NHS Vault

Newspapers

2012-02-18T17:25:00.000Z

At Netroots today Clifford Singer posted a graphic showing the readership of newspapers who have left-leaning and right-leaning editorials. The graphic was meant to indicate that the majority of the UK media are right-wing. This lead Harry Cole to tweet "damn that free market eh?" which is a fair point because no one is forced to buy a newspaper.

After such a sensible tweet, Cole slipped back into his usual partisan mode by retweeting a less enlightening response from Frank Manning: "Hilarious: @PSbook reckon this slide shows right-wing bias in the media. Or, it could mean more people are right-wing." Well, no, it doesn't. People buy The Sun for the sports and celebrity gossip coverage not its political content. The politics comes "free" with the rest of the content. (The same can be said of the Mirror.) The bias aspect comes from the fact that we know how people vote, so we expect their views should be reflected in the political allegiance of the newspapers.

The sales of the National newspapers can be found at the National Readership Survey website. The following shows the readership of left/right/centre aligned newspapers, and the votes cast at the last election.

74% of the newspapers bought are right leaning, yet 40% of voters voted for right wing parties.

Response to Minister Burns

2012-02-15T19:32:00.000Z

Today Health Minister Simon Burns issued ten reasons why the government needs the Health and Social Care Bill. Remember, it is a bill not an act of parliament, it has not been enacted, so it is not correct to ascribe any current changes to the NHS to this bill.

Here are my responses:

1. If we want to reduce bureaucracy and management costs, then we need legislation.

This is a bizarre statement. If the Bill was needed to reduce management costs, then there would be no reduction in the numbers of managers. However, the government takes pride in how many managers it has sacked since the election:

March 22, 2011, Department of Health:

a reduction of 2,770 managers and senior managers in the NHS between September 2009 and September 2010 – this equates to 2,416 full time equivalent (FTE) or a 5.7 per cent reduction.

At the Conservative party conference Andrew Lansley said:

"Unlike Labour, we will make sure that every penny of our investment goes right to the patients who matter, not the huge Labour bureaucracy which we inherited," he will say. "And all that is why, since the election, we now have 1,500 more doctors and 5,000 fewer managers in the NHS."

If the Bill was needed to "reduce bureaucracy and management costs" how have the government reduced the number of managers since the election by 5,000? Surely this should be impossible since the Bill is not yet law?

The Bill does not mention management. It cannot affect management in Foundation Trusts because they are autonomous and the government has no control at all over their management. Likewise, GP practices are "independent contractors" and the government has no control over how GPs manage their practices. The "managers" that the government does control are those in Strategic Health Authorities and Primary Care Trusts (PCTs), and the Bill abolishes these. However, the Bill also creates the NHS Commissioning Board (NHS CB) and Clinical Commissioning Groups (CCGs), and it beefs up the responsibilities of Monitor, the Office for Fair Trading and the Competition Commission of all of which will need "managers". Indeed, the Bill mandates that the Competition Commission performs a review of the competitiveness of NHS providers before 2019 and every seven years after that, and since the NHS is such a large organisation, this will require the employment of thousands of "managers".

2. If we want to give doctors and nurses significantly more power than they have now to provide care for their patients, then we have to change the law.

This conjurers up an image of a bureaucrat accompanying every doctor and nurse periodically taking the clinician aside to tell them what to do. It does not happen. Indeed, many of the managers are former clinicians - doctors and nurses - who are making managerial decisions. Minister Burns says that it would be great if doctors and nurses made managerial decisions, but what would that make them? Yes, it would make them managers! If that happened after the Bill is passed, we would find that #1 ("reduction of bureaucracy and management") will kick-in and cull these managers. Then more doctors and nurses will have to make managerial decisions and ... and before we know it, there will be no clinicians left in the NHS! #1 and #2 are proof - if ever we need it - that the Bill should not be passed!

The Bill says that the three hundred new CCGs (an additional layer of management) will be making managerial decisions, but what evidence do we have that any of the managerial decisions is made by a doctor or nurse? The Bill does not says "the only people allowed to make a managerial decision must be a practising doctor or nurse".

Further, do we need the Bill to create these CCGs? There are now 266 CCGs and yet the Bill has not been passed. The Prime Minister said in PMQs on the 25 January this year:

"The point is this: there are thousands of GPs throughout the country who are not just supporting our reforms, but actually implementing our reforms. Let me give the right hon. Gentleman just one example of a supportive GP, who happens - [interruption] I think they want to hear from this one particular GP, who hails from Doncaster. When he was the acting chairman of the Doncaster GP commissioning group, he said: "Becoming one of the first national pathfinder areas is a real boost for Doncaster." I think that what is good for Doncaster is good for the rest of the country, too."

Can the Prime Minister explain how this GP managed to create this pathfinder CCG without the Bill? Minister Burns says that it is impossible, and he would have to wait until the Bill is passed.

It is not clear if CCGs will actually carry out any commissioning. Lansley has already said that one quarter of the commissioning that PCTs carry out (primary care: GPs, dentists, opticians, pharmacists, health visitors...) will be performed centrally by the unelected super-quango, the NHS CB. Further, a leaked document from the Department of Health last year said that "The largest of CCGs, and even the NHS CB itself, will not deliver best value by doing everything in house" suggesting that a proportion of the commissioning that CCGs need to do will be outsourced. The leaked document suggests that this work will be carried out by Commissioning Support Organisations (CSOs) hosted by the centralising, super-quango, the NHS Commissioning Board. These CSOs will be staffed by ex-PCT managers, so "doctors and nurses" will not be involved.

3. Most people agree that local authorities, because they’re also in charge of schools, town planning, transport and housing, should also be in charge of public health.

The Bill does mention about making local authorities responsible for public health, but does it need legislation?

It is interesting that Minister Burns uses the term "most people", it is more likely that most people haven't a clue what public health is.

Minister Burns says:

"But we can’t do this without changing the law. Without the Bill, we can’t transfer powers or money from the NHS to local authorities"

But you can. The spending review in October 2010 transferred £1bn a year from NHS capital funds to local authorities to boost the funding of social care. Was that transfer illegal?

4. Most people agree the health and wellbeing boards are a great idea.

There's that "most people" again. I wonder if Minister Burns has carried out a survey (if so, can we see it pleases)? If it is merely a bold assertion, then perhaps I will be permitted to reply with my own bold assertion: most people do not want this Bill.The Health and Wellbeing boards (HWB) are beefed up versions of existing Health Scrutiny Boards, and it seems that the same people will sit on the HWBs. This is still re-inventing the wheel, even if the new wheel is a big bigger.

5. We need this to Bill prevent discrimination in favour of private health companies over the NHS – it’s the first piece of legislation to do this.

If that were the case, then the technical document that accompanies the Operating Framework 2012/13 (PHF09) would be regarded as illegal. This document has the following indicator:

Patients should have the opportunity to choose a range of providers for their first outpatient appointment, including those in the Independent sector. This indicator shows a percentage of patients who have exercised choice, since it is likely that an alternative NHS provider was also offered to them. An increasing percentage of CAB bookings being made to the IS may be indicative of more choice being offered to patients.

This indicator says that the DH insists that PCTs must increase choice and it makes the assumption that an increase in choose and book (CAB, the mechanism to choose a provider for NHS care) bookings made with independent sector (IS, ie private hospitals) indicates that patients have been given choice. Minister Burns says that the private sector must not be favoured over the NHS, yet the DH is saying that they will performance manage PCTs based on increasing the number of patients using private hospitals. Why is the Department of Health producing illegal documents?

6. Most people agree that we should give more power to patients

I may get bored of repeating this, but there is that "most people" again. Minister Burns continues: "more power to patients - that they should have more choice and be much more involved in decisions about their care". We already have choice, it is the Choose And Book system mentioned above. Further, last year the government said that from April this year £1bn of NHS services will be available through Any Qualified Providers. This announcement was made without the Bill.If the Bill is necessary to extend choice, how could the government have made this announcement?

7. The Bill puts in law for the first time a duty on the NHS and local government to tackle health inequality.

This is nonsense. The Health Act 2006, clause 24 says that PCTs have such a responsibility.

8. The Bill places a duty on key organisations to integrate health and social care services.

No it doesn't. This is yet another bold assertion from Minister Burns.You can only truly integrate health and social care if you integrate the budgets and the provision. The Bill does not do this.

9. Currently, patients do not have a very strong voice in the system.

Minister Burns says that HealthWatch will provide "a hotline to the Care Quality Commission and the NHS Commissioning Board". Well I can trump that. Through your MP you have a hotline to the Secretary of State for Health (Minister Burns' boss), but the Bill is abolishing this route.

10. The Bill changes the current arbitrary private patient cap that stifles the development of groundbreaking new treatments by the likes of Great Ormond Street and the Royal Marsden that NHS patients will benefit from.

This is nonsense. Great Ormond Street is not a Foundation Trust and so it is not covered by the current private patient cap. But more concerning is the naive belief from Minister Burns that the leprechaun gold of private patients will pay for "innovations". In fact, private patients, because they are paying, will insist that they have the treatments that have already been tried out on thousands of NHS patients and proven to be effective. What private patient will use their own money to pay for being a guinea pig? It does not make sense. Indeed, nothing Minister Burns makes sense. It is more likely that private patients will be paying for treatments developed using public funds (which is right: they have already paid their taxes, and are entitled to innovations funded by the NHS).

11. We need to pass the Bill because otherwise we will be seen to have wasted hours of Parliamentary time on a Bill no one wants

The "saving face" argument. OK so I added this one, but basically it is the only reason the government has to pass the bill: if they don't they will lose face. I agree with this one, it is the only reason for passing the Bill.

Zombie NHS Trust

2012-02-14T11:45:00.000Z

Hinchingbrooke Health Care NHS Trust (note the name) is a franchise. The franchisee is Circle. It is clear that the arrangement at Hinchingbrooke is not privatisation because Circle is not purchasing the trust.

Subway is a franchised company, managers invest into, and run the branch on behalf of the corporation. To the customer, it appears they are buying from a well-known global chain, it looks like they are actually buying from Subway, with the same menu and the same global standards. The actual branch is owned and run by the local manager (who also pays an initial franchising fee of $15,000 and 12.5% of gross sales every week to the corporation). Franchising puts the financial risk on the local manager, who effectively buys a chunk of the reputation of the corporation. The customer is reassured by the global reputation and it is this that the franchisee purchases.

In the case of Hinchingbrooke the franchise arrangement is turned on its head. The franchisee is Circle, who are taking over the running of an NHS Trust. The trust is still owned by the NHS so one could say that Circle are buying part of this "brand". But it is important to note that - unlike Subway franchisees who own their shops - Circle does not have the financial risk of investing in the ownership of a hospital. Normally the franchisee buys the reputation of the organisation, and while Hinchingbrooke will still be branded as an NHS Trust, the intention of the government is for the public to think it is a Circle hospital. This is franchising back-to-front.

Clause 178 of the Health and Social Care Bill abolishes NHS Trusts. But, you say, Hinchingbrooke is an NHS Trust, so what will happen there? Clause 178 (3) covers this:

178 (3) Where arrangements ("franchise arrangements") under which a person exercises (or is to exercise) the main functions of an NHS trust on behalf of the trust are in force immediately before the commencement of this section, the trust is to continue after that commencement to be constituted as an NHS trust until--
(a) it is dissolved or becomes, merges with or is acquired by an NHS foundation trust,
(b) where none of those events occurs before the end of the period of three years beginning with the day on which the franchise arrangements come to an end, the end of that period, or
(c) where other franchise arrangements come into force before the end of that period, the end of the period of three years beginning with the day on which those other franchise arrangements or any subsequent franchise arrangements come to an end.

This says that since Hinchingbrooke has been franchised before the Bill, it will remain an NHS Trust while the franchise arrangement is in force (or 178(3)(c), the franchise is renewed). Joe Farrington-Douglas points me to the following parliamentary question:

Andrew Gwynne (Denton and Reddish, Labour)

To ask the Secretary of State for Health whether the NHS Trust for Hinchingbrooke Hospital plans to pursue its application for Foundation Trust status; what the timetable is for any conversion to Foundation Trust status; whether there will be any differences in the process followed; and what consultation he has had with Monitor on this issue.

Simon Burns (Minister of State (Health), Health; Chelmsford, Conservative)

Hinchingbrooke Hospital NHS Trust is expected to become, or become part of, a national health service foundation trust. There is currently no agreed timetable for this, which will be determined ahead of the end of the franchise contract when it is anticipated the trust will be ready to move forward to foundation trust status.

All future applicants for foundation trust status will follow the current process to apply to Monitor. There will be no lowering of the standards required to achieve foundation trust status. Through regular meetings with Monitor, (the statutory name of which is the Independent Regulator of NHS Foundation Trusts), the Department is assured that Monitor is aware of the trust's current position.

So Hinchingbrooke is intended to become an FT at the end of the franchise. The franchise is for ten years, so Hinchingbrooke Health Care will be an NHS Trust until 2022. However, clause 178 (1) and (2) say this:

178 Abolition of NHS trusts in England
(1) The NHS trusts established under section 25 of the National Health Service Act 2006 are abolished.
(2) Chapter 3 of Part 2 of that Act (NHS trusts) is repealed.

So Hinchingbrooke Health Care will be an NHS Trust for ten years but this says that the concept of NHS Trust will have been abolished! To accommodate this 178 (5) effectively says, "the laws abolished in sections (1) and (2) continue to apply to NHS Trusts that have been franchised". Since 178 (3)(c) says that the trust can be re-franchised, Hinchingbrooke Health Care can be an NHS Trust forever.

Hinchingbrooke Health Care will be a zombie trust living a state that does not exist.

FTN Letter

2012-02-12T21:22:00.000Z

Last week there was a letter in the times signed by managers from NHS organisations supporting the change to the Private Patient Income Cap. (Note: it is not a 49% cap, the Bill says that income from NHS patients must be more than the private income. So that is a cap of 50% minus one penny.) I have analysed the list of names and the organisations (data here).

There are 57 signatories from 53 organisations. Out of these there are four nursing directors, one Chair, 51 Medical Directors, one (nursing) director from a private patient unit and one Business Unit Director.

Looking now at the organisations. Nine are NHS Trusts (ie they are not yet FTs); eight are teaching trusts (in total, there are 26 in England); nine are specialist trusts (there are 20 in England); ten are mental health trusts (one of which is a NHS Trust); two are community services providers; one is an ambulance trust; and the rest, 19, are FT acute hospital trusts of varying sizes.

The trusts who are most likely to benefit from a raised PPI cap are the specialist and teaching hospitals, and 40% of the English teaching and specialist hospitals are in the list. These types of trusts have the largest PPI, these are all represented in the list of signatories.

Mental health provision has been widely privatised over the last couple of decades with many private and voluntary providers now being paid by the NHS, as well as the many providers carrying out solely private work. The FT Mental Health Trusts on the list all had zero private patient income in 2003, but currently have a 1.5% PPI cap (the Health Act 2009 said that for a Mental Health Trust the PPI cap would be a minimum of 1.5%). If I wanted to be cynical I would say that these trusts have looked to the opposition - the private mental health providers - and decided that they want to get part of that business.

The glaring omission from this list, considering Cameron's promise of a "bare knuckle fight", are District General Hospitals; yet these are the trusts who are most likely to suffer from the cuts to the national tariff (1.5% cut in April 2011, "at least" 1.5% in April 2012). Indeed, whenever a Coalition MP is challenged over the PPI cap they never say that they want a big teaching hospital to "benefit" from more private income, instead they always say that they want their local DGH to "benefit". However, DGHs are unlikely to "benefit" because private patients are more likely to go to a big teaching or specialist hospital than a DGH, and this explains why few DGH managers have signed the letter: it simply does not concern them.

One final point. FT Governors are reminded frequently by their trusts not to associate the name of the trust with any political action they take. After all, an FT is a community, public benefit corporation and a governor's opinions are not that of the FT, they are of the individual governor. (I am an FT governor, and whatever I write here is my own opinion, and not the opinion of the governing board, nor the FT.) Have the signatories asked their governing bodies? If not, then I think the governors should censure them. After all, if governors as supposed to keep their political campaigning and their FT duties separate, so too should board directors, and this letter was definitely intended to be a political letter.

Re-politicising the NHS

2012-02-10T23:22:00.000Z

Various commentators have pointed out how the NHS has re-toxified the Tory brand, and put the blame for this squarely on Andrew Lansley. In fact Lansley has done something worse - he has re-politicised the NHS.

One of the most significant achievements of New Labour was the creation of the National Institute for Health and Clinical Excellence (NICE). The fag-end of the Major government was dogged by postcode lottery scandals, and it was so long ago that people seem to forget what a huge scandal it was. At that time it seemed that a day didn't pass without something in the Press about someone complaining that they could not get treatment in their area that was available in another area. Where you lived determined the level of care you go. This was simply unfair. The postcode lottery dragged in politicians who, frankly, hadn't a clue about how the issue rose and just wanted it to go away.

NICE solved that issue, and it did so in a way that pleased everyone. First, clinicians were pleased because NICE is evidence based and all its decisions are backed up by peer-reviewed research. Second, patients were pleased because NICE is authoritative, and its decisions carry a lot of weight. This meant that a patient in one area could demand that they received a NICE approved treatment. If there were any rationing through a NICE decision the public were happy because it would apply to everyone and this satisfied the British sense of fair play. Third, politicians were happy because they were no longer held to account for complicated decisions over which they had no control. Of course, there are still some people who complain about NICE decisions, and there are always anomalies, but in general, NICE neutralised and de-politicised the postcode lottery.

Then we had Richard Taylor. This retired physician upset the political apple cart by standing for election on an NHS issue (he was against the re-configuration at his local NHS hospital at Kidderminster) and winning against the a government MP (largely because the Liberal Democrats decided, two elections in a row, not to field a candidate). The election of Taylor made politicians realise that it wasn't just national NHS policy that could affect their party's vote, but a local NHS decision, over which they had no control, could seriously threaten their own chance of re-election. The politics of this: local issues over which an MP has no control, was very similar to the postcode lottery that New Labour had neutralised.

During the New Labour times of plenty cases like Kidderminster were few, but the threat was always there. Lansley realised that if there was a Conservative government, and they enacted his plans for the NHS, there would be lots of Kidderminsters created; he feared the effect that this would have on Conservative MPs. Lansley had to create a NICE for all of the NHS. This was the reason behind the creation of the NHS Commissioning Board and it was the reason behind the abrogation of the Secretary of State duties (clause 1) and pushing these duties onto CCGs (clause 4). Both the NHSCB and the CCGs are unelected and unaccountable. Lansley calculated that in exchange for removing the so-called political micro-managing (which actually existed for patients benefits, but clinicians disliked) and removing managers and making clinical groups responsible for configurations, he thought that he could de-politicise the entire NHS.

Just as New Labour had neutralised the postcode lottery through NICE (Taylor notwithstanding) Lansley thought he could neutralise NHS reconfigurations through GP consortia (CCGs) and the NHSCB.

The problem is, rather than de-politicing the NHS Lansley has manage to re-politicise it. The overwhelming opposition of bodies like the RCGP or FPH is not due to a handful of troublemakers, the usual suspects. This opposition is from clinicians who until recently were largely apolitical. The Bill, Lansley's heavy handed implementation and Cameron's downright lies about NHS outcomes have persuaded many numbers of clinicians - doctors, nurses and other clinical staff - into active opposition. This is bad for the Conservatives because at the next election these clinicians won't forget how a Conservative-Liberal Democrat government had duped and bullied them.

Of course, it will also mean that an incoming Labour government will have to tread carefully because there is now a phalanx of clinicians ready to scrutinise their policies. I think that this will be a good thing because it will mean that Labour will have to create a much better health policy.

In a short space of time, rather than de-politicising the NHS, Lansley has managed to re-politicise it. This will have repercussions whose effects will be felt for many years.

Would you invest in Circle?

2012-02-09T10:23:00.000Z

The pro-market "reformers" use one simple argument that using private providers will "improve" the NHS: they say that the profit motive drives innovation and innovation makes the service better. (I have no problem with the idea that innovation will make the service better, but I object to the idea that the profit motive is the only way to drive innovation.)

So let's have a look at what the market - investors, the very people who predict the profitability of a business and use this to decide whether to invest - think about Circle. The following is the graph of the share price of Circle Holdings over the last 6 months. (Graph is from Interactive Investor.) There are two things to point out. First, Circle was floated on AIM last summer; second the jump in November was when it was finally declared that Circle would take over Hinchingbrooke (before then it was the "preferred provider" and there was six months of negotiation about what would be in the contract).

The graph shows that initially the market thought that the Hinchingbrooke deal was a good idea, but since then, there has been a consistent decline so that now the share price is at the same level it was before the Hinchingbrooke contract was signed. In other words, the market say that Hinchingbrooke will not make Circle a lot of money. It will be interesting to see how the price changes over the next six months as more details come out about how difficult it will be for Circle to run the hospital. Bear this in mind. Circle has nailed its colours to the mast on Hinchingbrooke. Its other ventures are small scale compared to this. If Hinchingbrooke turns out to be vastly more difficult to run than Parsa thinks (as is inevitably the case) the Circle share price will plummet.

