overturn GP decisions) are needed. Labour should campaign that the Department of Health should publish the numbers of referrals that have been delayed by GPs or rejected by the Referral Management Systems. This is another fairness issue and Labour should show that it is a Conservative government that is being unfair.
3. Accountability. Labour should campaign that it is our NHS, and as part of this, campaign for more accountability. Labour can latch on the "no decision about me, without me" message by pointing out how the new NHS structures - National Commissioning Board, Monitor, CCP - specifically excludes patients' opinions, so they are making decisions without me. Labour should also point out that private companies, and the new mutuals and social enterprises that Cameron wants created under the Right To provider policy, will not be accountable to the public. Labour should campaign that one of the qualifications of Any Qualified Provider should be to have board meetings in public and that non-executive directors of such organisations should be publicly elected - both of which will be rejected by the government, but it will bring to light the lack of public accountability with these organisations.

Labour Values. After the Blairite reforms the public no longer know what Labour's values are, they do not know what Labour stands for. The next few years must be used to position Labour as the party of the NHS that the public want (and the three aspects above, in my opinion, are what the public want). My feeling from talking to patients is that they assume that the NHS is publicly owned and publicly run. The public do not want the concept of an NHS kitemark on the private companies that do NHS work, a policy that was promoted by New Labour and is now promoted by this Tory government. Labour should position itself so that it promotes what the public want (a publicly owned NHS), rather than telling the public what New Labour thinks the public should want (a largely non-public kite-marked system). A commitment to a public system - and with an attached warning that any NHS service that is privatised, or turned into a social enterprise, will be taken back into public ownership under a Labour government - would severely curtail any Tory policies that would take NHS services out of public ownership.

Creeping privatisation. Labour also must stop flirting with policies involving mutuals and social enterprises. By all means give staff more involvement in how an NHS service is run, but mutuals and social enterprises are not the way to do this because they are not publicly owned (and hence fail the public accountability requirement). Personally I would be happy for a Labour government to mandate that BMI, Spire, Netcare, etc should become social enterprises before they can do NHS work (fat chance!) but that should be the limit of social enterprise in the NHS. Labour should also campaign against Circle which is not a social enterprise (the mutual - profit-share - part of Circle is only 49.9% of the company so they are a majority profit making private company). Circle gives social enterprises a bad name, it is about time this was made abundantly clear by Labour.

Any Qualified Provider

In case you were wondering: the any in Any Qualified Provider applies to the provider part, not to the qualifications that qualified implies.

Well, I hope it does. As usual this government's incompetence comes up with an ambiguous statement that is easy to misunderstand.

Inverse Poll Tax

One of the big issues we have with democracy in the UK is that there is a large number of people who do not want it. They clearly do not want it because they either do not vote, or (worse) do not even bother to register to vote. Part of this problem came from the Poll Tax (ahem, Community Charge) in the 90s where if you were on the electoral register you were liable to pay the tax: a tax on voting. One of the strategies against the Poll Tax was for people not to register to vote. Ironically, this actually benefited the Tories whose natural demographic were more likely to register and more likely to be in favour of the Poll Tax. We're still suffering the effects because many people regard the electoral roll with some distrust. (Thanks, Thatcher, for that effective part-destruction of our democracy.)

A principle of you have to pay a tax to vote is abhorrent. But why not turn the idea on its head? If you register to vote you become entitled to state benefits, or rather, to get benefits you have to be on the electoral roll? This won't necessarily increase the number of people voting, but it gets us nearer there. I am against the Conservatives' general idea that people who receive state benefits are in some way in hock to the state. That's nasty. But registering as a voter shows that you recognise that you are part of society and want to contribute, even if it is just putting an X on a piece of paper once every five years.