NHS Expenditure

The government keeps telling us that they will deliver real terms increases in the NHS budget, but the evidence proves otherwise. Today The Independent says that

"NHS total expenditure [fell] from £102.8bn in 2009-10 to £102.0bn in 2010-11 (in 2010-11 prices, rounded to nearest £0.1bn) – a real terms fall of 0.7 per cent."

Further, the House of Commons Library Standard Note SN/SG/724 (updated September 2011) says that Net NHS Expenditure in 2009-10 (in 2010-11 prices) was £103.2bn and in 2010-11 the expenditure was £102.0bn a real terms decrease of -1.1%.

The House of Commons library standard mote gives tables of NHS funding from when the service was created. Table 2 gives the expenditure on the NHS in England in 2010/11 prices (ie real terms) from 1974/75 to 2014/15. The last five years are the planned expenditure by the current government.The following graph shows the data plotted.

I have published a graph like this before, this new one is updated to show the new figures in the standard note (effectively, the dip seen for 2010-11). I have fitted three lines to this data, one for the Thatcher/Major years, one for Blair/Brown and the final one for the Cameron era. It is very clear that the current government is squeezing the NHS.

In the following graph I have plotted the data from 2006 with the Blair/Brown trend line plotted in blue and the Thatcher/Major trend in red. Clearly Cameron's funding is less than if the Blair/Brown spending had continued at the same rate, but what is striking is how Cameron's spending compares with Thatcher/Major. If the NHS were funded by Conservatives from the 80s we would have real terms increases of about £1bn every year, instead there is flat funding.

CCG Size: designed to fail

I have taken the data from the Department of Health for the current Clinical Commissioning Groups. The relevant figures are:

CCGs
Number of CCGs: 266
Mean population per CCG: 198,973
Median population per CCG: 167,210

PCTs

Number of PCTs: 152
Mean population per PCT: 340,900
Median population per PCT: 282,200

I have plotted out the numbers of PCTs and CCGs in various population bands:

The PCTs are in dark blue and the CCGs are in light blue. It is immediately obvious that the centre of gravity of the graph of the CCGs is much lower than for PCTs: the clinical commissioning groups are much smaller than PCTs. More concerning is that out of 266 CCGs four fifths of them (219) have populations less than 300k. (For comparison 87, or 57% of PCTs were under 300k.) Three hundred thousand is the figure given by Civitas as the rough rule of thumb for the minimum size for a commissioning group to be financially viable:

In 10 European countries analysed, seven have seen a consolidation of commissioning organisations over the past 15 to 20 years, two have seen no change. In only one country (Spain, due to devolution) has the number of commissioning organisations increased. In all countries apart from Switzerland the average population coverage of a commissioner is above 300,000 people.

With so many small CCGs is GP commissioning designed to fail?

The Mackay Amendment

Paul Waugh reported a few days ago that the government would "look favourably on an amendment by Lord Mackay", so I thought that I would investigate what this amendment does. Since the Bill amends several other bills the only way to understand an amendment is to follow the amendment's instructions.

The National Health Service Act 2006 starts with a clause on the responsibilities of the Secretary of State:

1 Secretary of State's duty to promote health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.
(2) The Secretary of State must for that purpose provide or secure the provision of services in accordance with this Act.
(3) The services so provided must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

The current version of the Health and Social Care Bill will change this clause to:

1 Secretary of State’s duty to promote comprehensive health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.
(2) For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.
(3) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

Note that subsection of the 2006 Act says "must for that purpose provide or secure the provision of services" and this is amended to "must exercise the functions conferred by this Act so as to secure that services are provided". The contentious point is the removal of the requirement to provide, the implication is that the Secretary of State will no longer provide health services.

The Mackay amendment changes the 2006 Act to say:

1 Secretary of State's duty to promote health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.

2) For that purpose, the Secretary of State—
(a) retains ultimate responsibility to parliament for the provision of the health service in England, and
(b) must exercise the intervention and other functions of the Secretary of State in relation to that health service so as to secure that services are provided in accordance with this Act.

(3) The services so provided must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

(4) For the purposes of this section, the intervention functions of the Secretary of State in relation to the health service in England are the functions of the Secretary of State under—
(a) section 13Z1 (failure by the Board to discharge any of its functions),
(b) section 253 (emergency powers),
(c) section 82 of the Health and Social Care Act 2008 (failure by Care Quality Commission to discharge functions),
(d) section 67 of the Health and Social Care Act 2011 (Monitor: failure to perform functions),
(e) section 242 of that Act (failure by NICE to discharge any of its functions),
(f) section 266 of that Act (failure by the Information Centre to discharge any of its functions), and
(g) section 285 of that Act (breaches of duties to co-operate).

The changes are subsection 2 and 4. This splits the responsibility into two. The first part says that Lansley has the ultimate responsibility for the provision of health services. This clashes with clause 4 which says that the Secretary of State must promote autonomy of the health service. I suspect that clause 2(a) will not be accepted because to do so would require that the autonomy clause is removed, and this is known to be one of Lansley's red lines.

The new part is in subsection 2(s). To explain its significance let's go back to Baroness Williams' opposition to the Bill at the Lib Dem conference in September. The Baroness said that a "major health emergency in the country was an example of when the secretary of state's role was unclear". Section 2(b) and section 4 explains the intervention that the Secretary of State is able to make in an emergency.

Section 4 lists several sections from the H&SC Bill and several existing acts. Section 13Z1 (a new section added to the NHS 2006 Act by the H&SC Bill) says that the Secretary of State can intervene if he considers that the NHS Commissioning Board has failed to discharge its duties and similarly section 82 of the Health and Social Care Act 2008 says that the Secretary of State can intervene if the Care Quality Commission fails to discharge its functions.

Section 253 of the 2006 Act says that the Secretary of State can intervene in a service in an emergency, but crucially Foundation Trusts are excluded. Section 67, 242, 266 and 285 of the Health and Social Care Bill already say that the SoS can intervene if one of these bodies (Monitor, NICE, the Health and Social Care Information Centre) fails, or if these bodies fail to co-operate with each other.

Section 4 of the Mackay amendment says nothing new, it merely lists existing sections in the new Bill or sections in existing acts when the Secretary of State can intervene. I cannot see that we gain anything by having the Mackay amendment, so I fail to understand why Lib Dem would consider this as a solution.

Privatisation

OECD defines privatisation as:

Privatisation refers to transfer of ownership and control of government or state assets, firms and operations to private investors.

At the RCGP conference this year Andrew Lansley was asked to define privatisation. He gave two definitions. After being challenged by Dr Clare Geralda Lansley gave the follwoing (his second definition):

Privatisation is the transfer of public service responsibilities into the private sector - we are not transferring responsibility for the NHS into the private sector.

This is not the OECD definition, who say that it is the transfer of the ownership of assets as well as the control of those assets. Lansley talks about the responsibility for the NHS which is a much wider issue. The government/NHS Commissioning Board can still be responsible for the NHS even if all the assets are owned by the private sector, because in Lansley's mind the NHS is the source of the money to pay for treatment: the taxpayer.

This brings me onto the first definition that Lansley gave:

As far as the public are concerned, privatisation would mean - if you would ask them - having to pay for their care instead of receiving that care provided by the NHS free-at-the-point-of-use based on their need. We are not going to move to a place where there is any additional payment.

Again, this is very different to the OECD definition, which says nothing about how services are funded.