Comments from a "staunch conservative doctor"

2012-02-06T17:26:00.000Z

The following is a comment on Conservative Home by someone whosays he is a "staunch conservative doctor", TrueBlueDoc:

"There are also specific pathways that are a complete mess - take a look at sexual health. Chlamydia testing will be done by the local authorities. Contraception provided by GPs will be commissioned by the national commissioning board through its primary care commissioning department. Long acting contraception commissioned by the clinical commissioning groups. HIV care and we are back into the National Commissioning Board again, but this time a different department, the Specialised Department. What a mess. With the PCT, the buck stopped with the Accountable Officer and Chief Financial Officer. Ok they were often insufficiently accountable, but at least you could argue that as commissioners of the whole lot their necks were the ones that should be chopped."

If this is a common point of view amongst Conservative doctors then the Bill is dead.

Why Patients Are Not Objecting To The Health Bill

2012-02-04T13:03:00.000Z

There is a some bemusement from clinicians as to why the public - patients - are not objecting to the health bill. As a patient with a long term condition, I will explain why.

NHS patients treat the NHS like mains-supplied water. When you need it, it is there. Turn the tap on, and the water flows. Go to your doctor and get treated. You don't have to think how either is provided. You don't think about how it is funded. (Even people on metered water don't think: flushing this toilet will cost me 1p.) You know it is there and you use it when you need it.

And that is exactly how it should be.

But it will change under the Health and Social Care Bill.

The problem is that when fundamental changes are suggested, like with the Bill, patients do not understand the issues, because they should not need to understand the issues, they just want to be assured that when they go to their doctor they will get treated. And this vital, and deeply held belief that the NHS is always there for them, is too ingrained for patients to ever countenance that it may be at risk. Yet it is.

If a politician issues a platitude like "no decision about me, without me" patients will take that as reassurance. The deeply held view that the NHS will always be there for them means that patients do not demand from the politician that there is a guarantee that all the care they need will be provided. And they should do, because the whole point of the Bill is to remove that guarantee.

Sir David Nicholson's announcement that CCGs will be allowed to provide only the services that they want to provide and not what their patients need, should have resulted in an outcry from patients. Yet there was none.

Lansley's weak and ineffectual attempt to get private clinics to act responsibly and remove the substandard PIP implants that they had used should have been a warning to patients that the same will happen when unaccountable private providers are introduced to the NHS. Yet there was no outcry from patients.

Patients assume that the NHS will always provide for them. They cannot believe that the politicians they have elected could possibly bring in a system that will remove their access to some treatments. Similarly, you could never believe that you'll be in the situation that when you turn on the tap there's a chance that nothing will come out. We assume the tap will always provide water and we assume the NHS will always provide care.

Patients believe that the NHS will always be there for them: and that is how it should be. This deeply held belief is the reason why patients are not objecting to a Bill that will result in an NHS that is no longer there for them.

Family Doctor Association

2012-02-03T14:56:00.002Z

The latest group to give their support for the Bill are the Family Doctor Association. Their website says:

"The Family Doctor Association unites over 1000 UK GP practices that offer their patients continuity of care and the opportunity to see their own GP."

The FDA says that they represent GP practices in the UK. There are 10,112 GP practices in the UK so they suggest that they represent 9.8% of GP practices. Their website list three levels of membership, depending on practice size: £150, £200 or £250. They are a registered educational charity (299871) and their accounts for 2011 show that their income from subscriptions were £109,762.

So that means they had between 439 and 731 members. Hardly over 1000.

Bill Amendments

2012-02-02T12:51:00.000Z

Last night I read through all the government's amendments: not the most thrilling evening I've ever had. I don't think there is much that is contentious in there other than what is missing (ie there's no amendment to get rid of the autonomy clause and none to make the Secretary of State responsible). It did highlight to me that I know nothing about the NHS Information Register and so over the next few days I'll try and find out what it is.

Rather more interesting are the non-government amendments and the following three in particular.

Clause 1
LORD CLEMENT-JONES
LORD MARKS OF HENLEY-ON-THAMES
BARONESS BARKER
BARONESS TYLER OF ENFIELD

Page 2, line 12, at end insert—
"(4) The provision of the health service is a service of general economic interest within the meaning of Article 106 of the Treaty of the Functioning of European Union."

Clause 78
LORD CLEMENT-JONES
LORD MARKS OF HENLEY-ON-THAMES
BARONESS BARKER
BARONESS TYLER OF ENFIELD

Leave out Clause 78

Clause 98
BARONESS FINLAY OF LLANDAFF

Page 109, line 32, at end insert—
"( ) requiring the licence holder to hold indemnity, for the services provided, which will remain valid for the lifetime of patients treated,"

I am assuming that the amendment to clause 1 is to try and prevent the NHS being subject to EU competition law (or is it? my reading of the Article seems to suggest the opposite, but I'm no lawyer). Surely you cannot simply legislate to say that you are exempt? Whether the NHS is subject to EU competition law surely depends on the behaviour of the NHS? If you don't want it subject to EU competition law then you should not introduce a market.

Clause 78 is one I've not read before and it basically says that the Competition Commission must review how competitive NHS providers are. Of course, if they find that a provider is not competitive (eg it is the only hospital in an area) then presumably the Competition Commission can say that there has to be competing providers and maybe break up a hospital trust so that parts compete with each other. Be very scared of this clause because it could cause huge upheavals for years. The Lib Dem peers are right to want to get rid of this damaging clause.

The final amendment of the three (from the crossbench peer, Baroness Finlay) suggests that NHS services should exist as long as the lifetime of patients, and to ensure this, "licence holders" (ie providers) must provide an indemnity (presumably a bond) that will fund the service if the provider goes out of business. Private providers will not like this, and I am sure the government won't either, but it very clearly says that the most important thing is the patient, not the provider.

Frequency Analysis of Amendments

2012-02-01T21:32:00.001Z

The following is the frequency of amendments plotted against clause index (ie the number of amendments tabled so far for each of the 305 clauses). It lists the amendments tabled for the Report stage in the Lords, and lists the non-government amendments.

Clearly clause 1 and 4 are important and hence several amendments have been applied. The two big peaks are clauses 22 and 25.

The interesting thing is that the amendments are clustered towards the low end. Why? Well you start reading a document from page 1 and read forward. When the document is complicated, convoluted and obfuscating you are likely to give up after a while.

Of course there are only 41 amendments in total and hence not enough to make any real conclusion. But if I were the government I would sneak in something really contentious after clause 250. The likelihood of anyone getting that far is small!

Update:

I have now plotted the frequency of the government amendments.

The red lines are the government amendments. The cluster at about 250 are changes to the information register. Hah! I bet you hadn't read those clauses when the Bill was first published, did you? Clear the government didn't either, since they've now got to fix them.

More Selective "Research" from the Government

2012-01-30T19:07:00.000Z

Thanks to Dave Williams at HSJ for tweeting about Francis Maude's claims about patient choice of GPs. This post is not about that claim, but about another claim in the document that Maude cited.

Today Francis Maude will claim that thousands of patients have moved GP practice as a result of performance data published. When Williams asked the Cabinet Office to clarify, the Department of Health cited a document called Making Open Data Real: A Public Consultation in particular section A1.16:

A1.16 Seminal research in the early 1990s showed the impact of public reporting of mortality rates in New York; those physicians and hospitals publishing better health outcomes subsequently saw their market share grow.[43] In the UK, NHS Barnsley has shown the effect of simple kite marking information on choice. Fourteen GP practices, serving 40% of the local population, were accredited with Barnsley's own "Green Tick" professional standards kite mark. Between the launch of the scheme in 2008 and April 2011, 4,500 patients have so far chosen to switch to one "Green Tick" practices. On finding their GP practice had been validated, one patient said: "I have been a patient [here] for many years but seeing that the practice has received the award assures me that I am in the right place to receive the care I need when I need it."

The reference [43] is to work carried out by the RAND Corporation published by the Health Foundation. This report compares the results of papers published since 2000 on the effects of publishing performance data on improvements of hospitals. The NYC example interested me:

research in the early 1990s showed the impact of public reporting of mortality rates in New York; those physicians and hospitals publishing better health outcomes subsequently saw their market share grow

This seems to contradict the statement that Prof Gwyn Bevan made to the Health Select Committee in November 2010:

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

The Making Open Data Real document says that physicians and hospitals that published the better data saw their market share increased, so if Prof Bevan is right that would imply that there must have been a lot more patients (ie the overall number of patients increased) since those with worst results saw no change in the number of patients.

To find out who is right I read the Health Foundation document. On pp12-13 it shows the effect of publishing mortality data on patient choice of hospitals and surgeons.

On the New York State Cardiac Surgery Reporting System it says published reports "provide conflicting results". Here are summaries of those reports. First for hospitals:

Mukamel and Mushlin (1998)	"providers with better outcomes had higher growth rates in market share"
Hannan et al (1994)	"did not find a change in hospital surgical volume during roughly the same time period"
Chassin (2002)	compared market share of hospitals that were identified as statistical outliers in the year before they were named as outliers compared to the year after (1989 to 1995). Changes were small; fewer than half the hospitals saw an increased market share for high performance or decreased share for poor performance.
Jha and Epstein (2006)	"found no evidence" that the data "had a meaningful impact on hospitals' or surgeons' market share"
Cutler et al (2004)	reported an initial decline after being designated as a 'poor-performer' but "this decline was not statistically significant one year after the initial report". They did not find a corresponding increase in volume among low-mortality hospitals.

As you can see, there is no overwhelming endorsement that publishing mortality data increases the number of patients using a hospital.

Now for surgeons (in the US surgeons are typically independent contractors).

Mukamel et al (2004/05)	Medicare enrolees were less likely to select a surgeon with higher mortality
Mukamel and Mushlin (1998)	suggested that physicians with better outcomes had higher growth rates in their charges
Hannan et al (1994)	did not find a change in individual providers’ volume of surgery
Hannan et al (1995)	did not find patients changed, but found that the worse surgeons stopped practising
Jha and Epstein (2006)	reported that it was more likely that surgeons performing in the bottom quartile ceased practising
Mukamel et al (2000)	said that only 20% of managed care organisations in New York indicated that the reports were a major factor in their contracting decisions. But analysis of actual contracting patterns show that mortality scores did not affect their choice of surgeon
Mukamel et al (2002)	found that only in parts of NY state did higher reported quality made it more likely that an MCO would contract a surgeon

Again, the results are mixed, and there is no clear result saying that publishing data increased the business of the better performers.

Clearly the government's selective reading of the Health Foundation report chose to use the results that agreed with their point of view and ignored the other reports.

The unacceptable is now acceptable

2012-01-29T18:21:00.000Z

If you think the Health and Social Care Bill will be an NHS that is better for patients, then think again.

Sir David Nicholson, the Chief Executive of the NHS and now of the unaccountable super-quango, the NHS Commissioning Board, said last year:

"If you've got a long-term condition, you might want to think in future about different GPs and whether they're providing a full range of service for that condition."

Reflect on what he said. What he didn’t say was "the NHS reforms will guarantee that you will get the care that you need". He is saying the exact opposite. He says that it is acceptable for CCGs not to authorise the services we need. That is an admission that Lansley is creating an incompetent and unfair system where it is the responsibility of patients to find the care they need.

It is appalling. If you have a long term condition, every GP should provide the full range of services you need. The statement from Sir David Nicholson says that you have to be a healthcare consumer and "shop around" for your care. This is simply not possible for most patients. Think about it. When you feel ill the last thing you want is to browse the options and ask for quotes as if you are getting your kitchen painted. You want to rely on the NHS to provide the services that you need and anything less is not acceptable. Sir David is saying that to him, and to the government, the unacceptable is acceptable.

NHS Reform A Goldmine for Surgeons?

2012-01-28T15:56:00.001Z

Last week was a bit of a disappointment for opponents of the Health and Social Care Bill. Opposition was clearly growing as the BMA, RCN and RCM all announced all-out opposition to the Bill and it was hoped that the Royal Colleges (who are professional membership organisations) would also announce their opposition. Initially it seemed that this would be the case when a draft agreement was leaked early in the week, however, after what appears to be a huge amount of lobbying from Lansley, their opposition crumbled. Now the rather weak response from many of the colleges and faculties are to ballot members and fellows, which is simply a delaying tactic.

The most ire was generated by the Royal College of Surgeons being consistently in favour of the Bill: they didn't need a telephone call from Lansley to be prompted in offering their support. The response from many who oppose the Bill is that surgeons are the most likely to benefit personally from the new fragmented and privately provided NHS. I honestly don't know if this is the reason why the RCS refuse to oppose the Bill, but if it is, they are wrong. The Bill will not deliver a goldmine of easy pickings for surgeons.

The consensus is that two parts of the policy: the raising the Private Patient Income cap on Foundation Trusts (FTs) and the so-called Any Qualified Provider (AQP) policy will be beneficial to surgeons. The thinking is that the raising of the PPI cap will allow more private work to be carried out in NHS hospitals - presumably with surgeons acting as independent contractors earning private rates. Further, AQP is expected to bring in more private providers to do NHS work (so-called "choice") and the government expects groups of clinicians - like surgeons - to form mutuals or partnerships and offer themselves in competition to NHS hospitals. The conventional thinking is that these two policies will make surgeons very rich. I suspect that this is wildly optimistic.

It is clear that the RCS are in favour of AQP. In response to the NHS White Paper they said (January 2011):

In terms of providers, we believe a level playing field should exist, meaning all providers supporting the entire range of clinical standards of modern surgery, including education and training and making outcomes available to aid the profession and patient choice.

So basically they are licking their lips on the thought of the extra opportunities of their members to work for private providers.

I think they are wrong. To explain why, I first need to remind the reader of a home-truth. I don't particularly like to quote Mr Byrne but it is important here: there's no money left. This applies both to the public sector - the NHS - and to the private sector. Austerity is upon us and that means no one can get rich.

The major problem is that private healthcare is in dire straits and there have been a series of bad indicators over the last few weeks. In general terms, Private Medical Insurance (PMI) is still in recession. A large proportion of PMI is provided as an employer benefit and in times of recession this is an extra - and largely unnecessary - expense that will be the first to be dropped as profits are squeezed. When there is a successful NHS (as there is) I am sure that over the last year many employers have come to the conclusion that PMI is an employee benefit they cannot afford.

At the same time self-pay has slightly increased, but this is a small part of private hospital income. In addition, in general terms, the economy is tanking. This will affect self-pay as people fall back on the free-at-the-point-of-use NHS (which they have already paid for) so that they have the money to pay their mortgages. And at some point in the future the Bank of England will raise base interest rates. This is unlikely to happen before the next election since the last thing the government needs is huge numbers of repossessions just before an election and they will make it known to the "independent" Bank that it will be in non-one's interest. However, interest rates can only go up. More money spent on the mortgage means less money to pay for things that you don't need to pay for (including PMI and self-pay). Private healthcare will suffer, and so will the surgeons who rely on this income.

The Competition Commission is now looking at private healthcare and the likelihood (going on the OFT interim report from last year) is that they'll recommend a shake up which will cut costs to patients and the profits of the providers. Surgeons may find that their private practices will no longer be profitable.

Health Service Journal this week reported on the most recent Laing's Healthcare Market Review that in 2010 income by private healthcare dropped by 1.5% the first time there has been a drop in the thirty years that Laing and Buisson have been providing the report. This shows the effect of falling PMI. The report also says that a quarter of the income of private acute care providers was paid for by the NHS, illustrating how dependent the private sector is on the public purse. As the NHS seeks savings, this figure can only go down, and that will mean less for surgeons.

It is significant that Laing and Buisson say that private hospitals have "higher average costs than NHS hospitals. They typically take on patients at the lower NHS prices when they have unused capacity" and that "many independent hospitals are likely to struggle to maintain profitability at NHS tariff unless they can significantly rationalise their cost base". The cost base is, of course, mostly the money paid to surgeons.

All of this indicates that there is unlikely to be a huge shift to private hospitals through the AQP policy. private hospitals will not put themselves on the list of AQP providers if they think they cannot make a profit on the NHS tariff. The RCS may be keen on the idea of AQP, but it is looking like it is unlikely to make private providers (and hence their independent contractors, the surgeons) much money.

There is another issue. At a time when credit was cheap and plentiful everyone over borrowed, and that includes the private hospital groups. The country's largest private provider, GHG, has created a Southern Cross-like problem for itself (similar, but with some differences) by restructuring as an opco-propco with a £1.65bn debt that needs to be re-financed in the next 8 months. The next 8 months. If there is a Euro-crisis and a paralysis of the finance markets will they be able to do this? Surgeons should think twice about relying on private practice income.

The government's policy on QIPP (the £20bn "efficiency savings") seems to be more about squeezing tariff (the fixed price list providers are paid for about half of treatments) than about anything else. In April 2011the government cut tariff by 1.5%, in April 2012 they will cut it again, by "at least" 1.5%. This means a lot less money for both FTs and AQPs. If a surgeon moonlights for an AQP provider they'll find that the cut in tariff will affect their pay packet. Indeed, in the current climate surgeons will probably find an NHS salary much safer than their likelihood of making a fortune in the private sector. But even that is not guaranteed since FTs may find that they cannot afford to provide some operations.

FTs and private providers will be chasing after an ever decreasing and inadequate pot of NHS money, and they will squeeze their staff costs. Further, as the economy nose dives, there'll be less money in patients' pockets to pay for private treatment. Both of these mean that there simply isn't the money available to fill the surgeons' pockets.

Then there is another issue. The original plan for Foundation Trusts was to allow them to write their own employment contracts. Only one FT - Southend - has done this so far and they have eventually decided to go back to the national deal. The current government is very keen on local agreements and is encouraging FTs in this direction, but this could be bad for the surgeons. In a meeting that I attended recently an FT chief executive said that he wanted to change his consultant contracts to prevent them from "moonlighting". This makes sense, because if we are going to have a competitive market with AQP competing with FTs why would a chief executive want his employees working for the opposition? Surgeons beware: you may well find that soon you will be given the option of giving up your private practice or give up your NHS job. This will be a direct consequence of government policy.

When you add all of this: failing economy, failing private providers, the Competition Commission about to shake up the private healthcare market, the Byrne aphorism of no money left and cuts in tariff, the scope for anyone to making money is seriously reduced and the risks of the reforms are too high. Consultant surgeons have a very comfortable deal with the NHS at the moment, and any reform (under the Byrne aphorism) will be far less comfortable for them. It is better for them to keep the status quo, so perhaps someone could explain this to them and get them to join the opposition to the Bill?

The Real Effect of the Coalition Government on the NHS

2012-01-25T22:23:00.000Z

Forget Cameron's bluster about the number of doctors and managers.

The issues about the NHS over the last year have all been about nursing. A competent government would recognise that nursing numbers are important and that we need investment in more nurses. However, we don't have a government that can be described as being competent.

The aggregated number (full time equivalent) of nursing staff in hospitals and community services was 310,793 at the time of the 2010 election; in October 2011 (the latest data) there were 307,825. The following graph shows the trend over the last 18 months.

We need more nurses, yet the government's policy is to cut their numbers.

The Pause and the Future Forum

2012-01-22T23:16:00.000Z

last summer the government made the unprecedented decision to pause the passage of the Health and Social Care Bill and to "listen, reflect and improve" the Bill.

Listening? Really, did they listen at all?

I am a patient with an LTC (of 35 years), so surely my experiences of the NHS would be useful? Apparently not. The Department of Health said that if people wanted to be involved in a listening event they should contact their local SHA for details of events near them. I contacted the West Midlands SHA and they told me that there were no (yes, no) events in the area. Then I wrote to my MP (a Tory MP) and I heard nothing until after the "pause" was over. His researcher apologised for the tardy reply and said that since the pause was over so there were no events. So no one wanted to listen to me.

Then there is the Future Forum. This is usually described as being the Independent Future Forum. There are some highly qualified people on the FF, but excuse me, Sir Steve Bubb? Is he really qualified to talk about the NHS? And how were these people appointed? They were hand-picked by the Department of Health.

If I were asked to create a truly independent forum I would ask all the medical Royal Colleges and other professional organisations, the BMA, the health unions, patient groups and medical charities to nominate people they thought would be able to make a good contribution. This is not what happened. The FF was hand-picked by the government. Is it no wonder that the FF came up with recommendations that were completely accepted by the government? The government clearly chose the right people.

Big Society Volunteering

2012-01-22T22:18:00.001Z

I'm not much of a volunteering type, you won't find me at the local jamboree sitting in a bath of baked beans or falling out of a plane clutching a sponsorship form. I really do think that if a service is worthwhile then it is worth state funding.

However, I am an elected FT governor. This is unpaid, and other than the statutory attendance at public meetings, I also attend other Trust meetings and take part in other Trust events. I didn't have to put myself forward for election, and I can resign at any time, so I guess all of that means that it is voluntary. So I have volunteered for something.

A couple of weeks ago I was at one of the FT meetings and after the business was over I chatted with other governors. It immediately became very apparent that the local "worthies" are a very small group. This is not a criticism of them, in fact I am rather in awe of how much they do. Some governors are involved with groups like the Rotarians, WRVS, local care charities; as well as organisations like the Local Involvement Network (LINk) and patient involvement groups at the local PCT and local councils. Without these people the local town would not have a summer carnival. Recently the local council withdrew all funds to the town's youth centre, and the manager of the centre was distraught since this sleepy rural town has no other distraction for young people. Then one of the local charity groups - run by the same "worthies" - stepped in to provide the funds.

The more I get involved with local groups the more I see the same people: these local "worthies" are the bedrock of our community. However, they are mostly elderly, white and middle class. There tends to be more women than men, but I guess that is because of the "elderly" aspect. Quite a select demographic.