The House of Lords Select Committee on the Constitution says that the Bill will change the 2006 NHS Act to say:

(1)  A clinical commissioning group [CCG] must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility—
(a)  hospital accommodation,
(b)  other accommodation for the purpose of any service provided under this Act,
(c)  medical, dental, ophthalmic, nursing and ambulance services, 
etc 

Currently the Secretary of State determines what services will be funded by the NHS, Lansley does not want this responsibility and so it will be local Clinical Commissioning Groups who will decide. The CCGs will decide based on the amount of funding they have - if they do not have enough money they may have to prioritise urgent care and may decide that services that are less "medical" should be paid for by the patient. For example hospital "hotel services". A CCG could argue that if you were not in hospital you would be paying for food and accommodation, they could argue that "hotel services" are not a medical need and so you should have to pay for them when you are admitted to hospital. This argument has been made for many years, but it is usually opposed by arguing that without the "hotel services" the patient cannot get the treatment.

Under Lansley's very restricted definition of privatisation, "having to pay for their care" such a charge for "hotel services" would be privatisation. When such charges are imposed (and they will be, somewhere in the country in the next few years) I wonder if Lansley will admit that the NHS in that area have been "privatised"?

Further, note the statement "we are not going to move to a place where there is any additional payment". This is happening now! The doctorpreneur GPs in Haxby told their patients that the NHS would no longer fund certain treatments (as CCGs will be able to do in the future) and then gave the patients a price list for having the treatment carried out privately additional payments for care. So under Lansley's definition privatisation has already happened in Haxby.

Update:
The question about privatisation (with a reference to Bill Clinton and cigars) from Dr Pete Deveson can be found here (at 9:38). Lansley responds to the question with a disdainful shake of the head.

Personal Budgets

Ideologically I am against personal healthcare budgets. Years ago when I first explained to an American colleague why the NHS was so special I told him: "because whatever condition I have the NHS will give me treatment according to clinical need". Personal budgets go against that principle because it gives a hard cash settlement that specifies how much your condition is allowed to cost. I know that there will be assurances from the government and from Prospect-buying Blairites that no one with a personal budget will be denied care if their budget runs out, but we all know that the whole point of budgets is to give an upper limit beyond which you are not supposed to go: a financial constraint, not a clinical one. We also have to question why, at a time of austerity when the NHS has to save money, the government are forging ahead with a policy that will be more costly to administer and which (if we accept their reassurances) potentially cost more than now? The reason, as we all know, is that personal budgets allows the government to put a limit on what the NHS will pay a limit that the government can lower. This is the first step towards co-pay and top-ups. One third of patients who use the NHS have long term conditions and they use two thirds of the NHS budget; it is statistics like this get management consultants thinking, and their "solution" is personal budgets.

However, Lansley has now promised me a personal budget. I have a stable, but long term condition which means that I am exactly the target for a personal budget. At the Conservative party conference this year Lansley said that personal budgets would start in 2014. The Department of Health spin machine reports:

"People receiving continuing healthcare support from the NHS will have the right to ask for a personal health budget, by April 2014 Health Secretary Andrew Lansley announced today. ... The announcement follows the independent NHS Future Forum report which recommended action to promote personal budgets and implement them within five years to give patients access to tailored services."

So the personal budget programme will start with people who need continuing care (mostly elderly people) from 2014 and then before 2016 everyone with a long term condition (that includes me) will have one. (I do not think "have the right to ask for" means that you can choose not to have a personal budget because running two systems side-by-side will be too expensive and it is clear which one the government prefers patients to use.)

Since I will have to have a personal budget soon I decided to ask my local Foundation Trust what they intend to do to tailor their services for patients with personal budgets. Their reply was "I think personal budgets will be for people needing mental health care". I pursued with my questioning, pointing out what Lansley had said at the Tory party conference. It was clear to me from their response that the Foundation Trust hadn't thought about how it would change in the face of personal budgets, so here is a suggestion.

As a diabetic, I use a range of services, from top to bottom: eye checks to monitor my retinopathy; blood pressure checks (and medication); blood sugar tests (both finger prick glucose testing and HbA1c long term tests); kidney function tests (dipstick urine tests) and checks on my feet to monitor any nerve damage in the extremities. These are services I use at the moment. In the future there will be services treating heart disease and sexual dysfunction.

When I get a personal budget my GP (or a.n.other, it is not clear yet who will adjudicate) will collate the list of conditions I have and the list of preventative treatment and monitoring I need, and using the national tariff he will present me with a figure (in real cash or some made up currency) what my condition will cost every year. I will then be expected to go on a shopping trip with this budget. It is not yet clear whether I will hand my NHS Personal Budget "credit card" to each provider when I use their services, or whether I will "commission" the services off them and hence give an intention of developing a more long term relationship.

Some of the services are naturally primary care services: checks on blood pressure, kidney function and on my feet can clearly be done by a diabetic nurse or a healthcare assistant. Some services could be either in primary care or in hospital, for example monitoring of retinopathy. (Currently I am offered this service by my optician, GP and the local hospital; I choose the latter because I have had haemorrhages and a lot of laser treatment and I would prefer the monitoring to be done by a consultant.) Other services (like laser treatment for retinopathy) will be only provided by a hospital, but there is always the choice of several hospitals.

I do not look forward to the prospect of deciding who does what. This is where the FT can help. The FT could provide a care package. That is, they could put together a collection of services for people with personal budgets which would be a mixture of primary care, hospital care, and community services. These packages should have some flexibility in them (for example, I would prefer to have blood taken at my GP - because it does not involve a bus journey and the hospital does - but I would prefer the diabetologist at the hospital to interpret the results). The idea is to put together a list of services that most people use and provide an advocate who will facilitate the providers to work together for the patient. Such a care package could be put together by a GP, but in this example I will assume it is the FT that designs the package.

The advantage to the hospital is clear, they would be able to make patients aware of their services, and at the very least get some income from the administration fee for helping patients to choose. For the patient there will be an advocate who will help them choose, and will also be there throughout the year to give advice if the patient has a problem with the providers. (For example, if I am told to have my eyes monitored every 6 months and it is now 8 months since my last appointment, the advocate will chase up the appointment for me. If the advocate works for the hospital and the eye monitoring is carried out by the hospital it is more likely that the appointment issue will be resolved.) The advantage for primary care is that they will be able to provide some of the services and with closer working with the local hospital they will; provide such services cheaper.

A care package will be much better for the patient not least because the patient will not have the effort of choosing the services themselves. And the closer working between the providers that a care package will offer will help forge the mythical "integration" that the NHS is seeking.

Cherry picking

The Croydon List is study performed by the London Health Observatory and the Croydon PCT in 200x to determine how much can be saved by not performing cosmetic and ineffectual procedures.

The Croydon List also includes those procedures that have a clinical benefit but are performed when there is a "close benefit/risk balance in mild cases", or to put it in ordinary English, the patient is not yet blind enough, or in enough pain, to benefit from the operation. Let me give you some procedures that are in the ten most common procedures on the Croydon List:

Procedure	Min Reduction	Max Reduction
Inguinal hernia	25%	50%
Hip	15%	30%
Knees	15%	30%
Varicose veins	20%	80%

You can see from this that according to the Croydon List varicose veins operations are considered low clinical value (money can be saved by not doing up to 80% of those that are done now) and that savings can be made on the others by not performing "milder" cases.

The reason whey I mention this is because HealthInvestor (a magazine for private sector healthcare) reports a paper in BMJ that says that "patients undergoing surgery in independent sector treatment centres (ISTCs) have slightly better outcomes than patients treated by NHS centres" and HealthInvestor gives the conclusion that these results "lessen concerns that ISTCs are 'cherry picking'".