The Big Society is supposed to be local people running (or influencing the provision of) local services. How can we say that there is any "localism" if most of us are not involved? I am sure that the local "worthies" genuinely and selflessly want to improve services, but the improvements will be from their perspective and there is never just one way to provide a service, other ways are just as valid.

The local LINk is being replaced by Healthwatch. I asked an FT governor who is heavily involved with LINk about the change to Healthwatch: he told me that it will be the same people doing the same things as before. I asked another governor about the Health and Wellbeing Board. His response was less optimistic, complaining of it simply being "structure" with little purpose. He also pointed out that the newly appointed Chair of the Health and Wellbeing Board was the Chair of the PCT before clustering. Yet again, the same people.

Last week, when ordering my repeat prescription through my GP's website I noticed an announcement about their new Patient Involvement Group. I signed up. The week before I had an email from my local PCT saying that they want "patient champions" to be involved with the local Clinical Commissioning Group. I put my name forward. See that? This volunteering is addictive. I wonder how long it will be before I am known as one of the local "worthies"?

Foundation Trust Constitutions

2012-01-09T20:54:00.023Z

The following is the section of the National Health Service Act 2006 that outlines the constitutions of NHS Foundation Trusts. I have made amendments according to the latest version of the Health and Social Care Bill. Making these amendments is a painful task because essentially the H&SC Bill is a series of instructions telling you to go to a particular clause and either delete it, amend it, or add another clause. Since these instructions can be anywhere in the 460 pages it is difficult at any one time to know what the final amended clause will be. A sensible Bill would have simply said: "replace the existing Schedule 7 with the following version". The fact that the H&SC Bill does not do this shows that the real intent is obfuscation.

In the following I have shown deleted sections using ~~strikethrough~~ and I have highlighted new text. If the Bill alters something that it has already altered I have highlighted that in red. It is interesting to see what the constitution of Foundation Trusts will be after the Bill is passed. Equally interesting is the myriad changes that the Bill makes, and bear in mind that there isn't a single section marked "changes to Schedule 7", instead, these amendments are across 20 or more clauses in the Bill.

SCHEDULE 7
Constitution of public benefit corporations

Requirement for a constitution

(1) A public benefit corporation must have a constitution.

(2) As well as any provision authorised or required to be made by this Schedule, the constitution may make further provision (other than provision as to the powers of the corporation) consistent with this Schedule.
(1) The constitution must name the corporation and, if the corporation is an NHS foundation trust, its name must include the words “NHS foundation trust”.

(2) If the corporation is an NHS foundation trust, the constitution must specify its principal purpose (as to which, see section 43(1)).

Eligibility for membership

(1) The persons who may become or continue as members of a public benefit corporation are-

(a) individuals who live in any area specified in the constitution as the area for a public constituency,
(b) individuals employed by the corporation under a contract of employment and, if the constitution so provides, individuals who exercise functions for the purposes of the corporation otherwise than under a contract of employment with the corporation,
(c) if the constitution so provides, individuals who have attended any of the corporation's hospitals as either a patient or the carer of a patient within a period specified in the constitution.

(2) The constitution may specify one or more areas as areas for public constituencies, each of which must be an electoral area for the purposes of local government elections in England and Wales or an area consisting of two or more such electoral areas.

(3) A person may become or continue as a member of the corporation by virtue of sub-paragraph (1)(b) only if-

(a) he is employed by the corporation under a contract of employment which has no fixed term or has a fixed term of at least 12 months, or
(b) he has been continuously employed by the corporation for at least 12 months or, where he exercises functions for the purposes of the corporation as mentioned in that sub-paragraph, he has done so continuously for such a period.

(4) Chapter 1 of Part 14 of the Employment Rights Act 1996 (c. 18) applies for the purpose of determining whether an individual has been continuously employed by the corporation, or has continuously exercised functions for the purposes of the corporation, as it applies for the purposes of that Act.

(5) The constitution may divide those who come within sub-paragraph (1)(b) into two or more descriptions of individuals.

(6) An individual providing care in pursuance of a contract (including a contract of employment), or as a volunteer for a voluntary organisation, does not come within sub-paragraph (1)(c).

(7) The constitution may divide those who come within sub-paragraph (1)(c) into three or more descriptions of individuals, one of which must comprise the carers of patients.

(8) The constitution may make further provision as to the circumstances in which a person may not become or continue as a member.

Constituencies

(1) Members of a public benefit corporation are referred to as follows.

(2) Those who live in an area specified in the constitution as an area for any public constituency are referred to collectively as a public constituency.

(3) Those who come within paragraph 3(1)(b) are referred to collectively as the staff constituency and, if the power in paragraph 3(5) is exercised, each description of members is referred to as a class within that constituency.

(4) Those who come within paragraph 3(1)(c) are referred to collectively as the patient's constituency and, if the power in paragraph 3(7) is exercised, each description of members is referred to as a class within that constituency.

(5) A person who is a member of a constituency, or of a class within a constituency, may not while that membership continues be a member of any other constituency or class.

(6) A person who comes within paragraph 3(1)(b) may not become or continue as a member of any constituency other than the staff constituency.
The constitution must require a minimum number of members of each constituency or, where there are classes within the constituency, of each class.

Becoming a member

(1) An individual who is eligible to become a member of a public benefit corporation may do so on an application made to the corporation.

(2) The constitution may provide for any individual who is-

(a) eligible to become a member of the staff constituency, and
(b) invited by the corporation to become a member of that constituency (and, where there are classes within the constituency, a member of the appropriate class),to become a member of the corporation as a member of that constituency (and class) without an application being made, unless he informs the corporation that he does not wish to do so.

(3) The constitution may provide for any individual who is—

(a) eligible to become a member of the patients' constituency (otherwise than as the carer of a patient), and
(b) invited by the corporation to become a member of a specified constituency (and where there are classes within the constituency, a member of the specified class),to become a member of the corporation as a member of that constituency (and class) without an application being made, unless he informs the corporation that he does not wish to do so.

(4) The constituency and, where applicable, class to be specified—

(a) if he is eligible to be a member of any public constituency, is that constituency,
(b) otherwise, is the patients' constituency and, where applicable, the class of which he is eligible to become a member.

~~Board~~ Council of Governors

(1) A public benefit corporation has a ~~board~~ council of governors.

(2) Only members of the corporation and persons appointed under the following provisions may become or continue as members of the ~~board~~ council.

(3) The members of the ~~board~~ council other than the appointed members must be chosen by election.

(4) Members of a constituency or, where there are classes within it, members of each class may elect any of their number to be a member of the ~~board~~ council.
(1) The following may not become or continue as members of the ~~board~~ council of governors—

(a) a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged,
(b) a person who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it,
(c) a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him.

(2) The constitution may make further provision as to the circumstances in which a person may not become or continue as a member of the ~~board~~ council.
(1) More than half of the members of the ~~board~~ council of governors must be elected by members of the corporation other than those who come within paragraph 3(1)(b).

(2) At least three members of the ~~board~~ council must be elected by the staff constituency or, where there are classes within it, at least one member of the ~~board~~ council must be elected by each class and at least three members must be elected altogether.

~~(3) At least one member of the board must be appointed by a Primary Care Trust for which the corporation provides goods or services.~~

(4) At least one member of the ~~board~~ council must be appointed by one or more qualifying local authorities.

(5) A qualifying local authority is a local authority for an area which includes the whole or part of an area specified in the constitution as the area for a public constituency.

(6) If any of the corporation's hospitals includes a medical or dental school provided by a university, at least one member of the ~~board~~ council must be appointed by that university.

~~(7) An organisation specified in the constitution as a partnership organisation may appoint a member of the board.~~
(7) Any organisation specified in the constitution for the purposes of this sub-paragraph may appoint one or more members of the council (but no more than the number specified for those purposes in the constitution).
(1) An elected member of the ~~board~~ council of governors may hold office for a period of three years.

(2) Such a member is eligible for re-election at the end of that period.

(3) But such a member ceases to hold office if he ceases to be a member of the corporation.

10A The general duties of the council of governors are—

(a) to hold the non-executive directors individually and collectively to account for the performance of the board of directors, and
(b) to represent the interests of the members

10B A public benefit corporation must take steps to secure that the governors are equipped with the skills and knowledge they require in their capacity as such.

10C For the purpose of obtaining information about the corporation’s performance of its functions or the directors’ performance of their duties (and deciding whether to propose a vote on the corporation’s or directors’ performance), the council of governors may require one or more of the directors to attend a meeting.
The corporation may pay travelling and other expenses to members of the ~~board~~ council of governors at rates decided by the corporation.
The constitution must provide for the chairman of the corporation or (in his absence) another person to preside at meetings of the ~~board~~ council of governors.
(1) The constitution must provide for meetings of the ~~board~~ council of governors to be open to members of the public.

(2) But the constitution may provide for members of the public to be excluded from a meeting for special reasons.
(1) The constitution must make provision as to—

(a) the conduct of elections for membership of the ~~board~~ council,
(b) the appointment of persons to membership,
(c) the practice and procedure of the ~~board~~ council,
(d) the removal of a member from office.

(2) The constitution may make further provision about the ~~board~~ council.

Directors

(1) A public benefit corporation has a board of directors.

(2) The constitution must provide for all the powers of the corporation to be exercisable by the board of directors on its behalf.

(3) But the constitution may provide for any of those powers to be delegated to a committee of directors or to an executive director.
(1) The board consists of—

(a) executive directors, one of whom is the chief executive (and accounting officer) and another the finance director,
(b) non-executive directors, one of whom is the chairman.

(2) One of the executive directors must be a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984 (c 24)); and another must be a registered nurse or a registered midwife.

(3) A person may not be appointed as an executive director if he is within paragraph 8(1).

(4) A person may be appointed as a non-executive director only if—

(a) he is a member of a public constituency or the patients' constituency, or
(b) where any of the corporation's hospitals includes a medical or dental school provided by a university, he exercises functions for the purposes of that university, and he is not within paragraph 8(1).
(1) It is for the ~~board~~ council of governors at a general meeting to appoint or remove the chairman and the other non-executive directors.

(2) Removal of a non-executive director under sub-paragraph (1) requires the approval of three-quarters of the members of the ~~board~~ council.

(3) It is for the non-executive directors to appoint or remove the chief executive.

(4) It is for a committee consisting of the chairman, the chief executive and the other non-executive directors to appoint or remove the executive directors.

(5) The appointment of a chief executive requires the approval of the ~~board~~ council of governors.
(1) It is for the ~~board~~ council of governors at a general meeting to decide the remuneration and allowances, and the other terms and conditions of office, of the non-executive directors.

(2) The corporation must establish a committee of non-executive directors to decide the remuneration and allowances, and the other terms and conditions of office, of the executive directors; but the constitution may make provision for those matters to be decided pending the establishment of such a committee.

18A The general duty of the board of directors, and of each director individually, is to act with a view to promoting the success of the corporation so as to maximise the benefits for the members of the corporation as a whole and for the public.

18B(1) The duties that a director of a public benefit corporation has by virtue of being a director include in particular—

(a) a duty to avoid a situation in which the director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the corporation;
(b) a duty not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity.

(2) The duty referred to in sub-paragraph (1)(a) is not infringed if—

(a) the situation cannot reasonably be regarded as likely to give rise to a conflict of interest, or
(b) the matter has been authorised in accordance with the constitution.

(3) The duty referred to in sub-paragraph (1)(b) is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.

(4) In sub-paragraph (1)(b), “third party” means a person other than—

(a) the corporation, or
(b) a person acting on its behalf.

18C (1) If a director of a public benefit corporation has in any way a direct or indirect interest in a proposed transaction or arrangement with the corporation, the director must declare the nature and extent of that interest to the other directors.

(2) If a declaration under this paragraph proves to be, or becomes, inaccurate or incomplete, a further declaration must be made.

(3) Any declaration required by this paragraph must be made before the corporation enters into the transaction or arrangement.

(4) This paragraph does not require a declaration of an interest of which the director is not aware or where the director is not aware of the transaction or arrangement in question.

(5) A director need not declare an interest—

(a) if it cannot reasonably be regarded as likely to give rise to a conflict of interest;
(b) if, or to the extent that, the directors are already aware of it;
(c) if, or to the extent that, it concerns terms of the director’s appointment that have been or are to be considered—
(i) by a meeting of the board of directors, or
(ii) by a committee of the directors appointed for the purpose under the constitution.

18D (1) Before holding a meeting, the board of directors must send a copy of the agenda of the meeting to the council of governors.

(2) As soon as practicable after holding a meeting, the board of directors must send a copy of the minutes of the meeting to the council of governors.

18E(1) The constitution must provide for meetings of the board of directors to be open to members of the public.

(2) But the constitution may provide for members of the public to be excluded from a meeting for special reasons.

~~Initial directors of former NHS trusts~~

(1) This paragraph applies, where the application for authorisation is made under section 33, to the exercise of the powers mentioned in paragraph 17 to appoint the initial non-executive directors and the initial chief executive.

(2) The power to appoint the initial chairman of the corporation must be exercised by appointing the chairman of the NHS trust, if he wishes to be appointed.

(3) The power to appoint the other initial non-executive directors of the corporation must be exercised, so far as possible, by appointing any of the non-executive directors of the NHS trust (other than the chairman) who wish to be appointed.

(4) A person appointed in accordance with sub-paragraph (2) or (3) must be appointed for the unexpired period of his term of office as chairman or non-executive director of the NHS trust; but if, on any such appointment, that period is less than 12 months, he must be appointed for 12 months.

(5) The power to appoint the initial chief executive of the corporation must be exercised by appointing the chief officer of the NHS trust, if he wishes to be appointed.

(6)Sub-paragraphs (a) and (b) of paragraph 16(4) do not apply to the appointment of any initial non-executive director in pursuance of this paragraph; and paragraph 17(5) does not apply to the appointment of the initial chief executive of the corporation in pursuance of sub-paragraph (5).

(1) A public benefit corporation must have—

(a) a register of members showing, in respect of each member, the constituency to which he belongs and, where there are classes within it, the class to which he belongs,
(b) a register of members of the ~~board~~ council of governors,
(c) a register of interests of the members of the ~~board~~ council of governors,
(d) a register of directors,
(e) a register of interests of the directors.

(2) The constitution may make further provision about the registers including, in particular, admission to, and removal from, the registers.
The constitution must make provision for dealing with conflicts of interest of members of the ~~board~~ council of governors and of the directors.
(1) A public benefit corporation must make the following documents available for inspection by members of the public free of charge at all reasonable times—

(a) a copy of the current constitution,
~~(b) a copy of the current authorisation,~~
(c) a copy of the latest annual accounts and of any report of the auditor on them,
(d) a copy of the latest annual report,
~~(e) a copy of the latest information as to its forward planning,~~
~~(f) a copy of any notice given under section 52.~~
(g) a copy of any order made under section 65D, 65J, 65KC, 65L or 65LA,
(h) a copy of any report laid under section 65D,
(i) a copy of any information published under section 65D,
(j) a copy of any draft report published under section 65F,
(k) a copy of any statement provided under section 65F,
(l) a copy of any notice published under section 65F, 65G, 65H, 65J, 65KA, 65KB, 65KC or 65KD,
(m) a copy of any statement published or provided under section 65G,
(n) a copy of any final report published under section 65I,
(o) a copy of any statement published under section 65J or 65KC,
(p) a copy of any information published under section 65M.

(2) Any person who requests it must be provided with a copy of or extract from any of the above documents.

(3) The corporation is also to make the registers mentioned in paragraph 20 available for inspection by members of the public, except in circumstances prescribed; and, so far as the registers are required to be available—

(a) they must be available free of charge at all reasonable times,
(b) a person who requests it must be provided with a copy of or extract from them.

(4) If the person requesting a copy or extract under this paragraph is not a member of the corporation, the corporation may impose a reasonable charge for doing so.

Auditor

(1) A public benefit corporation must have an auditor.

(2) It is for the ~~board~~ council of governors to appoint or remove the auditor at a general meeting of the ~~board~~ council.

(3) An officer of the Audit Commission may be the auditor if he is appointed by the ~~board~~ council with the agreement of the Commission.

(4) But a person may not be appointed as auditor unless he (or, in the case of a firm, each of its members) is a member of one or more of the following bodies—

(a) the bodies mentioned in section 3(7)(a) to (e) of the Audit Commission Act 1998 (c. 18),
(b) any other body of accountants established in the United Kingdom and approved by the ~~regulator~~ Secretary of State for the purposes of this paragraph. [the Bill says (c), which I cannot find, so I assume it means (b)]

(5) Where an officer of the Audit Commission is appointed as auditor, the Commission must charge the public benefit corporation such fees for his services as will cover the full cost of providing them.

(6) The corporation must establish a committee of non-executive directors as an audit committee to perform such monitoring, reviewing and other functions as are appropriate.

(7) In this paragraph “the Audit Commission” means the Audit Commission for Local Authorities and the National Health Service in England and Wales.

Accounts

~~(1) A public benefit corporation must keep accounts in such form as the regulator may with the approval of the Treasury direct.~~

(1) A public benefit corporation must keep proper accounts and proper records in relation to the accounts.

(1A) ~~The regulator may with the approval of the Secretary of State~~ The Secretary of State may with the approval of the Treasury give directions to the corporation as to the content and form of its accounts.

(2) The accounts must be audited by the corporation's auditor.

(3) But the Comptroller and Auditor General may examine—

(a) the accounts,
(b) ~~any~~ the records relating to them, and
(c) any report of the auditor on them.

(4) If trustees are appointed under section 51, the Comptroller and Auditor General may also examine—

(a) the accounts kept by the trustees,
(b) any records relating to them, and
(c) any report of an auditor on them.

(5) In auditing the accounts the auditor must comply with any directions given by the ~~regulator~~ Secretary of State as to the standards, procedures and techniques to be adopted.
(1) A public benefit corporation must prepare in respect of each financial year annual accounts in such form as ~~the regulator may with the approval of the Treasury Secretary of State~~ the Secretary of State may with the approval of the Treasury direct.

(1A) ~~The regulator may with the approval of the Secretary of State~~ The Secretary of State may with the approval of the Treasury direct a public benefit corporation—
(a) to prepare accounts in respect of such period or periods as may be specified in the direction;
(b) that any accounts prepared by it by virtue of paragraph (a) are to be audited in accordance with such requirements as may be specified in the direction.

(2) In preparing its annual accounts or in preparing any accounts by virtue of sub-paragraph (1A)(a), the corporation must comply with any directions given by ~~the regulator with the approval of the Treasury Secretary of State~~ the Secretary of State with the approval of the Treasury as to—

(a) the methods and principles according to which the accounts must be prepared,
(b) the ~~information to be given in~~ content and form of the accounts.

(3) In determining the form and content of the annual accounts, or of any accounts to be prepared by it by virtue of sub-paragraph (1A)(a), the ~~regulator~~ Secretary of State must aim to ensure that the accounts present a true and fair view.

(4) The corporation must—

(a) lay a copy of the annual accounts, and any report of the auditor on them, before Parliament, and
(b) ~~once it has done so,~~ send copies of those documents to the regulator within such period as the ~~regulator~~ Secretary of State may direct.

(4A) The corporation must send to the regulator within such period as the ~~regulator~~ Secretary of State may direct—

(a) a copy of any accounts prepared by the corporation by virtue of sub-paragraph (1A)(a), and
(b) a copy of any report of an auditor on them prepared by virtue of sub-paragraph (1A)(b).

(5) The constitution must provide for the functions of the corporation under this paragraph to be delegated to the accounting officer.

(6) In this paragraph and paragraph 27 “financial year” means—

(a) the period beginning with the date on which the corporation is authorised under section 35 and ending with the next 31st March, and
(b) each successive period of twelve months beginning with 1st April.

Annual reports and forward plans

(1) A public benefit corporation must prepare annual reports and send them to the regulator.

(2) The reports must give—

(aa) information on any occasions in the period to which the report relates on which the council of governors exercised its power under paragraph 10C,
(ab) information on the corporation’s policy on pay and on the work of the committee established under paragraph 18(2) and such other procedures as the corporation has on pay,
(ac) information on the remuneration of the directors and on the expenses of the governors and the directors,
(a) information on any steps taken by the corporation to secure that (taken as a whole) the actual membership of any public constituency and (if there is one) of the patients' constituency is representative of those eligible for such membership,
(b) any other information the regulator requires.

(2A) Before imposing a requirement under sub-paragraph (2)(b) that the regulator considers is sufficiently significant to justify consultation, the regulator must consult such persons as it considers appropriate.

[155(3) says that the SoS may by order decide to change (2)(b) and repeal (2A)]

(3) It is for the regulator to decide—

(a) the form of the reports,
(b) when the reports must be sent to it,
(c) the periods to which the reports are to relate.
(1) A public benefit corporation must give information to the ~~regulator~~ Secretary of State as to its forward planning in respect of each financial year.

(2) The document containing the information must be prepared by the directors.

(3) In preparing the document the directors must have regard to the views of the ~~board~~ council of governors.

27A (1) A public benefit corporation must hold an annual meeting of its members.

(2) The meeting must be open to members of the public.

(3) At least one member of the board of directors of the corporation must attend the meeting and present the following documents to the members at the meeting—

(a) the annual accounts,
(b) any report of the auditor on them,
(c) the annual report.

(4) Where an amendment is made to the constitution in relation to the powers or duties of the council of governors of a public benefit corporation (or otherwise with respect to the role that the council has as part of the corporation)—

(a) at least one member of the council of governors must attend the next meeting to be held under this paragraph and present the amendment, and
(b) the corporation must give the members an opportunity to vote on whether they approve the amendment.

(5) If more than half of the members voting approve the amendment, the amendment continues to have effect; otherwise, it ceases to have effect and the corporation must take such steps as are necessary as a result.

Meeting of ~~board~~ council of governors to consider annual accounts and reports

(1) The following documents must be presented to the ~~board~~ council of governors of a public benefit corporation at a general meeting-

(a) the annual accounts,
(b) any report of the auditor on them,
(c) the annual report.

(2) Nothing in sub-paragraph (1) prevents the council of governors from holding a general meeting more than once a year

Combined meetings of members and governors

28A A public benefit corporation may hold a meeting which combines a meeting under paragraph 27A with a meeting under paragraph 28.

Instruments etc

(1) The constitution must make provision for the authentication of the fixing of the corporation's seal.

(2) A document purporting to be duly executed under the corporation's seal or to be signed on its behalf must be received in evidence and, unless the contrary is proved, taken to be so executed or signed.

Power to make provision about voting
(1) Regulations may amend this Chapter so as to add, vary or omit provision relating to voting by members of the council of governors of a public benefit corporation that is an NHS foundation trust, by its directors or by its members.

(2) The power under sub-paragraph (1) is exercisable only in relation to provision in this Chapter that was inserted, or otherwise provided for, by Part 4 of the Health and Social Care Act 2012.

The Privatisation of NHS Commissioning

2012-01-08T20:00:00.000Z

(I originally wrote this article for the Drop the Bill campaign website.)

What is Commissioning?

Healthcare commissioning is often described as "purchasing healthcare" but it is far more than that. In this article I want to explain what commissioning is, and how it will change under the government's Health and Social Care Bill.

NHS commissioning is designed to ensure that we have a comprehensive and universal healthcare system. To do this commissioners must understand the needs of the population and ensure that these needs are met by the NHS. Commissioners need to determine demographics like the age of the population and prevalence of smoking, alcohol misuse and obesity; they need to be aware of local issues like the local industry and the implications of this on employees' health and they also need to be aware of levels of deprivation. All of this data enable commissioners to predict the healthcare needs for the population, and determine if the local healthcare providers can meet these needs.

Commissioning healthcare means that the NHS guarantee of care according to need is met: commissioners know that when a patient has a healthcare need, there is a provider with the capacity to treat them. Commissioning also helps the providers, because when commissioned – and contracted to do the work – they can plan to ensure that they have the appropriate resources (facilities and staff) to fulfil the contract. A pledge to provide a comprehensive and universal system means that everyone, regardless of medical need, gender, age, ethnicity or disability gets appropriate treatment. This means that commissioners also have a responsibility to monitor providers to ensure that there is equality of access to healthcare. Commissioners also have a responsibility to ensure that the care is high quality and value for money. All of this means that commissioning is complex and requires skilled commissioners.

Commissioning and the Coalition

In 2010 around 80% by value of NHS healthcare is commissioned by Primary Care Trusts (PCT). There are 152 PCTs in England covering, on average, about 300 thousand people each. A population of 300 thousand can be considered "local" enough to be aware of the needs of the area, but large enough to be able to commission for the majority of healthcare needs. The other 20% of NHS healthcare is more specialist commissioning – for example, organ transplants and rare cancers – where there will be too few patients within a PCT area to justify commissioning at the PCT level. In 2010, this 20% was carried out by the ten Strategic Health Authorities (SHAs) and the Department of Health.

Since the 2010 election, and without any Parliamentary approval, the government has restructured these NHS organisations. The PCTs have merged into 51 "clusters" (each covering around a million people) and the SHAs have merged from ten into four. These new organisations are only temporary because the Health and Social Care Bill has clauses that will abolish them. The Bill says that an independent super-Quango called the NHS Commissioning Board (NHSCB) will be created and will take over much of the work of the Department of Health and the SHAs. PCTs will be abolished in April 2013 and local commissioning will be carried out by statutory organisations called Clinical Commissioning Groups (CCG).

When, earlier this year, Andrew Lansley was pressed about the budgets of CCGs he admitted that they would have access to 60% of the NHS budget and not the 80% that is handled by PCTs. That is, CCGs will do three quarters of the commissioning that PCTs do now, the other quarter will be centralised and carried out by the NHSCB. Some of this is understandable: since CCGs will be made up of local GP practices they cannot commission the primary care carried out by GPs because this would present a conflict of interest. However, the NHSCB will also commission other areas of primary care: optometry, dentistry, pharmacy. This is care that is currently commissioned locally by PCTs but in the future will be commissioned by the NHSCB super-Quango (possibly on a regional basis, by one of the four merged SHAs that will be subsumed by the NHSCB). This is not localism, it is centralising. A quarter of commissioning will be centralised into a remote, national organisation, taking primary care decision-making further away from the patient.

GPs "In Charge"?

Every GP practice has to be a member of a CCG, but this does not mean that GPs will be "in charge". In England there are 8,200 GP practices and 40,000 GPs (roughly five GPs per practice); there are 266 "pathfinder" CCGs, so on average there will be 31 practices or 150 GPs per CCG. Is it likely that all 31 will have a representative on the CCG board? Will the 150 GPs who work for those practices sit on the CCG governing board? The answer is a very clear: No.

For a board to be effective it will be small, and since the primary aim of a CCG will be to keep within budget there will have to be places for non-clinical directors like the finance director, a chief operations officer and a chief executive (the latter is the statutory accountable officer). The few places on the board for clinical members will hardly be representative of all the GPs in the practices part of the CCG. Some CCGs may try to solve this issue by having an additional governance council made up of practice representatives, but effectively such a council will delegate most of its powers to the governing board and rubber stamp their decisions. Such a solution will result in superfluous management at a time when the NHS has to cut management by a third. It is interesting that the number of "pathfinder" CCGs is similar to the number of PCTs in 2006 (303). The NHS was re-organised in 2006 – merging the 303 PCTs into 152 – because it was then thought that smaller primary care commissioning groups would have higher management overheads and it was hoped that the merger would cut management costs by 15%. We are moving back to the situation in 2006.

The government argues that since there are more "pathfinder" CCGs than PCTs this will mean that the decision making that CCGs do will be "closer to the patient", but a quarter of PCT commissioning will be moved to the remote NHSCB. Further, the figure of 266 CCGs is not significantly larger than the number of PCTs in 2010 and is unlikely to make services any more "local". Since the smaller CCGs will find it difficult to meet the government's new financial constraints we will see them merge with neighbouring groups over the next few years: more instability in the NHS. The "localism" argument is merely an excuse; in four or five years time what little commissioning carried out by CCGs will be no more "local" than it is now.

Will CCGs Actually Commission Care?

This raises the question of whether CCGs be able to commission services? Under the last government Practice Based Commissioning (PBC) groups were set up and some of these produced good results (Lansley frequently uses these PBC groups as examples when justifying his policy). However, the significant difference is that PBC groups could always get expertise and support from the local PCT. In the areas where PBC was successful it is significant that the PCT remained intact, and was not closed down. Since CCGs will completely replace PCTs the new commissioning groups will have to take on all the commissioning responsibilities and it is questionable as to whether they are able or in a position to commission effectively.

The re-organisation of primary care is occurring at the same time as big changes in secondary care. The government has essentially told our NHS acute hospitals that they are responsible for their own debts. Trusts are also told that they are "autonomous" so if a hospital trust's debt means it will go bankrupt, the government will accept no responsibility and will not bail it out. Some of England's NHS hospitals have large debts and are not viable as free-standing businesses, so this has resulted in a slew of mergers with the more powerful hospitals taking over the weaker, debt ridden trusts. Consequently, the competitive, market-driven healthcare system designed by Lansley will be dominated by large providers and healthcare will be purchased from these trusts by the CCGs.

Some CCGs are the same size as the PCTs that they replace, but many are much smaller. A quarter of "pathfinder" CCGs cover populations less than 100 thousand; 60% of the "pathfinders" are under 200 thousand. In a competitive system, the smaller CCGs will be at a disadvantage when negotiating contracts with the much larger and more powerful acute trusts. As a result, to be able to effectively negotiate with acute trusts, the smaller CCGs will have to share some commissioning with neighbouring groups, or buy in the expertise from the private sector. The Bill says that a CCG will not be authorised unless it can show is has made "appropriate arrangements" to fulfil its commissioning responsibilities, however, it does not say that the CCG must perform commissioning. Purchasing commissioning support from the private sector is a sensitive issue, and was highlighted by the Future Forum report in the summer of 2011. In response to this report, the government said that CCGs "will not be able to delegate their statutory responsibility for commissioning decisions to private companies or contractor". In practice, something very different is happening.

The Privatisation of Commissioning

PCTs will be abolished in April 2013, and since this was announced in August 2010 PCTs have haemorrhaged skilled commissioners, with some moving to "pathfinder" CCGs and others taking up jobs with private sector companies. This loss of commissioners prompted the government to order the clustering of PCTs, since there was a danger that individual PCTs would no longer have enough staff to carry out their duties until their abolition.

A recent draft document from the Department of Health on commissioning identifies the services that need to be performed and it introduces the term Commissioning Support Organisations (CSO) to describe the companies that will carry out this work. The document is clear that CSOs are private companies and not NHS organisations. The draft document says that commissioners in PCTs will be re-organised into CSOs and as an interim they will be "hosted" by the NHSCB (that is, the commissioners will be employed by the NHSCB). Significantly, the document says that these hosted CSOs will have to "operate on commercial lines" and that hosting will only last until 2016 when they will be expected to be "freestanding".

There is no NHS solution to commissioning; the government's decision to make PCT CSOs "freestanding" and "commecial" means that they will be privatised by 2016. The Department of Health’s draft document admits that only the larger CCGs will attempt to perform commissioning themselves and that the smaller CCGs will have to "secure support from external suppliers" – the existing private CSOs and the privatised PCT CSOs.

The Government’s plans for NHS commissioning are inconsistent and ill-thought out. The new, untried clinical commissioning groups will deliver neither more localised commissioning nor are they likely to be any more financially viable than the PCTs they replace. The smaller "pathfinder" CCGs will have to merge with other groups, resulting in instability at a time when the NHS needs more stability. Commissioning will be carried out by private companies like KPMG, UnitedHealth and McKinsey, and a collection of CSOs made up of former PCT commissioners. Since there will be no NHS solution to commissioning, it is reasonable to assume that the new private commissioners will not look to the NHS for the provision of healthcare. The result will be the eventual privatisation of all that we regard as being the NHS, leaving the NHS as solely the source of funding, and even that will eventually morph into a healthcare insurance system.

The priority of the worried sick over the worried well

2012-01-02T12:58:00.000Z

Breast reconstruction after mastectomy is one issue, breast augmentation is a totally different issue. The former is repairing the effects of a clinical procedure, and the later is best described as cosmetic surgery: it is healthcare consumerism. This blog is about women who have demanded to have breast augmentation.

The NHS is care according to clinical need and is not healthcare consumerism.

Should the NHS remove the substandard PIP implants? Go back to the basic principle I mentioned above: care according to clinical need. Is there a clinical need to remove the implant? If it has ruptured then yes, there is a clinical need. However, the French study implies that there is a 3% chance of rupture, so that means there is a very good chance that the implants will not rupture and there is no immediate need for intervention. Since the implant was inserted through healthcare consumerism, the woman should use her consumer rights and demand redress from her surgeon. That is, return to the cosmetic surgery company assert her consumer rights and demand that the surgeon addresses the issue. The implant was not fit for purpose, she had a contract with the surgeon who provided the implants, and her consumer rights are that he addresses the issue and replaces the implant with an implant that was fit for purpose.

There is an issue of the psychological effects on a woman who has these implants. Should the NHS treat that? Of course it should: mental health is a vital part of the work that the NHS does. This is care according to clinical need, the mental health needs of the woman with PIP implants. The NHS has a range of treatments for anxiety and the most easily available is to seek the advice and re-assurance of her GP.

To anyone saying that we should pander to the demands of the worried well who have PIP implants, I would ask them why those women should be a priority over the worried sick, the women who are right now being denied hip replacements because under the Croydon List they are deemed to be in not enough pain to justify the NHS paying for the operation.

If Lansley caves into the demand that the NHS removes all PIP implants then this will be the death of the NHS ethos of care according to clinical need. He will have accepted that the NHS is a demand-based system, like the healthcare system in the United States.

Duck smoking ban

2012-01-01T23:02:00.003Z

One suggestion is that setting the private patient income cap (PPI) at 49% will mean that NHS hospitals will have the majority of their income from the NHS and hence this will magically protect them from EU Competition Law. I am not a lawyer, but if it was that easy to protect the NHS from the ravages of EU competition lawsuits why wasn't a high PPI set before, for this very reason? If Baroness Williams thinks this is a solution then I think she is very naive or deluded.

As to setting a cap at 49% to protect against a two tier system, I think the figure is daft. Putting the cap at 49% is a bit like legislating to ban ducks smoking: sure, it protects their health, but seriously, is it ever likely to happen?

Take a look at the current PPI caps. Most trusts have caps of 1% or less, which means that the percentage of their income from private sources in 2003 was at this level. For many trusts the private income is from services, not actual in-the-flesh private patients. There are a few notable exceptions, like Moorfields who have a private hospital in Dubai, and these few will be affected by the 49% cap, but the majority of trusts will not be affected. As I have mentioned before: where are all of these private patients going to come from? But hey, why do something effective when you can stop ducks smoking?

My opinion about EU competition law is that no healthcare company will want the expense of court action while there is a much cheaper option available. Monitor has such an option: the Competition and Cooperation Panel. This has the power to force competition (ie privatisation) in the NHS and since the panel was first created (as part of the Department of Health), their adjudications have been on the side of the private sector. I also hate the phrase "the majority of patients will be NHS" (which is the real source of Williams' nonsense figure). A single private patient jumping the NHS queue is just as bad as ten, 100 or every other (ie 49%) of patients. To see what I mean, put yourself in the position of a patient having waited patiently for an hour to see a doctor and then watching someone walking into the clinic and going straight in to see the doctor before you: it does not matter to you if that is the only private patient to get that privilege that day, it is still wrong.

My local hospital was the infirmary of the workhouse. The workhouse no longer exists of course (although the management offices are in some of their original buildings). The infirmary treated the poor from the entire community using charity donations. The creation of the NHS modernised how treatment was funded by making it sourced from general taxation. If the hospital takes on private patients we will be going backwards. Back to the days of the workhouse!

The focus so far has been on private patients, but the PPI cap is on income. One source is intellectual property. My opinion is that IP - a new technique, say - developed in one NHS trust should be shared with all of the NHS. Raising the PPI cap means that trusts will start to look at their innovations as revenue generating rather than for the benefits for patients. They will charge other trusts to use their new technique. This is abhorrent and against the ethos of the NHS. I think it will retrict the spread of innovation rather than promote it.

However, the reform of the private patient income cap is far more nuanced. Take a look at Great Ormond Street. Their income from private patients was £25m out of a total income of £270m in 2007 (the best figures I can find). This is 9% and is an increase on the 6% that it was in 2003 (the source of the PPI cap). GOSH realised that this would stop them from becoming an FT so they created a charity to swallow up this private work. But look at where this private income came from - it was mostly poor, sick kids from foreign countries and the private income was charity donations. Can we, as progresssives, argue against treating sick, poor, needy kids from abroad? What happens in the future when a child pushes the income over the 49% (or indeed, the current PPI cap?), do we stand at the airport and tell the staff to put the child back on the plane? Has Baroness Williams come up with a solution to this difficult issue? No. And I bet she is not even aware of it.

The 49% is a nonsense figure (as was the actual PPI cap anyway, but that is another argument). It is avoiding the real issue which is that NHS hospitals are NHS hospitals because they treat NHS patients.

We need to have a cast iron rule of NHS hospitals for NHS patients so that no NHS patient can ever feel second in the queue to a private patient. We need a detailed set of rules about how NHS intellectual property is handled, to make sure that the whole NHS benefits. We need rules about how charity cases (like GOSH patients) fit in. We need rules about how NHS trusts can provide services (like pathology) to the private sector in a way that benefits the NHS (perhaps a quid pro quo approach - requiring the private hospitals to do community healthcare preventative work, or a requirement to provide capacity when local waiting lists get high). Does anyone think that any of this is covered by a simple pronouncement of a PPI cap of 49%?

The PPI cap needs reforming, but removing it altogether, or raising it to 49% will cause more problems than it will solve.

UPDATE:
HSJ report that expert Sharon Lamb (a commercial partner at health law firm Capstick), said it was "unlikely that most FTs will come up against that limit in the short to medium term, based on the current volumes of private patient income that they earn" and that David Worskett (director of the NHS Partners Network) said: "I think it’s almost entirely symbolic. It will make virtually no difference… to the decisions trusts take." Confirming that yet again, the Lib Dems are producing completely pointless policies.

In case there is any doubt...

2011-12-30T19:03:00.001Z

In 1946 the government issued a white paper describing the new NHS (Cmd 6761). The document starts with these paragraphs:

The Bill provides for the establishment of a comprehensive health service in England and Wales. A further Bill to provide for Scotland will be introduced later.
All the service, or any part of it, is to be available to everyone in England and Wales. The Bill imposes no limitation on availability – eg,. limitations on financial means, age, sex, employment or vocation, area of residence or insurance qualification.

Right at the very beginning of our NHS there was a pledge to provide a service that was comprehensive and universal; available to all regardless of income or location. These principles are precious yet vulnerable. Reforms over the last two decades have chipped away at these principles and the final push to abolish them takes the form of the Coalition government's Health and Social Care Bill.

NHS Predictions for 2012

2011-12-30T13:08:00.000Z

I am not a betting man so I will not put money on these predictions. Here are my fears for the coming year (I have no hopes because I can only see things getting worse).

At some point an influential figure (whether that is a government minister, the prime minister, the CEO of a large NHS trust or a healthcare professional body) will say that NHS patients should expect to pay for cataract removal. The argument will be that patients pay for Lasik or spectacles to be able to see and this is no different, logically or morally, to having to pay for a cataract operation to see. This will be described as not being in contradiction to the NHS ethos of free-at-the-point-of-use because that principle will always apply to life threatening conditions (see what they've done there?).
There will be a rationalisation of prescription charges. This will result in people who are being treated for cancer will find that their cancer drugs will no longer be subject to prescription charges. The flip side is that the DH will make up for the loss of prescription charges in one area by introducing them in another area. The Department will review the entire prescription charges policy and they will take the view that only essential, life-giving drugs will be exempt from prescription charges. So for example insulin will be exempt but drugs to treat hypertension - where there will be no immediate effect on mortality if the patients stopped taking the drug - will be regarded as non-essential and hence subject to prescription charges. The government will say that prescription charges for preventative drugs will reflect their policy of patients taking more responsibility for their health.
The Francis report will be published some time early in 2012. Some parts of the Press will use it to say that the entire NHS is not fit for purpose and the BBC, as usual, will find some obscure person and quote them saying that the NHS needs a complete overhaul. Andrew Lansley will silently punch the air when he hears this on the 8am news bulletin on Radio 4. However, the significant part of the Francis report will be the sections that show how local and national Conservative politicians have exploited and conflated what happened at Mid Staffs for political gain. The question is whether there will be a backlash against those politicians.
At some point there will be yet another scandal in care homes and CQC will be pilloried for not noticing the issues, and worse, for producing a glowing report for a clearly failing care home. Since CQC is a vital gangplank of Lansley's plans he will (yet again) make just a few derrogatory comments and leave CQC and its inadequate budget, largely unchanged. This will lay the foundations for yet more scandals in 2013.
The Department of Health will finally do what it should have done in the Autumn of 2010 and announce a minimum population that each CCG has to cover before it will be authorised. There will be upheaval as pathfinder CCGs merge and there will be a lot of grumbling as people say that local decision making is being moved to large faceless organisations. (The counter argument that it would have been better to have left PCTs alone will be lost in the din.) In the run up to the April 2013 handover date, there will be fewer than 200 CCGs, maybe as low as, (umm) the 152 PCTs they are supposed to replace.
The Health and Social Care Act will get Royal Assent. There will be a lot of huffing and puffing (or perhaps wheezing) in the Lords during the Report stage. There will also be heated debates in the Commons when consideration the Lords amendments. Labour, as always, will have an uncoordinated attack; Lib Dem MPs will give speeches saying, effectively, what they didn't like about the NHS under Labour but will be clueless about the effect of the Bill; and Tory MPs will say that Lansley is a god because they have been whipped to say it. If we are lucky (it's a big if) the Secretary of State will be forced to retain the responsibility for the NHS and for determining whether the NHS charges for treatment. But it is a big if.

I now have an incentive to return back in a years time and say which of these are right and which are wrong.

Memories of Paul

2011-12-29T23:43:00.000Z

When I was a student I shared a house with two friends, one of them was Paul. Everyone loved Paul, he was intelligent, easy-going and fun to be with. Perhaps too many people loved him, because sometimes he would request that if this girl or that girl turned up at our house, we were to tell her he wasn't in. On one occasion he insisted vociferously that we go to the pub (something we did not normally need to be persuaded) only to return to find out why: a girl he had met at a party had decided to call round, and she was so intent on seeing him that she had broken into our house and was waiting for him in his bedroom. It was all part of the rich tapestry of student life.

When Paul finished his degree he got a job with an accountancy firm to train as a chartered accountant. The office was in another town, where Paul moved, but he was still registered at the GP on campus. Whenever he had a GP appointment he would call into my lab so that we could go for a coffee. At that time it did not occur to me that it was odd how many times he was visiting his GP, but I later learned that for a while his immune system was compromised. Paul was very fit: he had been a county level cross country runner, was a keen cyclist and he did martial arts, so frequent trips to his GP was not normal.