However, this is exactly what the ISTCs have done because "The study reviewed the outcomes of patients undergoing hip or knee replacement, inguinal hernia repair and treatment for varicose veins across 25 ISTCs and 72 NHS providers in England". That is, they are procedures that the Croydon List says are either of little clinical use, or where cases can be considered not to be severe enough to be treated. If they are on the Croydon List it does show that ISTCs have cherry-picked the easier procedures to perform.

Yet Another Lansley U-turn?

I thought it was a mistake for John Healey to be so effusive about Lansley in his speech to the Kings Fund earlier this year. In that speach Healey said

"No-one in the House of Commons knows more about the NHS than Andrew Lansley – except perhaps Stephen Dorrell. But Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley."

Healey went on to say that "these are the wrong reforms at the wrong time", but the damage had been done, from this point onwards the Prime Minister would quote the first part "no-one knows more about the NHS than Lansley" and not the latter part "these are the wrong reforms at the wrong time". It was incompetent speech writing to compliment Lansley in any way at all, for he is wreaking irreparable damage to the NHS. And what's more, Lansley is extremely incompetent having entered the Department of Health with a totally unworkable policy that has had to be mutilated to make it work, replacing the existing workable policies with policies that barely work.

One example of this is GP practice boundaries. Consistently, over the last year, Lansley has defended his plan to give patients choice over GPs. A year ago, this choice could be any GP anywhere in England, which lead to some commentators speculating that GPs who looked favourably on complimentary treatments would get patients from all over the country. Lansley had deliberately avoided mandating that GP Consortia should cover practices from a geographical area so it could have been possible for a consortia to cover GP practices from all over the country. The Future Forum recognised that this was nonsense and reluctantly Lansley changed this policy to say that Clinical Commissioning Groups must cover a geographical area and preferably those practices within a local authority boundaries.

The issue of practice boundary (rather than commissioning group boundaries) has raged on for a year now. Fairly early on it became clear that abolishing GP boundaries would have a knock-on effect on the planned 111 urgent service. The problem is that if a patient needs a home visit from their GP this would be completely impractical if the patient is not local to the GP. So the 111 urgent service had to changed to cover patients in a geographical area effectively replicating the GP home visiting service provided by GPs. Lansley's intransigence on GP boundaries was adding expense to the new 111 service.

GP boundaries have an effect on commissioning. If a GP practice can have patients from any area this means that the Clinical Commissioning Group that contains the GP practice will not cover a population in a defined area. Local services commissioned by the CCG will by necessity cover a geographical area, but with a disparate patient list these would be difficult to commission. GP boundaries also have a significant effect on funding. If patients have a choice of GPs they may "shop around" for the GPs with the higher budgets. If a practice has a patient with an expensive long term condition this will mean less money for other patients, this may mean that other patients will move away to practices without expensive patients. If patients move from a practice this will compound the problem because as a practice patient list shrinks the expensive patients will take up progressively more of the shrinking budget. Abolishing practice boundaries will make it more likely that GP practices will go bankrupt.

A lot of GPs have been worried about the practice boundary issue because it is the essence of risk pooling: the money not spent on health patients can be spent on patients with health problems. At the RCGP Annual Conference last week Lansley was challenged on GP boundaries and issued what is clearly a u-turn (Pulse):

He said: 'I'm clear that whatever we do, general practice must always remain rooted in local communities. We need to think carefully about how to manage home visiting, about how patients who don't live locally to their practice can receive urgent care, and about how information is shared. We will make sure it is done in a way that will preserve the responsibility for CCGs for the health of their local population.' When pushed to clarify his position, Mr Lansley said: 'I am not abolishing, or about abolishing, practice boundaries. I am intending to extend patient choice.'

Clearly his position has changed. For a year now he has insisted that practice boundaries were 'a solid wall of defence' against patient choice and therefore he had to remove them. Now Lansley is admitting that boundaries must be retained but now he needs to 'think carefully' on how to extend patient choice of GPs.

This is clearly a case of incompetence, abolishing practice boundaries was never a policy that could work while GP practices are paid through a capitation (a fixed fee per registered patient). Abolishing practice boundaries may work if patients with expensive conditions are given personal healthcare budgets, but at the moment no one knows how, or whether, personal budgets will work, and currently they are unpopular with patients as a way to fund healthcare.


It really is time that Labour stopped praising Lansley for his "knowledge" of the NHS and start criticising him for forcing on us an incompetent policy. As one comment on the Pulse article says:

"This is another example of how Lansley has no idea how the system works at a grassroots level. Words alone fail me when trying to express how fundamentally flawed Mr Lansley and his health bill are, and just how deluded and misguided he is! He simply does not have the knowledge, competance or experience to usher in this "top down" reorganisation of the NHS - something which his party's manifesto pledged it would not undertake."

This says it all, Labour needs to echo these sentiments: Lansley is incompetent.

Norwich South

I think Norwich South shows what went wrong with Labour over their three terms of office. This first graph is the majority that Labour had from 1997 in a seat that has been a Labour seat for a decade before:

A huge 14,000 majority in 1997 has shrunk so much that the Labour candidate lost at the 2010 election by 310 votes. Why was this the case? Well, let's ignore for a moment the candidate who achieved the 14k majority and lost it last year, and instead look at how people have voted in that constituency. In this graph I have plotted the votes for the three main parties, and the Greens:

The Labour vote plummets: halving over the 13 years. The Conservative vote dips and rises slightly over that period. The main beneficiaries of the lost Labour vote have been the Lib Dems and the Greens, and in particular the latter: the Green vote has increased by a factor of ten. The interesting point is that the polls for the three parties are converging over that decade.

Now look at the British Attitudes Survey from 2009

This shows a similar convergence between Labour and the Conservatives. (The Lib Dem bounce in the year before the 2010 is not recorded here.) There is a rise in those people who regard themselves as having no political affiliation, or don't know, and  'other' also increases. In Norwich South the Greens have benefited from the rise in 'other' and possibly from those people with no affiliation choosing the Greens as a protest vote.

Of course, it could be the Labour candidate who inherited a constituency with 6k majority at a time when there was a national mood for a Labour landslide and then, after gaining a 14k majority in 1997, allowed it to slide by his behaviour in Parliament both as a minister and as a backbencher with a grudge. The losing Labour candidate was, of course, Charles Clarke.

Secretary of State Responsibility

The Department of Health has produced a document called the Memorandum for the House of Lords Delegated Powers and Regulatory Reform Committee. At 322 pages, it is rather long, but it is worth skimming through to see how the department thinks it can persuade the Lords.

In this blog I want to address the duty of the Secretary of State for Health.There is a lot of controversy about this at the moment and it is rumoured that the Liberal Democrats will capitulate and will not take part in voting in the House of Lords if the government can come up with words that reassure them about the role of the SoS. If this is the case then it is disgusting that Lib Dems have agreed to a shady backroom deal and shirk their Parliamentary duty, but to be frank, it would not surprise me.


The memorandum starts with the following paragraph:

10. The Bill maintains the overarching duty of the Secretary of State, which dates from the original NHS Act of 1946, to promote “a comprehensive health service designed to secure improvement in the physical and mental health of the people of England, and in the prevention, diagnosis and treatment of illness.” It distinguishes for the first time between healthcare and public health, laying the way for the new Public Health England. It also sets clear constraints on the Secretary of State’s ability to intervene in the NHS.