Then early in January he turned up at my lab. Over coffee he said that he was about to see his GP because he had discovered some lumps in his armpit. It sounded worrying, so I asked him to call back after his appointment. On his return he told me that his GP was very worried about the lumps and said that he needed to see a cancer specialist at the University hospital just over the road. The problem was that this was 1988 and when she called the hospital she was told that there was a three month waiting list. Paul then asked her if his health insurance would help. At the end of December he had worked for the accountancy firm for six months and this meant that he was now part of the company's health insurance scheme. His GP told him it would, and called the hospital again. This time he was given an appointment for the same specialist the next day.

Then followed a whirlwind of activity. The specialist confirmed that it was cancer - a tumour in his neck - and two days later he was operated on to remove the tumour. Then he had months of chemo in a private hospital out in the country, and radiotherapy in a local NHS hospital. For his chemo his girlfriend would drive him to my house the night before, and we would have our own chemo session in the local pubs. The next day I would drive him to the hospital and a few days after his girlfriend would pick him up from the hospital to take him home.

As an accountant he cast a beady eye over the care he was getting. I don't know if he had requested a copy of the bill, or whether it was standard practice, but he took an interest in the cost of the drugs he was given. I remember him telling me how shocked he was over the huge levels of overcharging, but since it was being paid by the insurance company (and the premiums paid by his employer) he really didn't feel able to complain.

On one of these chemo sessions Paul took ill. It wasn't the usual nausea, it was far worse, so bad that the staff at the hospital called the specialist immediately. This was the same specialist who worked in the NHS hospital. I remember Paul telling me that the specialist turned up in a dinner suit - he had been bleeped while in the audience at the opera. It was a provincial theatre, so the opera must have been touring and hence the specialist was probably missing a performance that was unlikely to be repeated for a long time. Private patients were that special.

Then Paul needed an MRI scan. This was the early days of MRI. The technique had been developed fifteen doors down the corridor where I worked, but because it was a research lab they did not have the facilities for really sick patients. Instead, Paul was scanned in the University Hospital over the road. This hospital was one of five in the region that had clubbed together to buy their own MRI machine. It was installed in a container which was driven around the contributing hospitals on a regular schedule, spending a week or so in the car park of each one.

Paul described to me what happened. He was driven from the private hospital in a private ambulance. At the University Hospital he was put in a wheelchair and a porter took him to the queue of patients waiting to be scanned. Some sat on seats, some were in wheelchairs and others on trolleys. Paul was pushed past this queue of patients. He was pushed past this pitiful collection of humanity and pushed right to the front of the queue. I know that Paul had been grateful for his health insurance, because he had been told by the specialist that he may not have survived the NHS waiting list, but I knew from his voice when he told me about the MRI scan that he was truly ashamed of being pushed to the front of the queue. He could have waited but his status as a private patient meant that the other patients, regardless of how sick they were, did not count.

Paul recovered. He had two years of remission, and then the cancer returned. This time he was treated in an NHS hospital closer to his home. Although he still worked for the accountancy company, the health insurance no longer covered him. Sadly, his specialist could not determine the cause of the cancer. He had various operations to remove tumours from various parts of his body. Then it was discovered that he had a tumour between his spine and lungs. It was inoperable. But worse: the mineral balance in his blood was haywire and his lungs filled up with fluid which required a painful procedure to drain them.

By this time, I had changed jobs and moved house. My new job was unreasonably hectic, but luckily one weekend I did not have to work and so I visited Paul for the day. It was shocking. This once fit energetic man could barely move, and even the simplest of actions was difficult for him. I remember that the chairs in the sitting room had bricks under their legs: this was so that the seats were higher so that Paul could manage to get up after sitting down. He was too weak to get himself out of a armchair.
We spoke at length about his treatment, but his wife, a midwife, kept quiet. I later learned that she knew more about his condition than he did, she had asked the specialist the questions that he could not bring himself to ask.

The following weekend I phoned him to see how his treatment was progressing and he told me that his specialist had told him that his chemo had been stopped. I immediately recognised what was happening, but Paul was an eternal optimist. He told me about how there was an ultrasound technique that the hospital were trialling that could be used to drain the fluid from his chest. He told me about a new drug that he would be given once he had rested a while and regained his strength. He knew he had a future, I knew that he had been sent home to die.

The following Friday was my birthday. It was one of the few weeks that year that I was working in the office rather than on site. Mid morning I got a telephone call from my wife. She was tearful, she had had a phone call from the brother of Paul's wife (who, coincidentally, was the other student I had shared the house with). Paul had died that morning. He had drowned from the fluid in his lungs. The cancer had killed him.

I hated the job I was doing then. I felt bullied by my managers to work far longer hours than I was contracted to do and I felt that this company was making me neglect my family. When I found out when Paul's funeral was to be I told my manager - not requested, but told him - that I was going to the funeral. Paul was 28 when he died, in our modern age, and in peacetime, we do not expect people to die that young. I realised that life is too fragile and too short to allow others to exploit and abuse you. I changed jobs a month later.

Paul was never an advocate for private healthcare: during his years of remission he told me that his treatment had convinced him of the need for the NHS. It was partly the waste of the private hospital, the fact that they could charge whatever they wanted and the bill would be paid. This shocked Paul because it meant that they had no incentive to limit care to just what was needed. But I think his experience of being wheeled past the rows of NHS patients and taken to the front of the queue had a profound effect on him. I remember him describing the queue of people, and how he realised that the NHS treated everyone.

Now the days of Paul's treatment are returning. Thatcher's NHS was dire, but at least the service had real terms increases that could be counted in billions rather than Cameron's that can only be counted in millions and only then on a good day. Now patients are being denied NHS care: they are being told that they are not blind enough, or in enough pain to have the operation they need. Most of us thought that such days had been banished to the past, that the NHS existed to give us the care we needed, when we needed it. But now it is getting worse, we are seeing the return to the Thatcher doctrine that people should expect to pay for private care, either out of pocket or through insurance, and that those of us who could not afford private care would, like the queues of patients waiting for their MRI scan in that 80s hospital, be second in line to the private patients.

We are going back to the NHS of when Paul's cancer first appeared, but sadly, it can never bring back Paul.

A radical thought

2011-12-28T12:45:00.000Z

OFT says that in 2008 the total market for private healthcare was estimated to be £5.5bn. They said that the NHS paid 23% of that or £1.3bn. Monitor says that in 2010 £252m of the income of Foundation Trusts (1.1%) was from private patients. It looks to me that so far private healthcare is "winning" by over a billion pounds per year.

So here's a radical thought. Rather than yet another upheaval in the vain attempt to try and get more of the leprechaun gold that is private patient income into NHS hospitals, why don't we just stop paying private hospitals to do NHS work? The NHS could do what it does well: cost effective, comprehensive, universal healthcare; the private sector can then do what it does: deep-pile carpet healthcare for people with leprechaun gold. And the NHS will be £1bn better off.

Private Patient Income Cap

2011-12-27T19:37:00.002Z

The private patient income (PPI) cap was imposed to limit the private income of NHS trusts. The cap includes the income from actual physical, in-the-flesh, patients, but it also includes income from other services like providing pathology or income from intellectual property. This cap is arbitrary, Foundation Trusts are limited to the percentage of their income that came from private work in 2003. In 2010/11 FTs generated £252m income from private patients, this is 1.1% of their total income of £26,867m. There are, however, a few FTs that make considerably more than this (as I outlined in my post earlier this year):

The Royal Marsden	30.7%
Royal Brompton and Harefield	14.4%
Moorfields Eye Hospital	13.7%
University College London Hospitals	6.6%
Papworth Hospital	6.1%
Guy's & St Thomas'	3.0%

The arbitrary nature of the PPI cap is unacceptable and needed fixing, but removing it entirely is not the solution. For a start, Intellectual Property should have been NHS IP and new techniques should have been used for all NHS patients, not just for those in the hospital that developed them. Then there is the fact that the cap does not distinguish between income from services provided by NHS hospitals for private hospitals and income from private patients. There is clearly a difference between the two, and I think that private patient numbers should be capped to prevent a two tier system, but the services should be regulated but excluded from the income cap.

The Times, apparently have a leak that says that the PPI cap will be raised to a maximum of 49%. I guess this is a "compromise" by Lansley to his Lib Dem opponents. The original policy in the White Paper (and in the Bill) was to abolish the cap completely. A "cap" of 49% will, frankly, have the same effect as abolishing the cap.

This leak has lead to some quite hysterical comments. The Independent, for example, reports:

"It is expected to cause more friction within the coalition with a senior Liberal Democrat warning that it was part of an ideological drive that many in the party would oppose, the newspaper said. "

without realising that the 49% figure was Baroness Williams' idea! (Again, I explain this in an earlier post.)

It may be that the large London teaching hospitals (basically the hospitals listed above) will attract more foreign patients (but sufficient to get 49% of their income from private work?), but it is unlikely that your average bog standard district general hospital will be able to do that. In terms of private patients from England, the last few years has seen a fall in the number of people with private medical insurance (PMI), and a slight rise in the number of self-pay. Can it be possible that literally millions of people from England will choose to have private treatment in an NHS hospital either as self-pay or PMI? I mean, actually choose to pay?

Lansley says:

"If these hospitals earn additional income from private work that means there will be more money available to invest in NHS services."

which he knows to be nonsense.

I have had discussions with governors at my local FT on this subject and the more naive Conservatives take Lansley's line. The majority of governors are more wary. Incidentally, my local FT was founded in the 1850s as a workhouse with an infirmary; the workhouse has closed and the infirmary (ie the hospital) has taken over the workhouse site. The current management offices occupy what remains of the original workhouse buildings, I am sure there is an allegory there... The infirmary treated the poor through charitable funds. The suggestion that private patients will fund NHS patients (the rich paying for the treatment of the poor) is not a million miles from the original founding principles of this hospital: is this what we want?

However, those governors who naively believe Lansley's statement seem to ignore the fact that private patients will not want to be treated with the hoi poloi, they will not want to have the same accommodation, nor be subject to the same waiting times, and all of this means that the trust will have to make the investment to provide a separate private patient unit so that the private patients will be kept separate from the great unwashed. Parking is a perennial problem at this Foundation Trust, and the relatives of private patients will not want to suffer the same problems that relatives of NHS patients do to obtain a parking place, so the hospital will have to provide a separate car park for them. Where will the capital for all this investment come from? We know that the large London teaching hospitals have been able to get such investment using their international (NHS-funded) reputation, but your average district general hospital won't. I know that my local DGH FT needs a new NHS eye clinic, so if they can find the money for a private patient unit with its own private car park, why can't they find the capital for an NHS clinic? When the conversation gets to this point governors make it clear to the hospital management that private patients are just too costly.

The second issue is that, as mentioned above, private medical insurers have found that in the last few years they are getting less business and consequently they are trying to squeeze their providers. For example, BUPA have recently de-listed BMI because the private hospital chain would not cut their rates. Under these circumstances would PMI accept that the private patient units in an NHS hospital deliberately subsidises NHS patients? Would self-pay patients be happy to learn that a proportion of the fee they are paying will pay for a patient to get the same care for free? I think not, and especially not if self-pay patients have been denied NHS care themselves (which will become increasingly the case in the next few years). This brings me to another issue.

The meme that is going round Twitter at the moment is that there are 160,000 beds in NHS hospitals and that if the PPI cap is raised to 49% 80,000 beds will be occupied by private patients. There are currently 11,200 beds in private acute hospitals at the moment, so even if all of those patients decided to go to a NHS hospital instead there would still be a shortfall of almost 70,000. This is not 70,000 per year, this is 70,000 at any one time, and represents a huge number of patients.

Where will all these new patients come from? This leads me to clause 10 of the Bill. This clause says that the responsibility of making the decision about charging for NHS treatment will be removed from the Secretary of State and it will be handed to Clinical Commissioning Groups. There will be about 250 of these, so it is likely that at least one will decide that the NHS will not pay for common treatments like cataracts, hips and knees. Further, the NHS cuts that is causing the impending NHS financial crisis will lead to Draconian rationing. CCGs will literally tell patients that they are not yet in enough pain for the NHS to pay for their hip operation, or they are not blind enough for a cataract operation. Such patients, understandably, will look to their savings, or will cash in a life insurance policy, or raid their pension fund, indeed anything to find the money to pay for the operation they desperately need.

These are the patients who will become private patients in NHS hospitals (since NHS private rates will be cheaper than the private hospitals). This is how the NHS will be privatised. The irony is that two years prior those patients would have had the same treatment for free, and this free-at-the-point-of-use principle would have been preserved if they had voted differently at the 2010 election.

Are you afraid of the facts?

2011-12-15T17:07:00.001Z

Joe Farrington-Douglas pointed out on Twitter Lord Owen's speech, on Tuesday, about compettition and Monitor. This section is interesting:

In 2006, a Labour Government commissioned a major study on competition and the effects on the EU. It is a scandal that I have been trying for months through Freedom of Information to get hold of this document so that we would have it before this debate.

I have been obstructed at every turn by the Department of Health. Do not tell me that it wants the facts out here so that we can discuss them and know about this issue. As the noble Lord [Howe] states, as an experienced lawyer, this is an area of very great complexity and yet we are not allowed to see this study, which we have paid for. It is not the possession of the Government-it was not even commissioned by this Government-but we are not allowed to see it. What is the Freedom of Information Act about? Are you afraid of the facts? Is there something that we cannot be trusted with? We are about to legislate on a very important area, which does have an impact on the EU, and we are deprived of one of the existing studies. So, all of us have had to go around and try to get expertise in this area and it is not easy to do so.

Why can't we have this report? And could Patricia Hewitt, who was Secretary of State at the time, tell us what the report said?

Lady Williams

2011-12-14T20:26:00.000Z

This is an interesting quote from a forthcoming interview with Andrew Lansley in the Spectator about Shirley Williams. (Quoted on the Guardian website):

When asked what he makes of her, the Health Secretary is lost for words. 'She is...' he splutters. 'How can I say, she is... a high maintenance date. We have had lots of meetings,' he continues. 'In a sense, to give her her due, even if I felt we had to devote an enormous amount of time simply to get to the point where we were clear about what it is she wanted, I think that allowed her to realise that we were not dealing with the bill as she imagined it was.'

Lady Williams is the Lib Dems' great hope for the Health Bill in the Lords. In this respect I agree with Lansley, Lady Williams does not appear to understand the Bill.

Diabetes Audit

2011-12-14T11:50:00.000Z

There is something a bit odd about the shock news released today that people who have a serious (but controllable) medical condition are not expected to live as long as people without it. As per usual, the BBC are reporting the news as if no one has ever been aware of it, but I came to the conclusion a year ago that the BBC have an agenda to broadcast as many articles as possible that puts the NHS in a poor light. (Not surprising really, since that is the agenda of the Department of Health and the BBC seems to be the biggest consumer of churnalism at the moment.)

Let's look at what the BBC are saying.

"Up to 24,000 deaths from diabetes could be avoided in England each year, if patients and doctors better managed the condition, a report concludes."

Let's look at the statistics. Diabetes UK say that there are 2.9 million people with diabetes (type 1 and type 2) or 4.45% of the UK population. They also say that 90% of diabetics have type 2 diabetes.

ONS says that in 2010 there were 493,000 deaths in the UK. Out of a population of 62 million that means slightly under 0.8% of the population. ONS provides detailed tables giving the cause of death.

The figures says that in 2010, 5,223 people died from diabetes. When just over five thousand people die from diabetes a year, the BBC says that almost five times more deaths can be avoided. How? Perhaps this statement from the BBC article explains why:

"Around 70-75,000 diabetic patients die every year."

This is not the number of people who die from diabetes, this is the number of diabetics who die. Such people could be dying of cancer, stroke or heart attacks; in other words the same things that everyone else dies of. Diabetes may well exasperate these conditions, but that is not the same as dying from diabetes; ONS says so.

The BBC says:

For patients with Type 1, the risk of dying was 2.6 times higher than it was for the general population. With Type 2, the risk was 1.6 times higher.

The figures that I gave above from Diabetes UK about diabetes mortality are also in a PDF report on their website called Diabetes in the UK 2010: Key statistics on diabetes. In a section called Life expectancy and mortality it has these statistics:

More than one in ten (11.6 per cent) deaths among 20 to 79-year-olds in England can be attributed to diabetes. If current trends continue, one in eight (12.2 per cent) deaths among 20 to 79-year-olds will be attributable to the condition by 2010.
Life expectancy is reduced, on average, by:
– more than 20 years in people with Type 1 diabetes
– up to 10 years in people with Type 2 diabetes

Note the date: 2010. In fact, the figures for the reduction in life expectancy comes from a Department of Health report dated 2001. The 11.6% figure comes from a report in 2008. In other words, none of this is new.

Then the BBC report this:

The Department of Health in England said shocking variations in care and an unacceptable death toll were evident.

Where did they get this impression from? Variation in the treatment of diabetes can be obtained from the Quality Outcomes Framework, that the Department of Health have been collecting since 2004.

Eh? They have known since 2004 that there were shocking variations and have done nothing about it? Are the Department of Health that incompetent?

The BBC report is churnalism of the press release on the NHS Information Centre. The news is not shocking, it is well known, the NHS IC merely have produced a report about something we all knew anyway. Perhaps the most interesting part of the NHS IC report is this:

"There is a strong link between deprivation and increased mortality rates. Among under-65s with diabetes; the number of deaths among people from the most deprived backgrounds is double that of those from the least deprived backgrounds."

This re-states something that was in the Diabetes Audit (pdf) from last year:

"In those aged 70 years and over, similar numbers of Q1 (12.1 per cent) and Q5 (14.8 per cent) have Type 2 diabetes, but under the age of 55 Type 2 diabetes is more than twice as common in Q5 (3.0 per cent) as Q1 (1.3 per cent). This may reflect lifestyle differences in exercise, diet and weight."

Q1 is the least deprived quintile of the population, Q5 is the most deprived. There is a clear message here: deprivation causes type 2 diabetes. The BBC didn't report that, did they?

NHS Funding

2011-12-13T23:22:00.000Z

Two interesting bits of information have come out over the last couple of days. The first is from an interview by James Forsyth with Andrew Lansley in the Spectator:

'I ask him whether, despite the ramifications of the autumn statement, the NHS budget will still be immune from cuts. His reply is unequivocal: "We have been very clear that the NHS is going to have real terms increases year on year. I mean clearly what we've said in terms of the coalition agreement is an agreement for a parliament. From our point of view, I would say yes is the answer to that because exactly the same principles apply. We have a profile of rising demographics and demand and cost pressures and technology in the NHS, so it is inconceivable that we can sustain the quality of services that we are looking for without the basis of real terms increases."

Does this mean that spending on the NHS will have to rise in real terms every year from now until kingdom come? "I believe so."'

Lansley is saying that a Tory government will not cut the NHS budget (as we know, their definition of real terms increase is actually real terms flat funding, but at least that is better than real terms cuts). This raises the question of whether Lansley is making up policy? Forsyth goes on:

'One senior figure at No. 10 tells me that "Dave, George and Steve", the holy trinity of Cameron, Osborne and Hilton, "all believe that the pressures on the Health Service are such that you are always going to have to increase spending on it"'.

So it seems that "real terms increases" after the election is a Tory policy. It is questionable whether it will be enough to de-toxify the Tory brand on the NHS after Lansley's mismanagement, but that is another article.

The problem is that at the Autumn Spending Review George Osborne admitted to his mismanagement of the economy and, shamefaced, accepted that his plan to wipe out the structural deficit will be delayed by two years. So rather than getting a balanced budget by the next election, the balance will be achieved two years later. If the economy is in such a Tory-imposed mess, how can Lansley promise "real term increases"?

The clue lies in an article by Nick Timmins of the FT. The title of the article tells you almost all you need to know: Debate looms about how to fund the NHS. In this Timmins says:

"Last month’s autumn statement has made that more or less inevitable. Faced with rising demand, the health service was already facing its toughest financial challenge – four years of what is, in effect, a real terms freeze. But the extra £15bn a year of spending cuts beyond 2015 announced by the chancellor means that – unless the economy improves – the service will be in a financial crisis or on the brink of one."

This is not the rosy situation that Lansley et al like to convey. Timmins is a reliable and expert social commentator: he knows his stuff. The NHS will suffer from a financial crisis at the next election and the Tory government will not be able to fund it sufficiently to fix the problem. Timmins describes what he thinks will happen:

"So when yet more money is excised from public services after the next election, it is inconceivable that the NHS will be given even the relative degree of protection it has received this time round. The result is likely to be a performance and financial crisis. Every time that has happened – in the 1980s, 1990s and early 2000s – the result has been a debate about how to fund the service, with all the old chestnuts dragged out. Whether, for example, to introduce charges, provide tax relief for private medical cover or switch to social insurance. Up to now, such arguments have always been lost. This time round, the outcome may be different, not least because other forces are at work."

While I do not think that Osborne deliberately engineered a failing economy so as to create an excuse for this debate, I do think that it was the intention of his policy of real terms flat funding. At the next election the Tories will go to the country telling the electorate that the only way for the NHS to have the larger increases necessary to avert the financial crisis is if the electorate accepts a new funding mechanism.

[As an aside, if there is an NHS financial crisis before the next election then surely the public will take this to finally decide that the NHS is not safe in Tory hands? If so then we have to direct our attention to Labour and get a pledge from them to maintain the current funding mechanism.]

When have we heard this before? We haven't had such an option specifically at an election (there's always a first time). However, after the Blair government introduced tuition fees (without an electoral mandate) we were told that we had to accept the new funding mechanism because it was the only way to provide the extra funding that higher education needed. Same argument, different public service.

We know that the introduction of tuition fees was a disaster, contributing to the heavy debts our children will have to bear. Let's hope that the next time that a political party either seeking a mandate, or in power without the mandate, will find all-out opposition to the funding changes that Timmins suggests could be offered.

Data

2011-12-05T16:09:00.001Z

There is nothing new about the collection of medical data. The industrial revolution had a huge effect on the lives of many people, particularly the poor, but it was the Boer War that brought public health to the forefront. The military found that a large proportion of recruits for the war were unfit for service. Although there were philanthropic health visitors before then, the scandal of the Boer War was the impetus to expand the service. By the end of the First World War there were more than 3,000 health visitors with a specific mandate to work with mothers and promote infant and child care and the prevention of the spread of infection. The Victorians were enamoured with figures, and health visitors, of course, could record lots of figures. A century of data of child development is valuable for people researching the subject.

When you look at data, you can look at it from one end of the telescope or the other. Holding the telescope normally, you can get detailed information about an individual. If you access health records from the early part of the 20th century you could get information about people who are still alive. Such data may be so detailed as to make it personal, but such information will have little importance other than to the individual. If you turn the telescope around and look at aggregated data, you get a much bigger picture, one which allows you to make decisions about large groups of people. However, since detail is a hindrance aggregated data means that the individual cannot be seen.

The announcement that the government intends to hand our medical records over to private companies worries some people because they feel their privacy will be invaded. Can you say that the data that the health visitors gathered a century ago was an invasion of the privacy of those children? In response to the government's plans to hand NHS data to private companies the campaign group Patient Concern said:

'This is the death of patient confidentiality. There is no guarantee that information will be anonymised. In any case, anonymised data can just as easily be re-identified.'

This is nonsense. Anonoymising data is one-way: once you have removed identifying data there is no way that someone else can put it back in. The suggestion from Patient Concern is as believable as homoeopaths claiming that water has "memory", the campaign group seems to be suggesting that patient data has "memory".

However, as I explained in my last blog, it depends on how you interpret the data. For example, a friend was an administrator in the transplant unit of a large hospital. At that time George Best needed a new liver. My friend told me that in his hospital a young person died. This person had indicated that they wanted to donate their organs and their family had agreed too. The person was an appropriate tissue match for Best, but the family were not told this because donations are anonymous, however, they were told that the young person's liver had been transplanted. This tiny piece of information was significant because a few hours later the media reported that Best had received a new liver. The family could easily put two and two together, and (so my friend told me) were upset that their child's liver would be transplanted into someone who would abuse it (as proved to be the case).

A small piece of information - the organ that had been transplanted - allowed the family to find out who had received the organ. While it is possible to anonymise a process, or to anonymise data, it has to be done carefully, particularly when you are handing a single patient's anonymised data. This does not mean that anonymised data can "easily be re-identified" but it does mean that sometimes people can make intelligent guesses. When data is aggregated even more detail is lost, and even the most intelligent cannot make guesses about the individuals involved.

UPDATE:
@NO2ID tweeted this article from the security guru, Bruce Schneier (if you have the chance, read Schneier's "Beyond Fear"). In the article he reports studies that have essentially used external data to make "intelligent guesses" with online databases.

Anonymising Data

2011-12-05T11:44:00.001Z

Today we hear that The Prime Minister wants to sell off NHS data (sorry, "he wants to make it easier for drug companies to run clinical trials in hospitals and to benefit from the NHS's vast collection of patient data"). This has prompted much howling from people scared that private companies will have access to their medical records. This is not the case (although Lansley wants you to voluntarily hand over your full medical records to private companies, but that is another policy yet to be debated).

It is easy to provide rich, anonymised data: simply remove your name and address. However, this removes important data since your location may be affecting your health. Researchers trying to use the data to look for connections between health and the various factors given in the dataset need to take into account any variations due to location. There are 28 million addresses in the UK. Your postcode covers about 15 addresses, so the combination of your house number and postcode identifies your home.

Your postcode comes in two parts. The first part is called the Outward Code, and the second part is the Inward Code. Each of these can be split into two. The postcode PO1 2AF can be split like this (this is data from the Post Office's lengthy document on postcodes and I have assumed total population is 60 million):

	Outward Code		Inward Code
	PostCode Area	Postcode District	Postcode Sector	Unit Postcode
Postcode	PO	1	2	AF
Number of areas	124	2,980	11,159	1.8 million
Addresses	226,000	9,400	2,500	15
People	484,000	20,000	5,400	33

The point of this table is that it shows that by giving some of the postcode you can make the data more localised, while anonymising the data. If the entire postcode is provided then there is a good change the patient can be identified. However, such data would be too granular to be useful for data mining anyway. Data grouped by Postcode Sector (giving 11,000 unique locations) or Postcode District (giving about 3,000 unique locations) is much more manageable.

Let's imagine that that a celebrity actress has just had an operation on her foot and is on crutches. She has recently been on Strictly Come Dancing so the tabloid paparazzi think it is newsworthy to have a picture of her on crutches. The paps obtain a spreadsheet of all the people who have had foot operations in the last month. If the spreadsheet has the actress's house number and postcode, they can can simply park outside her house and take pictures of anything that moves within. If they have just her postcode, they have a one in fifteen chance of getting the right address and most likely will knock on one door in that postcode area and ask which house the actress lives in - eventually they find out the right house.

If the data has the Postcode Sector, it means that it covers 2,500 addresses (or about 5,400 people). It is not feasible for the pap to visit all the streets in the Postcode Sector on the random chance that they may be able to see an actress on crutches. However, 5,400 people is around the size of the patient list of a GP practice, so if the paparazzi loiter by the GP practice that covers that area they are bound to be able to take pictures of someone on crutches with a bandaged foot. There is a chance that the patient will be the actress. The more "innovative" paps will realise that from the Postcode Sector they can identify the community health team, the paps can then find out who the physiotherapists are and try to extract the address from them. Incidentally, the Postcode Sector is also roughly the size of an electoral ward (there is a large variation of the population size of electoral wards across the country).

For location information to be useful for epidemiologically it needs some granularity, and the larger the area, the less useful the location data will be. If the data has the Postcode District this will cover about 20,000 people (9,400 addresses), which is a small town. Since there are 250 NHS Trusts (and about 500 hospitals) in England the PostCode District will identify the hospital where the operation was carried out (and most likely where follow up outpatients will be). The paps could wait outside outpatients on the day that the follow ups for foot operations are booked and hope the actress turns up. If the data has just the Postcode Area, then the paps cannot even identify the trust since there would be two, or (in cities) more trusts covering that area. However, it is likely that such data would have the trust identifying code, or the hospital identifying code.

The privacy concerns about NHS data being handed to private companies are unfounded. It is easy to anonymise data while still providing enough granularity. However, this is not my complaint against Cameron's decision. I will explain why I am not in favour of this policy in my next blog.

TUPE

2011-12-03T12:25:00.001Z

Transfer of Undertakings (Protection of Employment) regulations, or TUPE, was introduced by the last government to protect workers rights when they are transferred to another organisation (the law is the UK's implementation of a European directive). TUPE is on many people's lips now because the current government wants to divest itself of as much of its public service responsibilities as it can by shifting services into the so-called "voluntary sector" (social enterprises - not-for-profit private companies) or the private sector. To a large extent, the government does not care whether the public service is moved to the private sector or becomes a social enterprise, their only criteria is that the service should no longer be provided by the public sector.

When a service moves out of the public sector employees are rightly worried. After all, such employees signed a contract when they started the job and employment contracts are two way - the employer must keep to their contractual terms. TUPE attempts to ensure that the employee's terms and conditions are preserved even though the employer has changed. However, it is not all rosy. TUPE does not mean that an employee will still be able to contribute to the NHS pension scheme, the regulations merely says that the new employer must provide an equivalent scheme. And TUPE only affects existing employees, so new employees will be employed on different T&Cs (a two-tier system) and TUPEd staff changing roles within the new organisation will lose their TUPEd rights when they sign a new employment contract.

In the Autumn Statement, the government indicated that they wanted to change TUPE. The Chancellor said that this was to "help employers to hire people". There is some logic to this: making a profit from the NHS tariff is difficult enough, but it is made more difficult when an employer has to give their staff decent terms and conditions. Remove the requirement to pay staff a liveable income and it starts to get more attractive for the private sector to take over NHS services. If TUPE is abolished or watered down, it will mean worse conditions for staff: lower pay, loss of rights to training and loss of rights to a proper pension scheme.

However, TUPE is not just about transfers from the public to the private sector, it is about all transfers: within the private sector and within the public sector. So if a Foundation Trust (part of the NHS) takes over the Community Health Services from the local Primary Care Trust (part of the NHS), the employees are TUPEd. The transfer is within the NHS, but the regulations still apply. This is important because, nominally, FTs can employ staff on local terms and pay. At the moment only Southend Foundation Trust has used these "freedoms" to opt out of Agenda For Change and recently chose not to award annual increments that have resulted elsewhere under A4C.

TUPE effectively keeps T&Cs constant across the NHS. If TUPE were to be abolished this would quite rapidly result in local T&Cs and the first casualty will be Agenda For Change. Why not have local pay bargaining, after all, it costs far more to live in London than it does to live in Middlesbrough, so why not pay London workers more to reflect this? This happens already, NHS pay has a London-weighting. The problem with local pay is inherent in the name. It is not so much the difference between trusts in different parts of the country, it is the difference between trusts in the same part of the country. If there are two trusts in a city they can use local pay to compete for staff. If one trust pays more to attract more skilled staff, the effect will be that the trust that cannot pay the higher rates will not get the skilled staff. The result will be self-fulfilling: pay escalation for some staff and trusts that cannot afford the rates will have declining quality, declining patient numbers, declining income and then, ultimately, bankruptcy.

The real reason for wanting to abolish TUPE is that the government wants to move away from national pay bargaining and move to local T&Cs. The NHS works because it is one organisation. Fragmentation through different T&Cs and local pay bargaining will mark the end of the NHS since it will be the death of collaboration between NHS organisations.

Not in my name

2011-11-24T17:41:00.000Z

The government is very keen on using people with long term conditions as an excuse for their changes to the NHS. They say that without the changes we will use so much healthcare that we will bankrupt the NHS. I am not against change, but I am against blaming people for unpopular change.

On the 18 January 1976, at the age of 11, I was diagnosed with type 1 diabetes. I remember, during one of the appointments I had with the diabetes specialist, I was told that in later life I would have kidney problems; there was no "if", it was a definite statement based on the middle aged diabetics that he was treating at that time. I distinctly remember the specialist telling me that by the time I am 50 I will need a new kidney.

A lot has changed since then. I am three years off the half century and my kidneys are still working. Part of the reason for this is because of the preventative medication I have been taking for the last 15 years or so (ACE inhibitors and calcium channel blockers for hypertension). Part of this is because of better management of my condition through purer insulin and through finger prick blood tests. None of this costs much, in fact through new processes of making insulin the price of insulin has dropped over the last 30 years. It is cheap to keep me alive!

Dialysis, organ transplant and the long term follow up care for a patient with a transplanted organ is expensive. In 1976 a health economist could have looked at me and visualised a deep pit being dug to consume future piles of NHS money. The health economist would have been wrong. I am sure that I have cost the NHS a lot less than could have been predicted 35 years ago.

I am going to be uncharacteristically optimistic here: I do not think I will be a big drain on NHS finances in the future either. This is why I wish the government will stop using me as their reason for breaking apart the NHS.

What's happening in the Lords

2011-11-13T22:20:00.000Z

Yesterday I attended Labour's West Midlands Regional Conference. The day was dominated by a debate on the economy and workshops on developing policy. Notably absent was any session on the NHS: Labour are very quiet about what their policy will be, whether this is embarrassment because they handed the Tories a legislative framework that would enable them to marketise the NHS is unclear.

Anyway, in the final Q&A session, in response to a question on the NHS (just one!) Lord Hunt mentioned the changed voting habits of the upper house. Michael White mentions this too, in the Guardian:

"When Labour was in power, the party's chief whip Lord Bassam could expect to lose one in three divisions if the Lib Dem, Tory and crossbench peers decided to strike down an offending clause in legislation. On issues like 42-day detention of terror suspects, defeated by the Lords in 2008, the unelected house spoke for public opinion. David Cameron's rose garden pact with Nick Clegg has changed the maths. With 170 Tory and 88 Lib Dem peers (the 153 crossbenchers often split 50/50) the coalition partners usually have a de facto majority over Labour's 238. No one party was supposed to have one in the half-reformed system bequeathed by Tony Blair, but no one planned for coalition. Government defeats are down to around 15%."

Yet again, the Lib Dems are allowing this damaging Bill to be passed. The Lords exist to amend legislation, and they have experts who can see the important nuances of the laws and suggest ways to improve bills. The 30% of votes that Labour lost means amendments to make the bill in question better. The 15% figure now means that the government is imposing its view and forcing its peers to vote en bloc. This is political and reduces the effectiveness of the chamber and allows bad bills to be passed.

The Bill sailed through the Commons Committee stage precisely because the Lib Dem members voted en bloc with the Tories. Not one single Labour amendment was passed by the Commons Committee. In fact not one single non-Government amendment was passed, because the Tory whips threatened Tory and Lib Dem MPs telling them that the only amendments that would be allowed to pass the Commons Committee would be those proposed by the government. This is the behaviour of a authoritarian government that believes that it is always right (a very frightening concept). We are finding the same behaviour in the Lords Committee.

If the Tories had not been handed a Coalition, and were now ruling by supply and confidence, the Lib Dem peers would be free to make amendments and make this bill better. Even if the Tories had scraped through the 2010 with a narrow majority, the Lib Dem peers would more often than not be changing this bill. Now they are sitting on their hands. It is very clear: Coalition is bad, and allows bad laws to pass.

Choice

2011-11-08T20:33:00.000Z

I attended a patient forum meeting last night at my local hospital. During his talk the Medical Director told us a joke that he said was prevalent in the NHS of the 80s:

Receptionist: We can give you a date for your hip replacement: it will be 10:30am on June 22nd, 2015
Patient: Sorry, but I cannot make that appointment. The Gas Board is coming to install my cooker at 11 on that day.

Well, I guess the humour is all in the delivery. The point was to illustrate the "Soviet-style" of public services in the 80s: we were just too amenable to waiting long times.

Things have changed now, of course. The NHS constitution says that we have to be treated within 18 weeks and as David Cameron has found, there is a political cost to allowing waiting times to go up.

The 18 week RTT target was politically concocted, there is no special meaning to 4.5 months. (In Denmark, for example, the waiting time has to be less than 1 month.) Anyone who has been on a waiting list will tell you that it is not necessarily the amount of time that is the issue, it is the uncertainty of not knowing when you'll get the treatment. The uncertainty is especially acute if the patient is worried about the treatment.

Cutting waiting lists is expensive, so it is unlikely that any political party will promise to cut the (arbitrary) 18 week target. However, there is another policy that could be offered. Patients could be given one of two choices: treatment within 18 weeks, but the date is determined by the provider (the situation at the moment); or treatment on a date of the patient's choosing as long as it is outside the 18 week window (the actual limit may be different to 18 weeks). The idea would be to guarantee (as much it is possible to guarantee) that a patient will get the treatment on the day that is specified by the patient. This means that the patient will know that their cataracts will be replaced before they go on their birdwatching holiday, or their hip will be replaced before their child's wedding. There will be still work for NHS providers to so: they will have to have the capacity so that patients on the 18 week guarantee will fill the "gaps" between the patients who have booked.

So the joke would be partially true, patients may recieve treatment many months in the future, but the difference would be that they choose to have their treatment on that date. I think that this could be a popular policy at the next election.

Dithering

2011-11-03T13:17:00.000Z

During the second reading of the Health and Social Care Bill Lord Owen suggested that clause 1, the clause that determines the Secretary of State's responsibility, should be considered by a Select Committee of legal and health policy experts rather than the full Committee of the House. The Government claimed that this was an act to wreck the Bill and Lord Owen stressed that this was not the case, even offering to put a time limit on the Select Committee:

"My noble friend and I said we thought it was absolutely reasonable that to protect the business of the House they wanted this Bill before the new Session. We had already made it clear that this would have to be reported out from Select Committee by 19 December, and that was acceptable. The clerks tell me they have to report it out. They may say they want more time but there has to be a report. So I think we have dealt with one of the problems."

This explicitly says that the Select Committee will report before the 19th of December.

Lord Howe, the Government minister rejected this amendment:

"The provisions that the noble Lord, Lord Owen, asks us to send to a special Select Committee affect the entire Bill. The twin-track approach that he advocates carries a major risk: the potential disconnect between the special Select Committee and the Committee of the whole House. The Select Committee might recommend amendments to parts of the Bill that have already been debated by the Committee of the whole House. The result could be that, notwithstanding the offer made in good faith by the noble Baroness, Lady Royall, we could see a slippage of the timetable of the Bill that would be most unwelcome."

This basically says that Lord Howe rejected the idea of having a Select Committee because it may discuss amendments already discussed by the entire House (sitting as a Committee on the Bill) and this would delay the Bill further. The Government is desperate to ram the Bill through Parliament because if the Bill is not passed before April 2012 the timetable for major changes like abolishing PCTs and SHAs will have to be changed.

Then yesterday the Government had a re-think. Commenting on the group of amendments to clause 1 being debated, Lord Howe said:

"having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report to reflect further on these matters in a spirit of co-operation."

Now Lord Howe is saying that he does not want the full Committee of the House to discuss the clause, and instead he wants to submit an amendment during the Report stage of the Bill (in January). Later in the debate he added:

"I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters."

During the Second Reading Lord Howe said that the clause must be debated by the whole House Committee, rejecting the proposal to ask a Select Committee of experts; yet yesterday Lord Howe says that he wants informal talks with Lords rather than to allow debate in the full Committee.

The result of this dithering means that there is now a real danger of delay in the passage of the Bill, something that Lord Owen had tried to avoid with his original amendment. There is also real danger that there will not be sufficient time to debate whatever amendments that are made to clause 1. If Howe had allowed the clause to be examined by a Select Committee there would have been an opportunity for a full debate.

Lord Howe has handled this very badly, but it is symptomatic of the entire Bill: extremely badly drafted and badly managed.

GP Market

2011-11-01T11:04:00.003Z

There was a short piece on the Today programme yesterday (here at 52m52s, also on the BBC website here) where journalist Jane Dreaper interviewed Sir David Nicholson. There wasn't much discussed, but the following was interesting.

Sir David said that under the Health Bill data will be provided about what services your GP provides compared to other GPs in the area and nationally:

"this is a powerful mechanism for patients to make choices about which GP they use - if you have a long term condition you might want to think in the future about different GPs and whether they are providing a full range of services"

There are a couple of issues that Sir David is ignoring here. First - it should not be necessary to say this, but clearly Sir David seems to have forgotten - a long term condition (LTC) is 24x7 and it is usually for life. A patient will die with the LTC and most likely will die of the LTC. This makes continuity of care vitally important. The best control of their condition comes when patients with LTCs have a good and continuing relationship with their care team. The idea that patients can simply "shop around" for services means that such relationships will be difficult to form and maintain and this threatens continuity of care. Jonathon Tomlinson has written extensively about the relationship between GPs and their patients and Sir David could do no better than to read his latest blog.

Then there is the issue of how will patients know what services could be available? Occasionally I attend diabetic support group meetings and it is clear that there are some people who have had diabetes for decades and are still treating it like they were first taught to. Their blood tests show that their control is adequate so there is no need to tell them to do things differently. If a patient is treating their diabetes like it is 1980, they will not know if their GP is not providing all the diabetic services they should. It should not be the responsibility of the patient to move to a GP with the best services, it should be the responsibility of all GP practices to provide all the necessary services.

The final issue with Sir David's comment is that it appears to ignore the structures that he is putting in place. Every GP has to be part of a Clinical Commissioning Group (CCG). The Health Bill says that CCGs have the responsibility to ensure that healthcare services are provided for the patients in the area that the CCG covers. This is important: it is a responsibility of the CCG that the GP practices in the group provide the services that are required for their patients. So if a GP does not provide a service that will be as much the responsibility of the CCG as the GP. To get the service the patient needs, s/he will have to move to a GP practice in another CCG that supports the service. There are some large CCGs (for example the Manchester CCG has 107 GP practices, Liverpool has 91, County Durham has 88) so moving to another GP in another CCG will mean having to change to a GP in another city. That is simply not possible for most patients and certainly not possible for patients with long term conditions who need a continuity of care.

Sir David was suggesting a market of GP, but he has structured the NHS so that this is not possible.

NHS Expenditure

2011-10-30T20:41:00.000Z

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

2011-10-29T22:29:00.000+01:00

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

2011-10-28T22:55:00.000+01:00

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

2011-10-26T10:32:00.001+01:00

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

2011-10-24T22:38:00.000+01:00

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

2011-10-24T19:56:00.000+01:00

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?

2011-10-24T17:24:00.000+01:00

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

2011-10-23T22:22:00.000+01:00

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

2011-10-22T18:48:00.000+01:00

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

2011-10-21T12:39:00.001+01:00

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

2011-10-20T12:35:00.000+01:00

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

2011-10-19T16:37:00.001+01:00

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?