This is bizarre, first it says that the SoS duty conferred by the 1946 Act will be maintained, but then says that the SoS's ability to intervene is constrained. So which is it, the SoS maintains his historic duty or is constrained? You cannot have both.

The next paragraph makes it clear that the SoS will lose powers:

11. The Bill sets out a framework for the NHS in which functions are conferred directly on the organisations responsible for exercising them and the Secretary of State retains only those controls necessary to discharge core functions. This contrasts with the current model, in which the majority of duties, powers and functions are conferred on the Secretary of State and then delegated to NHS bodies.

This tells us that the current situation is that the SoS has "duties, powers and functions" conferred upon him but the Bill will strip him of these and will only get "those controls necessary to discharge core functions". This is exactly what we are complaining about. The original NHS Act put a duty on the SoS and we expect the minister to be responsible. The Bill removes that responsibility. It is clear that the SoS cannot run the entire health service himself and so has to delegate that responsibility to other organisations. But the important point is that at the moment the buck stops at the SoS. We hold him to account, and this means that he has an incentive to improve the service. The Bill removes that incentive.

The document is full of contradictions, it tells you what will happen and then tells you that the result will be something other than what the policy will do. For example:

15. The Bill also places a new duty on the Secretary of State to act with a view to promoting the autonomy of arm’s length bodies, commissioners and providers to exercise their functions as they see fit, so far as is consistent with the interests of the health service. This duty would require the Secretary of State, when considering whether to place requirements on the NHS, to make a judgement as to whether these were in the interests of the health service. If challenged, the Secretary of State would have to be able to justify why these requirements were necessary. It does not undermine his duty to promote a comprehensive health service. The Secretary of State will remain ultimately accountable for the NHS.

First this says that the SoS has a "duty" to lessen his responsibility as much as possible, then it says that this does not reduce his duty. If you restrict the duty of the SoS then the SoS's duty has been restricted! (Incidentally, "providers" are hospitals, community health services and primary care like GPs. This is saying that the SoS has no control whatsoever over what they will do.)

This statement on autonomy is like handing him a cage of sparrows and saying "it is your duty to look after these sparrows, but you cannot keep them in the cage". If the SoS opens the cage the sparrows will fly free, so he cannot be responsible for what they do. How can a SoS be responsible for organisations that are autonomous? Autonomy means that the SoS no longer controls them. This statement is clearly saying that the SoS cannot be responsible for the NHS, yet the last sentence tells us that he is!

To labour the point further, the memorandum says:

16. The overall framework proposed in the Bill is designed to give the NHS greater freedoms, improve transparency and help prevent political micro-management. The powers of the Secretary of State would be constrained and made more transparent. At the same time, political accountability to Parliament would be strengthened. For example, the Bill places a new duty upon the Secretary of State to keep health service functions under review and to report annually on the performance of the comprehensive health service.

Yet again: "the powers of the SoS will be constrained". But look at the last sentence: the new "duty" of the SoS is merely to report annually. Currently the SoS has to answer health services questions once a month and MPs can ask the Prime Minister a question about the NHS at PMQs which is held weekly. Instead of weekly or monthly accountability, we will have annual accountability. Is this really an improvement?

The SoS will no longer be able to tell NHS providers to improve. For example, in 2007 the government decided that MRSA infections had to be tackled and the government ordered a "deep clean" of NHS hospitals. In August 2010 Andrew Lansley pledged to end mixed sex accommodation by the end of the year (in fact, he has failed, as he admitted at the Tory party conference where he said that mixed sex accommodation has been "curbed by 90%", whatever that means). Under the new system the SoS will not be able to order "deep cleans" or to rid the service of mixed sex accommodation, because paragraph 12 says that the SoS "will be removed from operational management". Instead, the SoS will merely request that something should be done through something called "standing rules":

19. In line with the policy intention to give more autonomy to the NHS, the Secretary of State would not have a general power of direction over the Board or clinical commissioning groups. Instead, the Secretary of State would have a new power to make regulations ("standing rules") which set out the system rules with which the Board and clinical commissioning groups would need to comply in certain areas. These areas are specified on the face of the Bill, and the detail would be set out in regulations.

So when the SoS wants something to be done, he has to create a standing rule and pass this to the NHS Commissioning Board and/or the Clinical Commissioning Groups and ask them do to something about the issue. Of course, NCB and CCG do not provide healthcare, they commission it (the clue is in their names) and this means that if any operational changes need to be made the commissioners have to then ask the providers to make the changes. This is a labyrinthine process and is likely to paralyse the system. Further, the NCB will only be accountable once a year, (as will the SoS) so there will be no regular public accountability. Basically, nothing will be done and the SoS will tell us that it is not his fault that nothing is being done.

Can you seriously imagine someone like Lord Sugar wanting to change his business and being satisfied with writing a request for the change to be made and hoping that something will be done? Of course not. Lord Sugar will want to bang heads together, bark orders and if things don't get done, fire staff! That is what it means to be responsible. Yet the SoS, who we are told has ultimate responsibility for the NHS, will not be able to demand changes are made, and will not be able to sack those who fail to deliver.

The SoS currently has a power to create a Special Health Authority and delegate powers to that organisation to provide a service to all of England. The SoS has responsibility for the service and ultimately can intervene if the SpHA has problems. For example, the National Blood Authority is a special health authority and in fact, the National Commissioning Board itself is currently a Special Health Authority (its status will change once the Bill is passed). Currently SpHAs are created under the powers of the SoS, but the Bill restrict this power in the future:

23. The Secretary of State would continue to have a power to establish new Special Health Authorities by order, but this would be subject to limitations. In order to establish a new Special Health Authority, the establishment order would have to specify the period for which the body is to be established, which could be no more than three years. At the end of that period, the body would be automatically abolished and its staff, property and liabilities transferred in accordance with the establishment order. If deemed necessary, the lifespan of a Special Health Authority could be extended by order subject to the affirmative resolution procedure, or the functions, staff and property of the Special Health Authority could be transferred to a new body established as a non-departmental public body through primary legislation.

The "affirmative resolution procedure" mentioned here refers to a process where both Houses of Parliament have to agree to the motion.

This paragraph shows that the powers of the SoS are being seriously restricted, and even those things that the SoS is allowed to do, there is an automatic sunset clause. This is a legislative straitjacket, showing that the SoS will be largely impotent when it comes to running the health service in the future.

The government is trying very hard to convince people that the Secretary of State for Health will still be responsible for the health service. However, the House of Lords memorandum shows that this is not the case. Many of the SoS powers are being transferred to the NHS Commissioning Board, other powers (currently delegated - but not transferred - to Strategic Health Authorities and Primary Care Trusts) will be transferred to Clinical Commissioning Groups. This is very important, the SoS will transfer these powers, not delegate them, so he will not be, and never more will be, responsible for these powers.

After the Bill is passed the SoS will never again be responsible for the majority of the provision of the NHS.

Integration

Integration is the buzzword of the time. We are told that the Health Bill will promote the concept and a scan of the explanatory notes show that integration is covered in four clauses: 20, 23, 59 and 62. The first two alters the National Health Service Act 2006 the other two are clauses of the Health and Social Care Bill.

Clause 20 and 23 are almost the same, the former refers to the responsibilities of the NHS Commissioning Board, the latter refers to the responsibilities of the Clinical Commissioning Groups. Both of these say that the NCB/CCG must have a view to secure health services "in an integrated way" when "it considers" that this would improve quality or reduce inequalities. Similarly it says that the NCB/CCG must have a view to secure the provision of health services is "integrated with the provision of health related services or social care services" when "it considers" that this would improve quality or reduce inequalities. Further, clause 20 says that the NCB must encourage CCGs to work with local authorities to integrate health services and integrate health and social care services.