2011-10-14T18:12:00.001+01:00

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?

2011-10-12T16:40:00.001+01:00

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:

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;
will produce a postcode lottery on a scale that England has never before experienced and as a consequence, health inequalities will increase;
will mean that rationing will be rife and people will find that they have no recourse;
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

2011-10-10T23:23:00.000+01:00

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

2011-10-08T11:49:00.001+01:00

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

2011-10-02T17:32:00.000+01:00

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

2011-10-01T21:04:00.000+01:00

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.

Designer Insulin

2011-09-22T22:50:00.003+01:00

The BBC report on a BMJ article about analogue insulins, saying:

The NHS could have saved £625m over 10 years if the older types of insulin recommended in guidelines had been prescribed, claim UK researchers.

Apparently, if the NHS had used the current NICE guidelines fewer diabetics would have been prescribed analogue insulin and would be prescribed human insulin instead. Analogue insulin cost three times as much as the equivalent human insulin.

I take the cheaper human insulin. When I was prescribed analogue insulin there was very little consultation, very few checks, the doctor simply said that "it will be better for you". This happened twice (for my basal and short acting insulin). Each time I used it for two years, found that it wasn't "better for me" and went back to the human insulin. At this point there was no attempt from the doctor to find out why I had chosen to reject the analogue insulin, so I assume they really didn't mind one way or the other.

So basically I had had two years taking an insulin that neither I, nor the doctor thought was "better" for me. So basically I agree with the conclusion that it was a waste of money (and the large effort by me trying to get a good blood sugar).

Campaigning and Fixed Term Parliaments

2011-09-22T22:19:00.001+01:00

It is now law that UK Parliaments must last exactly 5 years. Get out your diaries for the next 50 years and mark the first Thursday in May in 2015, 2020, 2025... to be the day of the General Election. Since we know when the election will be, MPs will be able to schedule their canvassing. It is likely that those MPs who have a small majority will want to canvas for the optimum amount of time before the election to ensure they get re-elected.

Since voters have a short memory it means that once an MP is elected s/he can safely ignore the electorate for the majority of the term as long as they are seen everywhere for roughly a year before the election (and hence voters will not remember that they've been ignored for four years). MPs are paid a salary of about £64k and they do not have to attend Parliament: they do not have to take part in committees nor debates. The only job performance evaluation is on election day, and since elections are more a case of a popularity contest for the candidate (and/or their party leader) their performance in Parliament is largely irrelevant.

Since an MP is the representative of a constituency s/he is expected to do constituency work, but how do you know whether their presence in the constituency is electioneering, or constituency work? This means that an MP can legitimately spend a year canvassing and will be paid to do it.

Love it or loath it, the old system kept MPs on their toes. They did not know when the election would be. Consequently the electioneering occurred during the few weeks between the Prime Minister calling the election and the election day. That is all the time we have to put up with canvassing politician! Under fixed term Parliaments we will have to put up with canvassing politicians for (most likely) eight months. It works like this. The MP will finish a Parliamentary session in July the year before the election and then have a long holiday until September. At that point the public will see politicians on the TV and hence your local MP will have to be seen. For MPs with small majorities this is the time that the electioneering will start.

Rather than spend their time in London, they will spend it in their constituency canvassing (the public pays for them to have a home there). Since they will only need to return to vote in the cases when the vote is tight, that means they will be able to canvas every day until the following May. This gives them 8 months (with one day a week off, that means 200 days). A constituency will be about 18,000 homes. It is easily possible for an MP to visit 18k/200 or 90 houses a day (more likely they will avoid the areas where they are unlikely to get any votes, or areas where they can rely on the vote, which will cut the canvassing down considerably).

All of this means that the incumbent has a huge advantage. They will be paid to canvas and they will have a constituency base paid for. This means they can make sure that they can target swing voters to ensure their re-election.

Other candidates do not have this advantage. If they do not live in the constituency they will have the cost and disruption of buying or renting a home in the constituency. If the candidates is employed they will have to ensure that they work near the constituency (or change job), and they will then have to do their canvassing after a full day's work. This will mean that a candidate will be restricted in the number of homes they could canvas. The only people able to match the canvassing ability of an incumbent MP is someone with an independent income that they can use to finance their campaign. In other words: wealthy people.

The effect of fixed term parliaments is that it will favour the incumbent, and the only people who could challenge a sitting MP is someone who has a pot of cash that they can afford to spend on their campaign. Consequently, the House of Commons will get less representative as the only people able to campaign are the very rich.

Labour have a huge task to gain a majority at the next election. I estimate that Labour would need something like a 12% swing - compare this with the 8.8% swing that Tony Blair got in 1997.

For Refounding Labour I submitted the following idea. The Labour party should select its candidates early, preferably two years before the election (we know when the election will be!) The candidate will then be paid by the Labour party a living wage. say £18,000. The candidate then has the money to secure (rent) accommodation in the constituency and will be able to work full time canvassing. Since this is a wage, it should ensure that people without an independent income will be attracted to stand as a candidate. This should raise the number of women and BAME candidates and make the use of all women lists unnecessary.

A paid candidate will have two years to be seen as being a community leader, getting involved in local issues and hopefully getting results. This raises the profile of Labour in the area (which will hopefully have an effect on local authority elections) and will actually benefit the area. The ultimate result, of course, is that the area will get a Labour MP. If the candidate is elected, they will be an MP with a salary of £64k. This means (and only if they become an MP) they could pay back the money they were paid (say £12k a year, this means the "loan" will be repaid in three years). But there is an important point: they only pay back this money if they become the MP. If the candidate is not successful, they will not have to pay back the money. Since being a candidate should be treated as being a job (performance managed by the local constituency party who will feedback to the central party) the candidate must work as a full time campaigner. Since the candidate knows that they will be paid for the canvassing (and only repay when they become an MP and are earning 3.5 times more) it will not be seen as being a financial drain to be a candidate. The result is that it is more likely that there will be candidates from all walks of life, not just those who have an independent income.

The big issue is if a candidate fails to be elected. I suggest that existing Labour MPs pay for those paid candidates who are not successful. The 240 or so current Labour MPs standing for re-election at the 2015 election will have the advantage of being the incumbent, and so will be a paid canvasser as explained above. This means that there is no need to pay them a candidate's wage. To get a majority of 300 at the next election Labour would need approximately 60 more seats, so it makes sense to target the 100-most marginal constituencies. The money for these 100 candidates would amount to £3.6m and this could be raised by a 7% levy on all the Labour MPs from this point until the 2015 election (assuming MP salary of £64k, 3.5 years to the election). After the next election all MPs could then pay a levy of 4.3% every year (the 60 new MPs would pay this for this after paying off their candidate wage) which would fund 100 waged campaigners for the last two years of the parliament and this could be split between campaigners supporting the 50 Labour MPs with the smallest majority and the 50 target marginal seats.

Private Patient Income Cap

2011-09-19T12:27:00.002+01:00

NHS hospitals treat private patients. When Parliament were discussing the bill to create Foundation Trusts there was a rebellion from Labour MPs and so the Labour government agreed to place a cap on how much private income an NHS acute hospital can receive from private income (Private Patient Income or PPI). This cap was arbitrary: FTs were limited to the percentage of their income that came from private work in 2003.

When a trust is authorised as an FT it must agree not to exceed this cap. If it does, then the FT is in breach of its authorisation and can be de-authorised and return to being an NHS Trust. Mental health FTs are covered by different rules: the Health Act 2009 says that the proportion of income derived from private patients is capped to the greater of either the private income in 2003, or 1.5%. For example, in 2010/11 two FTs were in breach of their PPI cap: Basildon and Thurrock University Hospitals NHS Foundation Trust and Liverpool Women's NHS Foundation Trust. Monitor has agreed an action plan with these trusts.

So what is "private patient income"? This does not necessarily mean private patients because it includes services. So if an FT provides some pathology services to a private hospital that income counts as part of the PPI. In addition, according to Monitor's compliance rules, FTs can form partnerships with the private sector companies, and this has resulted in several FTs creating Private Patient Units (PPUs). An example of this is The Christie in Manchester which provides The Christie Clinic in partnership with HCA International. HCA (the parent company) is the largest for-profit healthcare company in the US. It also has the dubious distinction of paying the largest fraud settlement in US history when, in 2002, it paid more than $2 billion in civil law suits.

In 2010/11 FTs generated £252m income from private patients, from a total income of £26,867m (ie 1.1% up from 1.0% in 2009/10; figures from Monitor). This implies that FTs generate very little from private patients. However, there are some anomalies that bump up the PPI from FTs:

The Royal Marsden	30.7%
Royal Brompton and Harefield	14.4%
Moorfields Eye Hospital	13.7%
University College London Hospitals	6.6%
Papworth Hospital	6.1%
Guy's & St Thomas'	3.0%

The Health Bill that is just about to go to the House of Lords abolishes NHS Trusts, so the threat of d-authorisation will be pointless: all NHS Trusts will have to become FTs. The Bill also revokes the PPI cap. This means that Foundation Trusts will be no limit to how much income the trust will be able to generate from private patients.

So who are the private patients? Some patients will be foreigners travelling to the UK although as I have pointed out before, Deloitte does not mention the UK as a destination for US healthcare tourism. Moorfields Eye Hospital even has a hospital in Dubai. Approximately 20% of all healthcare spend in the UK is on private treatments so clearly there are people who prefer to pay for treatment that they could get on the NHS.

The supporters of the Bill say that private patients will bring in more money into FTs and this will provide a subsidy to NHS patients. However, PPI is unlikely to make a difference in most trusts because the income will be low. the downside of private patients is that it reinforces a two-tier NHS. A private patient will not want to be on an NHS waiting list, nor wait in a queue in a waiting room, nor have the same accommodation as an NHS patient. If they had money to give away and still wanted to be treated the same as an NHS patient, they would simply make a charity donation to the hospital. No, private patients want to get something for their money and that something is to jump queues and get better accommodation.

The following is a tweet from Dave West from HSJ, reporting from the Lib Dem conference.

What this says is that Shirley Williams is suggesting that the PPI cap should not be removed, instead it should be altered. She is suggesting that the arbitrary cap set at the level of PPI a trust generated in 2003 should be changed so that a trust cannot generate more than 50% of its income from PPI.

This is a typical pointless Lib Dem fudge. This PPI cap will have no effect on the majority of FTs. In 2010/11 FTs income was £27bn it is extremely unlikely that there is £13bn cash sloshing around in patients' pockets to pay for private treatment in NHS hospitals, so the 50% cap will only affect a few hospitals, and most likely the six listed above. Is it likely that The Royal Marsden will increase its PPI from 30.6% to 49.9%? There's very little chance of that. So the proposed amendment will have little effect at all.

I have never rated Baroness Williams as being capable of making the Health Bill better, and this suggestion reinforces my opinion. The Baroness could suggest an arbitrary cap of, for example, 30% (or maybe even lower, say 10%). This would give a clear indication that NHS Foundation Trusts should concentrate on NHS work. A lower cap, forcing the few outliers to divest themselves of some of their private patients, will give a clear signal. Setting the PPI cap at 50% basically says that the Baroness likes the idea of a two tier system where the same hospital treats patients differently depending on whether they are able to pay.

The Baroness could even suggest something cleverer and still stick to Lib Dem principles of equity. For example, the PPI cap could be in two parts: treating patients and providing services (for example pathology). The PPI on patient income could be set low (say 5% or 10%) to give a clear message that the NHS is about equity, and restrict the formation of a two-tier system; but the services PPI could be set high to encourage FTs to generate income from private hospitals other than from patients. The rules will have to be strict that services for NHS patients take precedence. If the intention is for NHS hospitals to be innovative, then they should use patent laws and licence private hospitals (but not NHS hospitals, there should be some benefits to be "in the NHS family") to use the techniques they developed and this income could come under the "services PPI".

UPDATE:
Andy Cowper at Health Policy Insight reports Simon Hughes interviewed by Andrew Neil on BBC2's Daily Politics saying that

"there's a lot of work still to do on the Bill ... it's by no means over ... there are three of four significant things still to be done ... we need to absolutely tie down that private work in any NHS hospital cannot become the dominant activity or the driver"

(my emphasis). This is the 50% PPI cap being trailed. If a hospital does less private work than 50% of its income, then it cannot be "dominant", right?

Corrigan's dumbing down of patients to close hospitals

2011-09-16T00:24:00.000+01:00

Paul Corrigan writes today in a pamphlet for the right wing think tank Reform that the hospital is dead. Corrigan is one of the architects of the Blairite NHS Planwith the underlying aim to privatise the NHS and so it is fitting that his pamphlet is published by the pro-market think tank Reform.

Corrigan's thesis is that about 70% of NHS funds are spent on patients with long term conditions and that hospitals are not designed to deal with those conditions. Hospitals fix illnesses and do not manage long term conditions. Or so he thinks. He then gives some free market mumbo jumbo to say that primary care is not good at long term conditions either:

The funding structure of the NHS has been constructed so that the GP practices do not get rewarded for providing efficient, preventative services to the patients. Rather, the payments are received by the hospitals as the patients become sicker. Consequently, in this type of healthcare system, there is a larger incentive to admit patients rather than to avoid admissions.

Corrigan clearly thinks the entire NHS top-to-bottom is not fit for purpose.

If a GP needs to have a financial incentive to treat his/her patients properly then s/he is a poor GP and should not be in the job. The incentive for the GP is to achieve a patient who can manage their condition effectively; just that. The same could be said of hospitals, but remember, the payment by results system that Corrigan criticises was introduced by the team he was a part of. Is he saying that he was wrong? I do not see a mea culpa in the pamphlet.

Corrigan argues that up to 40 hospitals will have to close in the next few years because he says that the care of long term conditions should be moved to "the community". This is the buzzword at the moment, yet no one seems able to say where this "community" is nor where the funding comes from to make the move. While there may be savings in moving care to "the community" (I do not know if this is the case) it certainly involves investment to make the move.

For example, a GP doctorpreneur in my area has decided that his new company is "the community" where treatment must be moved to, and he has decided to set up a primary care clinic. The clinic will replace his own GP clinic (so far, so good) and a community hospital which is run by the local hospital and is out of his control (so is unlikely to close). The new clinic will cost £10m with neither the doctorpreneur nor the local PCT (nor, indeed, anyone else) with any clue where the money will come from. The local hospital has an annual budget of £170m (which includes community health services) with an annual capital budget far smaller than £10m, and a long list of more important things to spend the money on. I will leave it up to the reader to think where the funding will come from and who, in the future, will control healthcare in that community in the future. (Hint: it will not be the NHS, nor anything the community controls.)

Corrigan also puts a lot of confidence in telehealth.

Telehealth ensures remotes delivery of care to patients, usually with long term conditions, in their own homes. The use of telecommunications and other computer-based systems make remote medical care possible. ... Telehealth is primarily used for diagnosis but has also been regularly used in monitoring various conditions related to the conditions of the patients. Recorded data or real-time images are used for clinical inspection which may be required for prevention, diagnosis, or treatment of a disease.

This is all very good as long as the the telehealth makes a difference. I am not sure it will. The problem is that it involves putting expensive kit in people's home, or more likely, expecting them to pay for it. Is this a good use of resources? Will it give better care to the more affluent and better educated and put the less well off and less well educated at a disadvantage and increase health inequalities?

Corrigan uses the example of one long term condition - diabetes - to support his thesis. I have some knowledge in the area since I have had type 1 diabetes for 35 years. Diabetics use blood glucose meters (Corrigan calls them glucometers) that cost about £25 and use test strips that cost about 50p each. The strips are available on prescription but the patient usually buys the meter, or more often, gets the meter free from the manufacturer on the Gillette razor blade theory (they give away the handles because they make a big profit on the blades, you just have to make the customer choose to use the blades). Currently diabetics use the most complex computer in the world to interpret the results from the glucose meter: their own brain. They record these results and then periodically use an equally complex, but slightly more expensive computer: their clinician's (GP or diabetologist) brain. The second computer is actually used for reassurance, and to make periodic changes, there is no need for the clinician to be consulted more often than three or four times a year (if that often) since it is the first computer (them!) that does most of the work.

Both of these computers (the patient and the clinician) needs to be trained and occasionally re-trained. But once a patient understands how to treat their condition, they can - and should - be allowed to manage it themselves. The patient is far better to be able to manage their care, for the simple reason that the patient has all the data at the exact time the blood glucose test is made, and the clinician doesn't. Diabetes is a balance between insulin injections (and or other drugs), carbohydrate and exercise. There are other factors too, like general wellbeing (a cold will raise blood sugar) and other factors which I know affects my blood sugar that no one can explain (the change from spring to summer lowers my blood sugar, and the change from summer to autumn raises it, yet I do not eat differently nor take different amounts of exercise; when my father died, for six months afterwards I needed 25% less insulin, yet I ate and exercised the same).

A patient with a long term condition has expert knowledge, the clinician reinforces, but must not replace this knowledge. Corrigan disagrees:

However, many hospitals and clinicians recognise this and have started to consider care beyond the hospital walls through the effective use of telehealth. At the Ulster Hospital in Dundonald, diabetes management was tackled by Dr Roy Harper in 2009. The aim was to empower patients to become better self-managers of their diabetes through education and self-management and to efficiently titrate patients just starting on insulin to achieve optimal blood sugar control. Patients were trained to use the monitors including their glucometer and all readings are transmitted. Nurses carry out a triaging process and escalate patients according to protocols designed with the specialist nursing team. Virtual clinics are held to review patients who require extra support or a change in medication. The team is able to review real time data without the need for a hospital visit by the patient or a home visit by a community nurse.

What Corrigan is suggesting is dis-empowering patients. Rather than the patient manageing their own condition by using their expert knowledge of how much they have eaten, how much exercise they have taken and how well they feel to interpret their glucose reading and to determine their insulin dose, he is suggesting that the responsibility should go to a remote nurse who only has a fraction of the information: the blood sugar readings. This is day-to-day monitoring that dumbs-down the most important part: the patient.

Corrigan touches on the actual solution to managing long term conditions: "education and self-management". This is the vital part: diabetics need to have periodic intensive education under clinical supervision so that they can experience getting their management wrong as well as how to get it right. This is something that should be done in a clinical setting - in a hospital - and not at home. Once educated the patient then needs minimal monitoring by a doctor. However, long term checks - like HbA1c, retina monitoring, and checks on the feet - are things that must be carried out and interpreted by a clinician and cannot be done by the patient. I would also say that periodically - perhaps every ten years - a diabetic's computer need a reboot. They should go through the whole process of re-training all over again as if they were newly diagnosed. This is not just to teach them to manage their condition according to the more up to date methods (and get them out of bad habits) but also to ensure that the newer drugs they are using are used effectively and not merely as a replacement for the older drugs they were used to. Again, this has to be done under clinical supervision in a hospital.

Corrigan is not advocating this type of care - a form of co-production with their care team - instead he is advocating that the patient becomes completely subservient and dis-empowered and that the doctorpreneur "in the community" has the control.

Nope, sorry, I do not agree. I far more prefer to see a diabetic consultant to ensure that my computer - my brain -is up to date, and monitoring that I am unable to do, by my GP.

Representative

2011-09-14T22:01:00.001+01:00

Here's some figures, it's fun to compare and to try to interpret them.

First up, the British Attitudes Survey. Every year they publish results of a survey question asking what party the respondent most identifies with. Here are the results from the 2010 survey showing how the value has changed over the last 25 years:

For the last date (2008) the results are:

Cons	32%
Lab	26%
LD	9%
Other	6%
None	25%

These suggest that the country is quite Conservative, about a third of people "identify with" the Tories. The interesting figure is "None", that is, the people who do not want to vote and are not interested. Look at how this figure has grown since about 1994: over the last two decades people have got more turned off from politics. If I was running a political party it would be these people I would target.

Now have a look at the results from the 2010 General Election:

	% MPs	% Vote
Cons	47%	32%
Lab	40%	35%
LD	9%	22%
Other	5%	10%
None

In terms of the number of MPs, Other and Liberal Democrats are similar to the BAS scores, but look at the value for the Tories and Labour. Since we do not have a "none-of-the-above" option on ballot papers it looks like the people who have no affiliation have given equal weights to Tories and Labour (bumping the Tory 32% "identity" to a value of 47% of MPs). Of course, individuals vote rather than select MPs, and the share of the vote shows the Tories at the BAS level and Labour, and in particular, Lib Dems, getting a boost from the lack of a "none-of-the-above" option.

I know that the number of MPs reflects the oddities of the first-past-the-post voting system, but even so-called "proportional" systems produce odd results. The election before the 2010 General Election was the 2009 Euro-elections. The results were:

	% MEPs	% Vote
Cons	37%	28%
Lab	19%	16%
LD	16%	14%
Other	28%	42%
None

The Euro-elections are based on the d'Hondt party list system where there are 11 regions (plus Northern Ireland) and each region returns between 4 and 10 MEPs with each party getting a proportion of MEPs according to the proportion of the popular vote the party gets in the region (Northern Ireland is an exception because it uses STV). The results above are for mainland UK (excluding NI). The Tory percentage of MEPs is 5% more than the BAS value and the Labour number of MEPs is 7% less than BAS. The LD number of MEPs is 7% more than BAS.

The large "Other" value is due to UKIP and BNP votes which are significant in Euro-elections, but not in other elections.