Clause 59 makes similar statements about Monitor, saying that it "must exercise its functions with a view to enabling health care services provided for the purposes of the NHS to be provided in an integrated way". Similarly Monitor must enable the provision of healthcare services to be integrated with social care services. Clause 62 says that Monitor must "have regard to" ensuring that different providers co-operate with each other.

All of this sounds fine, except that it does not say what "integration" is. The term is not defined in the Bill, nor is it defined in the explanatory notes. It simply says that services must be integrated if it is considered that this will mean a better quality for services or if it will reduce inequalities. The "it considers" phrase is interesting because it does not mandate such actions. It does not say what this consideration is, nor what redress there is if others have a different opinion. The Bill does not define what "quality" is when it comes to integration.

Presumably this means that integration (whatever that is) can be ignored if the NCB/CCG considers (whatever that means) that quality (whatever that is) won't be improved or if inequalities won't be reduced. None of this seems to promise anything at all.

The Bill explicitly maintains the separation of the duty to provide social care (a local authority duty) and health services (and NHS duty, that will be in the gift of CCGs). The Bill explicitly imposes a duty of competition and "choice" (see clause 71) which will fragment the service. The Bill explicitly sets up a price list system called the "the national tariff" yet nowhere within this pricing system does it mention the integration of services, or ensuring that the national tariff does not prevent the integration of health services or the integration of health and social care services.

Why is this important? Well competition is the antithesis of integration, competition means that providers must compete to provide services and therefore are always working to replace, rather than work with, other providers. Different providers can co-operate (clause 62 says that they must) but if there is a single provider for all services it is far easier for the services to be provided in an integrated way. For example, a single provider will have a single mechanism for patient notes; a single provider can provide a single system for patient complaints and the resolution of those complaints; and a single provider ensures that there is just one budget. Multiple providers allows for a considerable amount of buck-passing, with providers saying that it is "not their responsibility" or that their budget "does not cover that". There is nothing in the Bill saying that there is a duty to reduce (or eliminate) this buck-passing.

The Bill says that the NCB, Monitor and CCGs all have a duty to secure provision of integrated services, but Monitor has a responsibility to prevent "anti-competitive behaviour" so that would mean that CCGs would have to find a middle ground between integration of services (to keep NCB happy) and competition (to keep Monitor happy).

In HSJ Prof Bob Hudson says: 

"In the meantime, established joint arrangements between the NHS and social care are collapsing. The implosion of PCTs has destroyed the high trust networks that have been developed with some far-sighted councils; some CCGs are already demanding to have ‘their’ community nurses returned from integrated teams; councils are withdrawing social workers from integrated mental health teams; and disputes about responsibility for funding continuing health care are escalating. Far from moving forwards, the collaboration clock is actually being turned backwards."

This is concerning and does not bode well for the prospects of a comprehensive integrated service in the future.

Basically, the Bill plays lip service to integration but does not say what it is and makes little attempt to ensure that it happens.

PMI eyes PPUs

The Health Bill will abolish the private patient income cap (PPI) that was imposed by the 2006 NHS act. This cap says that Foundation Trust hospitals cannot earn more from private patient income than the proportion that was earned in 2003. Overall, Foundation Trusts' income generate 1.1% from private patients and services to private patients, but some specialist hospitals have large incomes from private sources (the Royal Marsden has the PPI cap set at 30.7%, Royal Brompton and Harefield the cap is 14.4% and Moorfields Eye Hospital the cap is 13.7%). Most of these hospitals have a private patient unit (PPU), quite simply because private patients pay not to rub shoulders with us, the hoi polloi.

In the last year or so, several trusts have said that they want to increase their private patient income on a rather naive assumption that thousands of patients are desperate to spend their money with them. Private health in this country is in the doldrums and has hardly recovered from the recession, so it is naive to think that a NHS hospital's PPU will be a money spinner. PPUs are likely to be a drain of money since there is no guarantee that they will get enough private patients to pay for the investment they have had to make to shield the private patients from the NHS public. However, Foundation Trusts have recently been hit with a 1.5% cut in tariff (the payment for most elective procedures) and need another source of income, and private patients appears to be an easy ssolution.

A report by ippr in 2008 suggests that spending on private medical insurance (PMI) remained static over the previous decade at 2.81% of the entire UK economy. They suggest that in 2005, 6,536,000 people were covered by PMI (10.9% of the population) and that 51% of the insurance was paid by employers. Additionally, they suggest that in 2005 19% of the payment for private healthcare in hospitals was self-pay. More up-to-date figures from OFT suggest that by 2009 self-pay had fallen to 15% whereas income for private hospitals from NHS patients was 23% and from PMI was 61%.

The ippr report says:

"If waiting times are high and/or perceived treatment quality of the public system is low, [PMI] is perceived to be necessary for timely, high-quality medical treatment. As such, demand for [PMI] will be driven by middle and higher income groups. If waiting times are low and perceived quality is high in the public system, demand for [PMI] shifts towards non-clinical features such as 'convenience' of access to treatment, and 'hotel-like features' of medical facilities; as a consequence, [PMI] tends to concentrate among higher income groups only."

which is common sense. It is reasonable to assume that in a time of austerity, when there is a free-at-the-point-of-use service available to all (hence basic coverage without the "non-clinical features" mentioned above), self-pay for private treatment would be considered to be an unnecessary luxury and private hospital income from self-pay would fall. PMI is less sensitive to an economic downturn (since the contributions are smaller), but clearly as incomes shrink it too would be considered an unnecessary luxury both by individuals and employers and so the proportion of people covered by PMI should fall.

Considering that the UK economy is in such a poor state, all of this suggests that private hospitals are in a bad position. Indeed, the Nabarro Healthcare Industry Barometer 2011 (pdf) survey says that 60% of respondents think that their income will not return to "pre-credit crunch levels" until after 2014 (this was up from the figure of 55% in their 2010 survey). Interestingly, the Nabarro survey says that 35% of respondents thought that "budgetary pressure in the NHS led to increased demand for private care provision". Further, the government policy of Any Qualified Provider, which means that patients can choose care in a private hospital, is one way that private hospitals can make up for any falls in self-pay or PMI patients, so it will be interesting to see how the 23% figure given above will change when AQP is introduced.

Private medical insurance clearly need to do something to increase their subscribers and one way to do this is to lower the cost of the product. A few days ago I got the following junk mail from Aviva:

This is the usual nonsense: "you deserve private medical treatment" when in fact everyone deserve a comprehensive health service. However, I have highlighted an interesting paragraph:

"By choosing the Trust Care hospital list, you can reduce your monthly premiums by 25% by simply using private facilities within NHS Trust hospitals."

This ignores the fact that by choosing the NHS you can reduce your monthly premiums by 100%! The letter raises some questions. Why is it that insurance for NHS PPUs is 25% cheaper than private hospitals, what is it that makes them cheaper? If PMI is recommending NHS PPUs does this mean that in the past when they have emphasised that private hospitals are clean and have expert care - and by implication that the NHS does not - that they were actually, wrong? Will we see PMI actually promoting NHS PPUs in the future?

PPUs have got the private hospitals spooked. The Nabarro survey says that 37% of respondents either agree or strongly agree that removing the PPI cap is a "threat to the independent healthcare sector". Since Aviva is now pushing PPUs as cheaper alternatives to private hospitals this backs up the pessimism about PPUs in the Nabarro survey.

There's more of us than there are of you

According to Monitor the memberships of Foundation Trusts at 31 March this year were 1,236,132 public members (opt-in) and 516,361 staff members (opt-out). According to the BBC political party membership in 2011 was Conservative 177,000, Labour 190,000, and Lib Dem 66,000. So the political parties with 236k members (the Coalition) are making laws that will affect the trusts which have 1.2m public members.

There's more of us than there are of you, perhaps you should ask us (FT members) what we want before you make changes?

Monitor and CQC: unfit for purpose?

The report yesterday from CQC about dignity and nutrition at NHS hospital trusts raises several questions. Clearly it is unacceptable that people are not fed. However, one question that has not been asked is: why did these trusts get into the this situation?

The report lists trusts that they categorise as raising "major concerns and those that raised "moderate concerns". Interestingly the media give the aggregate of these two – 20 trusts – rather than reporting that there were just two that raised "major concerns". These two worst trusts are NHS Trusts, that is, they have not yet achieved Foundation Trust status. Of the 18 that raised "moderate concerns" nine are Foundation Trusts.

When Foundation Trusts were introduced the initial criteria were financial: if a trust showed that it had the financial skills to keep in the black (indeed, to make a surplus every year) then it was awarded FT status. When the Mid Staffs scandal blew up, the Foundation Trust regulator, Monitor, initially suspended all applications and then changed the authorisation criteria so that a trust has to show that it fulfils clinical as well as financial criteria. After authorisation a FT must continually prove that it meets the authorisation criteria (listed here, pdf) or else it will be in breach of its authorisation. Monitor has a range of powers varying from requesting that changes are made, to interventions like replacing board members, to the ultimate sanction of de-authorising a trust. (Of course, after the Health Bill is passed de-authorisation will not be an option since there is nothing a trust can be de-authorised to.)

Monitor states that FTs boards must continue to show that their trust complies with their authorisation criteria including:

• delivering healthcare services to specified standards under agreed contracts with their commissioners;
• maintaining registration with the Care Quality Commission and addressing conditions associated with registration;
• complying with healthcare targets and indicators
• cooperating with the Care Quality Commission and a range of NHS and non-NHS bodies which may have a remit in relation to the provision of healthcare services

This says that to remain as an FT a trust must show that it provides high quality healthcare. CQC inspects all FTs and reports their findings to Monitor who then issues notifications of breaches. Monitor says that:

"In cases where the Care Quality Commission indicates that it has material concerns regarding an NHS foundation trust’s registration with Care Quality Commission standards, Monitor will work with the Care Quality Commission to establish the most appropriate course of action to return the trust to compliance with those standards in a suitable timeframe."

So it is quite clear that between them CQC and Monitor have a responsibility to ensure that FTs have high standards of clinical care. If a trust's standards fall this should be picked up by CQC, who will then inform Monitor. Monitor then determines the intervention that is needed. 

Monitor lists nine FTs where an intervention was necessary, most of these interventions were due to poor financial governance and only one was listed in the CQC nutrition and dignity report. Monitor also lists 12 hospitals in breach of their authorisation, none of which are in the CQC report. CQC lists on its website the trusts that it has concerns about. This gives just three acute hospital FTs and none of which were mentioned in their report on elderly care. 

Why didn't CQC notice before that there were nutrition and dignity issues at the 20 trusts? Monitor exists to ensure that FTs are high quality. CQC has a responsibility to report on poor care. CQC and Monitor exist solely to ensure that Foundation Trusts are high quality, and any perennial failure in quality of FTs indicates that these two regulators are not fulfilling their responsibilities. There are serious questions that needs to be answered about whether these two regulators are actually fit for purpose. Finally, when the Secretary of State removes his own responsibility for the NHS bear in mind that we will be left to the mercy of these two organisations, there will be no one to take leadership over any failings in quality.

Update: Community Care have an article today about the reaction from Action on Elder on the CQC report. AEA say:

"These inspections suggest CQC has little or no sense or urgency in terms of its regulatory activity, often leaving very vulnerable people in neglectful or abusive settings while waiting for 'action plans' to be delivered by a care provider. In our view this is a major failing in its 'duty of care'."

Remember that CQC has not yet taken over the responsibility for inspecting primary care: GPs, opticians, dentists etc. If CQC are failing now, what will it be like when their workload increases due to these extra duties?

Silver lining?

I am a pessimist (some would say a curmudgeon) so the votes in the House of Lords does not surprise me, especially since many of the Tory peers who voted probably had not been in the chamber for years and were voting out of mere loyalty to a political party.

The Bill:

1. will not save money, quite the opposite, it will cost billions to implement and the bureaucratic structures that have been created will slow down any re-configuration that is needed and will cost a pile of money in the process;
2. will produce a postcode lottery on a scale that England has never before experienced and as a consequence, health inequalities will increase;
3. will mean that rationing will be rife and people will find that they have no recourse;
4. together with the financial squeeze and the wasteful bureaucracy created by the Bill will result in a financial crisis

The time to get ill in England was a decade ago, from now on, you'll find yourself more and more on your own.

One could argue that if Labour had won the election last year the NHS would have faced tightening finances too. Labour promised the same flat funding and also promised the £20bn "efficiency savings". However, Labour did not promise a £2bn re-organisation, but whether this extra £2bn of funding would have been enough to avert the financial crisis the NHS will suffer is something we will never know. The forthcoming financial crisis and the rationing inherent in the Bill will mean that the NHS will be the main issue at the next election.

The government know that there will be a financial crisis in the NHS, and they know that if it is not averted we will see patients on trolleys in corridors. Currently, Lansley is backtracking on NHS finances. At the Health Select Committee yesterday he said that the "efficiency savings" were "up to £20bn" rather than strictly £20bn. This will allow him to relax the "Nicholson Challenge" diktat when it becomes apparent that either the NHS cannot achieve a 4% cut every year, or that cutting so deep will push the service into crisis. Further, Lansley is also suggesting that some hospital trusts may be bailed out, something that the white paper last year said the government would not do.This is being done to make sure that there are not too many trust bankruptcies before the next election. Further - to try and persuade Lib Dem and Crossbench peers to vote against the Owen amendment - the government has conceded that the Secretary of State will have responsibility for the NHS (although we have yet to see the actual details, in particular, whether clause 10 will be removed).

So is there a silver lining? On a purely political basis, there is. From this point on the government cannot say that the state of the NHS is the fault of the last government: by passing this Bill they are making the NHS work their way. If this bill is killed then the Conservatives can say that the NHS that Labour bequeathed was wasteful and inefficient and say that this is why it is suffering a financial crisis.

When the Health and Social Care Bill is passed, the NHS will be Lansley's NHS and any ensuing financial crisis will be entirely the government's fault. At the next election Labour will be able to say to the electorate: look at what the Tories have done to our NHS. And hopefully, Labour will promise to fix the postcode lottery and raise funding to curtail healthcare rationing. We will all benefit.

AQP and Commissioning

On the surface AQP (patient choice) and commissioning are antithetical since commissioning is carried out for a population, whereas patient choice is for the individual. However, the two can be combined. The House of Lords constitutional select committee report on the Secretary of State's duties outlines this:

12.  Clause 10 of the Bill amends section 3(1) of the NHS Act 2006. As amended, section 3(1) would provide as follows:
(1)  A clinical commissioning group [CCG] must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility—
(a)  hospital accommodation,
(b)  other accommodation for the purpose of any service provided under this Act,
(c)  medical, dental, ophthalmic, nursing and ambulance services, 
etc

In the 2006 Act it is the Secretary of State who has this responsibility. If this clause survives into the Act then CCGs will decide "to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility" the medical services in the area. That is, the CCG determines which services the NHS will pay for. So when GPs in Haxby offer private procedures to their patients they are merely jumping the gun: this is what it will be like in most areas after the Bill is passed. The CCG determines the services the NHS will pay for and private providers (including GPs themselves if they have a private business) can offer the services that are not paid by the NHS as private services.

The government's policy document Making Quality Your Business: A guide to the right to provide says:

To qualify as an AQP, providers will be subject to a qualification process. They will be required to show that they can meet the conditions of their licence with CQC and/or Monitor (if necessary), provide safe quality services to the contractual standards set by the NHS Commissioning Board and meet NHS prices – either set nationally or locally.

This is where the Q in AQP comes in, once a provider has met the conditions of CQC and Monitor it becomes an AQP. However, CCGs do have some leverage, the same document goes on to say:

Commissioners (PCTs and consortia) can set reasonable additional contractually binding quality standards to meet the needs of particular communities or patient groups. This could include referral protocols and thresholds to manage demand and support integration with local services. Providers will be expected to work within and as part of the local health system.

(Note that this pre-dates the introduction of the term CCG.) This says that CCGs can insist that AQPs meet the specific needs of their population and hence this is is another part of the Q in AQP and is part of the commissioning that the CCGs will do.

Once AQPs have been licenced (and hence meet the criteria of CQC, Monitor and the CCG) they will be put on the list of providers from which the patients can choose:

Commissioners cannot refuse to accept qualified providers once qualified, unless providers fail quality standards, reject the agreed price or refuse to comply with any reasonable, additional, locally set standards.

GPs cannot tell patients which AQP provider to use and they cannot refuse to add an AQP provider to the list of providers patients can choose from, so any talk of GPs "protecting" NHS providers is fanciful because Monitor will force them to add AQPs to the providers list.

The remaining "commissioning" part of CCGs is determining which services the NHS will pay for. This is clause 10 of the Bill and is also described in the Making Quality your Business policy document:

It will be for commissioners to decide which services are best delivered through an AQP approach or tendering but the presumption will be that for most services patients will have a choice of Any Qualified Provider.

This says that the government says that there should be a presumption that most NHS services will be AQP, but note that the commissioners (CCGs) decide which services are provided.

Fickle Patients

Earlier this week I wrote for UK Uncut an article about how I think that the government's Any Qualified Provider policy will be the main driver to privatise the NHS. My argument was that the policy will create thousands of new providers who will appear on the Choose and Book system, and when a patient chooses a non-NHS provider that will mean money for their care will go to the new provider (most likely profit making) and not to their local NHS hospital. The result will be that the service in the NHS hospital will close (through lack of patients), and this may well have a knock-on effect of closing other, more complicated, services in the hospital that are cross-subsidised by the simpler services. (Poly Toynbee takes up this theme in her column in the Guardian today. An article that deserves a read.)

My message in my UK Uncut article was this. It's our NHS: Choose it, or lose it.

The problem is that this depends on patient choice, and patients are fickle. Let me give you an example. A few years ago I attended the AGM of the hospital local to me and there was a talk by their consultant eye surgeon. The talk was about Age-related macular degeneration. Until recently this was an untreatable condition: if you suffered the condition then you would go blind. Then it was discovered that people with one version of the condition (the so-called "wet" version) who were treated for bowel cancer found that the macular degeneration was halted. These patients were treated with an expensive drug called Avastin. Studies showed that when tiny doses of Avastin are used, the "wet" macular degeneration can be halted.

The surgeon told the AGM that such a dose of Avastin cost £1. The problem is that the drug company realised that patients were desperate to save their sight and would pay accordingly. The drug company chemically altered Avastin to remove the cancer treating property, but keeping the macular degeneration properties, and called this drug Lucentis. For no other reason than the fact that it would make them loads of money, the drug company priced Lucentis at £1000 per treatment. The surgeon told us that on average ten treatments were needed.

Avastin or Lucentis: £10 or £10,000? The surgeon said that all evidence showed that there was no difference between the two drugs other than the price. However, the drug company only applied for a licence for Lucentis to be used to treat "wet" age-related macular degeneration. Remember that we are told by the government that the NHS is horribly "wasteful"? It isn't. The surgeon told the AGM that when a patient is referred to his clinic it is explained to them that the licenced drug and the unlicenced drug are the same clinically, but there is a factor of a thousand in the cost of the drug. The hospital has to get the patient agreement to use the unlicenced drug and save the NHS (on average) £9,990 when saving their sight.

Half of patients choose the expensive drug even though it gave them no extra benefits.

Patients are fickle. Even when they are given all of the facts, there are some patients who think "if it costs a thousand times more, it must be better". I am sure the hospital did not mention rationing because they are professional. However, the half of patients who chose Lucentis also chose to deny another patient of a treatment that could improve their life, since there is a limited amount of money and money wasted on a drug that is priced to be a cash-cow is money that cannot be spent on other treatments.

In the future, when patients are given an AQP choice between a private hospital and an NHS hospital there will be some patients who will say (without any evidence to support their view): "the private hospital must be better". I want patients to defend our NHS, but I fear that too many will be enticed by irrational arguments to use non-NHS providers and this will result in our NHS hospitals closing.

Patients are fickle. This is why we will lose our NHS.

Update:
My thanks to @DrPanik on Twitter for this link to the New York Times describing the Avastin/Lucentis issue in the US.

Hospital Closures and Catchment Areas

If patients behaved as consumers there would be no such thing as distinct "hospital catchment areas" because a patient would treat all hospitals in England as a candidate for their choice and consequently each hospital would have a "catchment area" of England. However, we know that patients do not want choice: they just want to use their local hospital. The most rabid governmental promoters of competition, the Cooperation [sic] and Competition Panel, say "on average patients travel around 12km to their chosen provider", the "chosen provider" is quite clearly a local provider. So hospital catchment areas are important.

Health Service Journal and the Financial Times have recently come out with lists of hospital trusts at financial risk. HSJ came up with a list of 22 trusts where their PFI payments are so large that they are unlikely to be able to meet the financial criteria required to be authorised as a Foundation Trust. The Financial Times list 17 trusts where their level of historical debt (which includes PFI) threaten their ability to be authorised as Foundation Trusts. There is some overlap between the two.

HSJ-22
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 (+ Nuffield Orthopaedic Centre)
North Bristol

FT-17 
Mid Yorkshire Hospitals
North Cumbria University Hospitals
Trafford Healthcare
Hinchingbrooke Healthcare
North Bristol
Royal United Hospital Bath
Winchester and Eastleigh Healthcare
Heatherwood and Wexham Park Hospitals
Buckinghamshire Healthcare
Surrey and Sussex Healthcare
Royal Cornwall Hospitals
North West London Hospitals
West Middlesex University Hospital
St George's Healthcare
Whipps Cross University Hospital
Barking, Havering and Redbridge University Hospitals
South London Healthcare


In the original Bill the government said that if a trust is not a Foundation Trust by April 2014 it would cease to exist (meaning, it would have to merge with an existing FT, or close). Such a pronouncement was simply bonkers: there just wasn't enough time to change the finances of trusts with extremely large debts. Lansley stuck to the ludicrous deadline until the Future Forum made it clear how daft this deadline is. The deadline has now been moved to April 2016 and there is talk of it being pushed further into the future.

Politically it was bonkers too because a deadline of April 2014 would have meant that the government would go into the next election under the shadow of closing hospitals. Voters like hospitals and it is a brave politician that says that an NHS hospital must close. So there is an important political aspect too. Last December I pointed out that Labour and Liberal Democrat areas have a higher number of Foundation Trusts than Conservative areas. Foundation Trusts in general are the hospital trusts with better finances, so my limited analysis from last year showed that Conservative and Liberal Democrat MPs would be more at risk than Labour MPs seeking re-election.

Since last December I have been working on this political aspect, but it is not easy. One way to look at the issue is to look at the constituency where the trust is located. However, since the average constituency size is about 70k and even a small district general hospital will cover a population of several hundred thousand, it is clear that more than one constituency will be affected by the financial issues at a single trust. There is also the fact that in urban areas the catchment of hospitals overlap, so in the overlapping areas (where patients have two or more hospitals that they can regard as "local") the poor finances of one hospital will have a lesser effect. Clearly, any analysis means taking into account several constituencies around the trust and making estimates to "weight" the effect of poor finances.

Even so, in June I created the following spreadsheet to try and analyse the political effect of hospital finances. This is an extract because I collated more information but I could not come up with a good conclusion from the data. If you take a figure of around 5% as a "marginal" then the figures (for the combined HSJ-22 and FT-17 list) show that three Labour marginals and five Conservative marginals are affected. If we assume the campaigning in these marginals will target the Coalition (and increase the Labour vote) then these hospital trusts will only affect five seats, and of these only two are where Labour came second (and could take the seat). I rejected this analysis because it is far too simplistic to assume that only one seat would be affected by the local trust's finances.

Over the last few months I have tried to get an idea of the catchment areas of trusts. It is not an easy thing to do. Some trusts list in their annual reports the populations they cover; some trusts list this in their descriptions on the NHS Choices and some list it in their descriptions on the Dr Foster Intelligence website. The problem is that not all trusts do this, so if you use data from these sources you have to do some guess work.

A better way to determine the catchment area is to look at the home addresses of the patients who use a hospital. Such information is collated by the Hospital Episode Statistics Online website. Home addresses are personal and it would not be ethical for this information to be made public. However, it is possible to convert a postcode into a local authority election ward and since each ward is about 10k - 15k such data will not have patient identification values but can still be used to determine catchment areas. Unfortunately HES Online do not provide this data by default, but can provide it on request (for a fee).

This is what the South West Public Health Observatory have done. They have analysed HES data which includes the home address of the patient and produced a series of maps with electoral wards colour coded according to the number of patients who use the hospital. Take for example North Bristol NHS Trust. This is on both the HSJ-22 and FT-17 lists. The SWPHO gives the following map for the catchment area (I have provided an extract to conserve space).

The darker the blue shading, the more patients use the trust (the circles also indicate the number of patients). If we ignore the cyan areas (since some patients choose to go to other hospitals in these areas) and concentrate on the three shades of blue, we can see that patients come from seven 2010 constituencies and partially from another constituency. These constituencies are:

Bristol East (Labour, majority: 8.3%, 3,722)
Bristol South (Labour, majority: 9.8%, 4,734)Bristol West (LD, majority: 20.5%, 11,366)
Thornbury and Yate (LD, majority: 14.8%, 7,116)
Bristol North West (Conservative, majority: 6.5%, 3,274)
Filton and Bradley Stoke (Conservative, majority: 14.3%, 6,914)
Kingswood (Conservative, majority: 5.1%, 2,445)
North Somerset - partially (Conservative, majority: 13.6%, 7,862)

If we use the simplistic analysis of looking at the constituency where the trust is located then only Bristol North West would be at risk. However, widening out the analysis to include neighbouring constituencies where many patients live, the figures show that if there is a backlash against the Coalition parties due to the situation at North Bristol NHS Trust then at least two Conservative seats (Bristol North West and Kingswood) would be affected.

Saddly, other Public Health Observatories have not carried out the same analysis (or if they have, they do not make it publicly available). So to do a complete analysis of the effects of the HSJ-22 and FT-17 work will need to be done using HES data to map the catchment areas of these trusts.

Catchment areas are important.

MHP is a consultancy agency that have recently got some publicity over an article they wrote about the political aspect of the financial situation of trusts using the new constituency boundaries. Unfortunately they have rather lazily taken the approach of looking at the constituencies where the trusts are locate (an approach which I rejected - see above). Their "analysis" that caused a bit of a stir amongst the health policy twitterati says

"New research reveals that 21 struggling NHS trusts will be located in marginal constituencies at the next election following a review of constituency boundaries. Of these, 12 are located in ‘super-marginals’ with a notional majority of less than 1,000 after proposed boundary changes come into effect."

I think that this seriously under-estimates the effect of the finances of these trusts: using the constituency where the trust's registered address is located is a poor method.

So why haven't I done a more complete analysis? Money. Currently I am unemployed and I cannot afford to pay for the data. A tailor made dataset from HES Online that lists the patients using a hospital broken down into the wards where they live will cost between £348 and £773. I do not have that sort of money to spend. Also, the analysis will take time and if I get offered a job I will stop that work immediately. If someone is willing to pay me, say, a month's work (plus the expenses of getting the HES data) then I am willing and able to do the work.

I am surprised that MHP didn't do this work correctly, since their analysis shows that they really do not understand catchment areas of hospitals.

Charidee

What are charities, the "voluntary sector", the "third sector"?

My definition of a charity is an organisation that has a social purpose not already provided by the state. Charities campaign and they provide support. These two aspects of charities are vital. And it is vital that they do these independent of the government. (Hence why the term Non Government Organisation is used for many charities.)

But should a charity provide services?

Support and campaigning are services, but should they provide services that are already (or should be) provided by the state? In my opinion, they should not. If charities provide services how can they continue to provide support for service users? How can they campaign on behalf of service users? They cannot, because they will be campaigning against themselves and supporting service users against themselves. There is a huge conflict of interest that no one seems to have noticed. Once a charity provides a service, it cannot support the people using that service. The only solution is for someone else to create a charity to support service users who are using a service provided by another charity. Madness!

Sadly, some charities seem to have decided that they are more than they should be. At the Labour party conference this week I attended a fringe meeting hosted by two charities, Rethink and Age UK. These charities described the Health and Social Care Bill as an "opportunity". They do not see the Bill as a danger, a Bill that will fragment the NHS. In fact, I got the impression that they regarded the NHS as the "problem", and themselves as the only "solution".

There is very little difference between such charities and the private sector. Indeed, such charities are run as if they are businesses, with high paid executives, plush offices and extensive marketing departments. The only difference between such charities and private sector companies are that the profits in the former are recycled back into the organisation and in the latter profits are distributed to the shareholders as dividends.

There is very little that is "voluntary" about the "voluntary sector". In most charities, the majority (and probably all) of the staff are employed. In some cases I would prefer a private sector company to provide a public service because at least with a private company there is accountability to the shareholders. With a charity the accountability is to the trustees, but who are they? Often no one knows who the trustees are, or how they get to be appointed.

(Not all charities are bad. Some are excellent and campaign for, and provide support for very vulnerable people. Often they do so with very little administrative costs. However, this is not typical of the "third sector", it is filling with organisations that are simply businesses with little or no accountability.)

So when someone talks to you about charities providing public services, unblinker yourself and see them for what they are: non-public, non-accountable private organisations.