Now look at the political affiliations in the House of Lords, here compared with the BAS score:

	% Lords	BAS
Cons	28%	32%
Lab	31%	26%
LD	12%	9%
Other	4%	6%
None	23%	25%

The House of Lords is unusual in that it has a "none-of-the-above" component that call themselves crossbenchers (I have listed these in the None row). It is interesting that within a few %age points the three main parties have Lords equivalent to their BAS score. But significantly, the Other and None figures are similar to the BAS scores.

Does this mean that the House of Lords is more representative of the population than elected bodies?

Simon Jenkins is wrong about everything

2011-09-11T15:53:00.000+01:00

There is a general aphorism that "Simon Jenkins is wrong about everything". On Friday he was a guest on BBC Radio 4 Any Questions. When the inevitable NHS reforms question came up he gave a characteristically ill informed answer (43m 45s). He said:

The NHS has been re-organised countless times in the last 20 years and every time it has proved unsatisfactory. ... the reason is that when it has been re-organised it has been re-centralised.

Well, yes, there have been countless re-organisations, but he has not been paying attention if he thinks each organisation has been centralising. The creation of SHAs and PCTs localised decision making. The original twenty SHAs were devolved responsibilities from the Department of Health and similarly the 300 original PCTs received some responsibilities that had been central. The new Bill does the opposite, it takes the work of the current ten SHAs and centralises it into the four regional arms of the National Commissioning Board and these regional arms will take a quarter of the commissioning that is currently done by PCTs. The current Bill is a centralising bill.

Jenkins continues:

the health systems that appear to work are where the government pays but does not organise, ... for instance Denmark. There the counties run the hospitals ... in effect the counties run the health service.

He is five years out of date and even five years ago he was wrong. Denmark used to have 14 counties and with a population of 5.5m that means an average of 400k per county. The median size of PCTs in the UK is 290K, so our system is more localised than the Danish county system. However, in 2007 the system was re-organised replacing the 14 counties with five regions and so each region covers about a million people. Compare that with the 290k that our PCTs, before the reforms, cover. I suspect that Jenkins was getting confused between Danish counties and English counties, so to give the comparison: our PCTs are more or less a third the size of an English county (there are 150 PCTs and 50 counties or metropolitan areas). Under Lansley's plans public health (vaccination, action against smoking, obesity, teen pregnancy etc, will be carried out by English counties, this is yet another centralisation).

As a consequence of Lansley's disastrous mishandling of the system, the PCTs are coalescing into "clusters" each of which is roughly the size of the Danish regions (about a million people). So for a brief time we will look something like the Danish system, that is until the 300 or so Clinical Commissioning Groups take over. International studies show that smaller commissioning groups are financially unsustainable and are unable to commission effectively. Civitas, for example, present evidence that commissioning groups should cover populations no less than 300k (close to the size of PCTs); the BMA give a higher figure of 500k for the smallest size of an effective commissioning group.

However, it is interesting to compare the Danish system with the NHS. There is a fabulous facility called the European Health Observatory provided by WHO and the following uses facts from their health system profile of the Danish system.

Denmark is much smaller than England at 5.5m (about the population of Scotland which would have been a better comparison for Jenkins to make). OECD says that the Danes pay about a third more than us for their healthcare (UK: 9.8% GDP, $3287; Denmark: 11.5% GDP, $4348). EHO say that most of this money is "earmarked proportional taxation" at the national level which is then redistributed to the five regions via block grants based on social and demographic indicators. This is very similar to England where parliament (the Chancellor) determines how much the NHS will get and the money is then distributed to PCTs using block grants based on population size, demographics and deprivation levels (the contribution for deprivation levels is being cut by the current government).

In 2007 there was a reform that changed control from the 14 counties to five regions. So that means the control of local healthcare is for a body that covers about 1 million people.
Median population covered by a PCT is 164K, so about half a Danish county or one eighth a Danish region. Hence PCTs provide a more localised service. Would it make any difference if local healthcare in England was coordinated through county bodies rather than PCTs?

In Denmark, GPs are private practice (not employed by the state) paid by capitation (a fixed amount per registered patient) and fee-for-service (for example, paid a fee per vaccination) - much like UK. Regions control the number and location of GPs. In England this work - the commissioning of GPs - is carried out by PCTs, but under Lansley's reform it will be centralised and carried out by the new quango the National Commissioning Board through its "regional arms" (four of them, covering between 10m and 15m people). In Denmark, GP's fees and working conditions are negotiated centrally - just like us. Access to primary care is free-at-the-point-of-use, just like the NHS. There is an option (about 2% of patients) to use any private GPs for an extra payment and such patients do not need to get a GP referral to see a specialist (much like private healthcare in the UK). Private healthcare in Denmark is not regulated.

Danish hospitals are owned and run by the regions, in England we moved to a system where the government owned NHS hospitals became NHS trusts, and in the late 90s NHS trusts became accountable to the local Strategic Health Authority. There were twenty SHAs, each covering about 2.5m people (compare this to Denmark where each region covers about 1.4m). SHAs were re-organised in 2006, so there are now ten (covering about 5m each). However, about half of hospitals are Foundation Trusts which means that they are autonomous and are not accountable to the SHA: the SHA does not "run" them. So compare the Danish centralised system where a central organisation (region) runs the hospitals to Foundation Trusts where they run themselves. (Again, Jenkins is wrong.)

There was a reform in Denmark 1993 to allow patients to be treated anywhere in the country (5-10% of patients take this option). The NHS had a similar reform in 2006, initially to cover specific private facilities (Independent Sector Treatment Centres) but tightened when Andy Burnham became the Secretary of State (to make the NHS the "preferred provider"). In Denmark private hospitals are less than 1% of provision. The Danes have co-payments for dentistry, physiotherapy, spectacles and pharmaceuticals. In the UK we call these "NHS charges", so in other words, the Danish system is very similar to the NHS.

One of the most significant thing about the Danish system is that there was very little change until 1970 when there were reforms to create the current system. There were some changes in 1993 to give patient choice (not significant, and largely used by the affluent and better educated, ie not equitable) and then again in 2007 when the system was re-organised from county based (14) to region based (5).

Frankly Simon Jenkins did not know what he was talking about. The Danish system has more similarities to the system we had in the 1980s before the Internal Market was introduced than to what the current government is proposing. The aphorism "Simon Jenkins is wrong about everything" is yet again upheld.

The nonsense that is "cutting admin"

2011-09-10T11:51:00.005+01:00

Are there too many managers in the NHS? I don't know, and I have never seen one iota of evidence to suggest that there are too many. The reason why the Conservatives went into the 2010 election saying that they would "cut administration by a third" is simply a gut feeling from Lansley. A political gut feeling. Lansley sensed that the Daily Mail brigade had decided that there was too much administration and as an election ploy he made his pledge to them.

The problem is that the majority of the "administration" that the these armchair auditors were complaining about was in hospitals, and Lansley cannot do a thing about administration in Foundation Trust hospitals because FTs are autonomous and are not run by the Department of Health. The only part of the health service that Lansley could change was Strategic Health Authorities and Primary Care Trusts, and so to meet his gut feeling, one third cut he had no option other than to sack the lot of them by abolishing the organisations. That is a big upheaval based on no evidence at all. (PCTs could well be over-managed, but we have no evidence of this, and no evidence if it is as high, or as low as one third too many. It could even be that PCTs are under-managed.)

All of that is politics and should have been pointed out at the election or afterwards, but it wasn't.

So now the civil servants in the Department of Health are implementing the policy. Government departments have to provide an Impact Assessment document indicating the effects of the policy. The government have just produced an IA for the Health and Social Care (Recommitted) Bill and over the next few days I'll post (or tweet) some items from it. My initial reading is that it is not a dispassionate, neutral civil servant document, instead it is a political document and could easily have come straight out of Conservative HQ. It justifies the policy rather than assessing the impact of the policy. (However, I have yet to read it in detail.)

Let's start with the original IA that was produced when the Bill was first published in January. Here is one example (and there are plenty more in that document) that indicates that this document is largely useless and highly political. The following figures have been updated in the more recent IA but I am giving them to illustrate another point (so if you want the more recent figures - I hesitate to use the term "more accurate" - then you should read the more recent version).

To be able to "cut administration by a third" the civil servants first have to determine how much administration there is. Table A1 says that PCT commissioning costs are £3.59bn (the document also notes that SHAs do very little commissioning so the majority of costs come from PCTs).

The following is Table A2 from the IA document that lists the "savings" that will be made (click on it to see it full size). You can see the £3.59bn in the top left hand corner, and below that the £353m commissioning costs from SHAs. These are "real terms figures" but the table assumes that the same amount of commissioning will be needed over the next ten years (bizarre, because as everyone keeps telling us, there are increasing demands due to the ageing population and new treatments, so it is not a good assumption to make that the amount of commissioning will remain the same for ten years).

The "Real commissioning budget" line takes the idea that administration must be cut by one third by 2014/15, so the figure of £2.63bn in the 2014/15 column is two thirds £3.59bn. The years between ramp down to this level.

What I expected from an IA document was the proof that "administration" could be cut by one third. I expected to see international comparisons, comparisons with the NHS in the past, comparisons with other services that commission services (like, for example, social care). I wanted some figures that said "if we run NHS commissioning like these other guys do, we will save this amount of money". There was no such statement. Instead, we get a table that says "if we cut administration funding by one third the costs of administration will fall to two thirds". Pathetic.

The huge damage that is being wrought on the NHS at the moment is being justified with pathetic documents like this. In the future people will ask "how did you allow this to happen to the NHS?" They will also ask "and on such flimsy proof?".

Objections

2011-09-08T21:54:00.003+01:00

Read this:

the removal of all references to promoting competition whether directly or indirectly.
any duty to promote choice being made subsidiary to duties to promote fair access, equality of outcomes, and integrated services.
the removal of the facility for transferring NHS assets, including land, to third party providers.
retaining the cap on Private Patient Income by NHS Foundation trusts.
the restoration of the duty of the Secretary of State to provide or secure the provision of, healthcare services, and the reinstatement of the power of the Secretary of State to delegate his functions to NHS commissioners and to direct them as necessary.
the retention of the ability of the local authority overview and scrutiny function to refer significant services changes to the Secretary of State for adjudication.
providing that Health and Well-being Boards (HWBs) have a majority of elected members and are able refer unresolved disputes with local commissioners to the Secretary of State rather than to a national qango.
the explicit prohibition of the wholesale outsourcing of commissioning work to private companies.
guaranteeing that commissioning groups are fully co-terminous with social services local authorities, except where HWBs and local authorities agree otherwise, and are funded solely on the basis of the health needs of the population.
the removal of the power to pay financial incentives to practitioners as a means of influencing their referral behaviour.
rejection of any personal health budget scheme which allow users to spend NHS funds on private health insurance or as a top up towards private health care or to buy services or treatments judged too ineffective or inefficient for the NHS to buy.
the inclusion of a duty on all NHS bodies, when arranging with non-NHS bodies to provide services, to avoid any risk of essential NHS services (including teaching and research) being destabilised in an unplanned way through loss of income or case-load
ensuring Directors of Public Health remain independent sources of expert advice.

Is this Labour's key objections to the Health and Social Care Bill? No. This is the objection from the Social Liberal ~~Democrats~~ Forum (Dr Evan Harris' group).

I tried to find a succinct list from Labour giving their opposition to the Bill, but I couldn't find one.
Labour could be re-elected at the next election on a huge majority if it exposed Lansley's Bill and then campaigned against it. We hear so little from Labour that we do not know if they want the Bill or not. We do not know if Labour wants to be re-elected.

All the talk at the moment is what this Lib Dem peer, or that Lib Dem peer will attempt to amend when the Bill reaches the Lords. Why aren't we hearing the same thing about Labour peers? Is it because the labour working peers are all Blair's chums who couldn't care less?

Labour is the party of the NHS. But if Labour does not raise its game on opposing the Health and Social Care Bill it will lose this title; or worse, it may get the name of the party who failed to raise a finger to protect the NHS.

Meanwhile, if you are a Lib Dem go to the conference and vote for Dr Charles West's motion. If you are Labour then campaign that these 13 points form Labour's objection to the Bill. If you are Conservative then you should be ashamed of your party.

(Updated to get the name of SLF right.)

Over to the Lords

2011-09-07T23:33:00.001+01:00

So now the Lib Dems have voted. Four brave souls - who clearly value the NHS more than their chance to become a minister - voted against the Bill: Andrew George, Julian Huppert, Greg Mulholland and Adrian Sanders. Ten others could not get off their arses to oppose the bill and took the typical Lib Dem sitting-on-the-fence position of abstaining.

The strategy, so I am informed by Dr Evan Harris, is for the Lords to make the Bill better.

I have a lot of respect for the Lords. My brother is an academic and is an advisor to a Lords Select Committee and as part of this he regularly gives well attended lectures in Westminster. He tells me that the Lords show more enthusiasm for the subject than his soon-to-be-£9k-fee-paying-thanks-to-LibDems students do! I have written that I think this aspect of the Lords - mostly non-political experts - is unique and important and should be preserved. I have suggested that there are ways to remove political patronage that will make it more democratic and keep the experts in the Chamber.

However, the Lib Dem manifesto from last year says:

Liberal Democrats will: Replace the House of Lords with a fully-elected second chamber with considerably fewer members than the current House.

So, they want to create a clone of the House of Commons where all but 14 Lib Dems chose to sign the end of the NHS as we know it. Remember that there is only one scientist in the House of Commons, and that is Dr Julian Huppert, the Lib Dem rebel. There is a smattering of doctors, including Sarah Wollaston who told us there were serious accountability issues in the Bill, yet she still voted for it! The bullying by the political parties (which Wollaston has also written about) clearly keeps the MPs in check.

The chamber that Dr Harris wants to be the saviour of the NHS will be savaged by his party leader's plan to "reform" the Lords. Clegg's bill will reduce the membership of the upper house from 789 to 300, 80% of which would be elected by STV. This will mean that there would be space only for 60.5 experts [300 is about half of 650, so at the current rate of one scientist per 650 elected MPs, that would suggest about half an elected "lord" in the new chamber], a number that would be easily outvoted by the whipped politicians.

Harris puts a lot of confidence in Shirley Williams. I am not sure why. Yes, once she belatedly realised that there was an issue she has opposed the Health Bill, but I have never read anything from her that illustrates that she really understands the dangers. I agree with Roy Lilley, Lord Owen will make the most significant changes and he is likely to destroy any government argument. Harris, showing his political colours, prefers Williams to Owen because, well, Owen is now a crossbencher (not a member of a political party) and is exactly the sort of expert that Clegg wants removed from the House.

Personal Healthcare Budgets

2011-09-02T12:51:00.001+01:00

One of the best features of the NHS is that you know that whatever unforeseen healthcare issue you have, you will always get treatment according to clinical need. Anyone who waters down this basic principle of the NHS does not deserve to hold public office.

Enter the concept of personal budgets for healthcare. I will write more about this subject but here are some initial thoughts. The first point to make is that all the major political parties are in favour of personal budgets. This would imply that the majority of people are in favour of them, and that there is a universal demand for them. But stop anyone in the street and ask them about NHS personal budget and you'll find that they either have not heard about them, or they are against them. If you get a positive response for personal budget, it will be usually followed up with the hope that it will result in more money spent on them. The sad truth is that there is no more money, and that in the future the money spent on healthcare will decrease, not increase.

What are personal budgets? The idea is that through a personal budget patients will be offered more choice and control over their care. However, at the moment the policy makers are very careful to say that they will be offered only be patients with long term conditions. Policy makers are also careful to say that they will be only offered to patients with "stable and predictable conditions". The combination of these two restrict their application to a limited number of perfect patients. Finally, policy makers are extremely careful to say that no one will ever be denied treatment as a result of having a personal budget. Life is never perfect, but let us assume the best case for patients.

If no one will be denied care, this implies that the situation we have at the moment - where care is according to need - will be the baseline, that is, the minimum spend. Politicians are acutely aware that they must not be seen to be introducing rationing. It would be political suicide for a politician to be seen to be introducing any policy that require patients to pay for top-up for NHS care. This means that when personal budgets are introduced they must be more than what the patient would otherwise receive through their existing NHS care.

Patients will not be simply handed a pot of cash to spend however they like. Instead, they will be handed a limited list of approved treatments (or providers) or patients will be asked to have a treatment or provider approved before they will be able to spend the money from their budget. This requires the work of an administrator, advisor or advocate and it will be in addition to anny administrators currently used. Further, since this will be devolved down to the patient level, rather than across a large number of patients, it will not benefit from economies of scale. The administrative costs of personal budgets will be more than not having personal budgets.

To make the budget more personal, a patient must be given access to the budget. Whatever access the patient is given, it is unlikely to be actual cash, otherwise the patient would be able to spend the budget on something other than healthcare (for example, heating bills). Instead, the personal budget is likely to be in some other form of currency: for example vouchers. The conversion of these other currencies will have a cost.

When you add all of this together, personal budgets will cost more for the same treatment than not having personal budgets. The only way that personal budgets can be made popular for those that will receive them, is if they will result in more spent on those patients. However, there is a fixed overall healthcare budget so if more money is spent on patients with personal healthcare budgets, this means spending less on those without them. I object to any policy that results in taking money from one patient to give to another if there is no clinical benefit for both patients.

Further, I dislike quoting Liam Bryne but "I'm afraid to tell you there's no money left" is apposite. Any policy, in the foreseeable future, that involves spending more will be rejected by the Treasury, so therefore every government policy must result in spending less. Since personal budgets involve spending more on administration, they mean spending less on healthcare, and any temporary rise in spending on healthcare designed to make personal budgets popular will ultimately result in bigger cuts in the future.

I can never support personal budgets.

Trivial

2011-09-01T22:09:00.002+01:00

I was first diagnosed with diabetes in 1976, in those days it was called juvenile diabetes or sometimes insulin-dependent diabetes, now it is called type 1 diabetes (because these days type 2 can occur in children, and insulin is sometimes used to treat type 2 diabetes). My diabetes was monitored by a six monthly appointment with a consultant paediatrician at the local hospital. My memories are of gleaming polished floors and patrician (and all male) consultants. The hospital was build before WWII with 70's extensions, and the paediatrics department was in the old part. Perhaps it was my age, but the enduring impression is of doctors whose opinions you could not question, not quite the consultant barking orders at you (like Sir Lancelot Spratt) but certainly everything he said was followed to the letter.

Appointments took a couple of hours because other than the consultation with the paediatrician there was also a trip to the pathology department to have several tubes of blood taken which were then tested for the following appointment (later on, finger prick tests - or more accurately finger jabs because they cut a wide hole in my finger - were introduced so I would have one of those as well as having blood removed from my arm). After leaving the hospital there was always a trip to the cake shop to make up for the blood tests (remember, this was the 70s). Although I do remember it taking time to go between various appointments in the hospital (as well as the blood tests) I do not remember waiting long to be seen.

When I reached 16, I was moved to the adult diabetic clinic in the same hospital where I was seen by a diabetes consultant. The adult clinic that was held in outpatients which was in one of the 70s buildings. To a 16 year old the adult diabetes clinic was a shock. My impression was that diabetes was a condition of the elderly and I was somewhat weird that I had an old people's disease. There must have been teenagers (or even middle aged people) who attended that clinic, but I never saw them, it was the old people I saw.

One distinct memory is queuing up for disposable needles at the hospital pharmacy. I had a glass syringe and so-called reusable needles. However, these blunted quickly which caused scaring and fat to disappear from my injection sites (30 years on, I still have lumps in my thighs from using reusable needles). Part of the problem was the impure insulin. When I was first diagnosed I took bovine insulin and after a few years I moved to porcine insulin; the hospital also started prescribing disposable needles. My control was much better on the porcine insulin, but since this was around the time I started using disposable needles I don't know if the improvement was due to the needles or the insulin. However, one thing is for sure, disposable needles made injecting quite a lot less unpleasant. I could not get disposable needles from my community pharmacy because GPs were not allowed to prescribe them (I was told: because of the cost), so I had to wait for a hospital appointment to get them.

My memories of the hospital adult clinic was not of gleaming floors, instead it was of long waits in waiting rooms full of old, ill people. I distinctly remember peeling paint everywhere.

During this time I had the same GP. She had a very much "hands off" attitude and since (other than the diabetes) I was healthy I never saw her. She did, however, make one of the best recommendations I received soon after I was diagnosed: she gave my mother the address of another family with a child my age who had diabetes. We learned a lot more about living with diabetes from that family than we did from any of the clinicians we talked to. Since diabetes is 24x7 and you can never "cure" it, learning to live with the condition is vital.

When I went to university (and later, when I got a job in the city where I had studied), I went to the hospital diabetic clinic (conveniently at the university hospital). The clinic was only for people of my age: young adults, and discovered that I was not the only young person with the condition. The university hospital was newly built and modern. There was none of that light blue paint that seemed to be used everywhere in the hospital I attended when younger. Instead, there was light wood everywhere and they even had carpeted floors in the clinic. My appointments were always on time, this (and the location - I could get to the diabetic clinic from the university department where I studied via a short cut through the medical school) meant that I could attend the clinic without missing much lecture time. I do remember being seen more often than not by registrars - perhaps an attribute of a teaching hospital - who were mostly female and not much older than me. (Yes, I was a young man, I paid close attention to such things.) After graduating I got a job at the university, so again, it was convenient to take little more than an hour off to attend a clinic.

My treatment changed over this period. When I started at university I used disposable syringes (the needles were attached) and porcine insulin. After a couple of years I moved to human insulin and then after I graduated I changed to using a pen. The first insulin pens would deliver two units of insulin per click, since I had a big dose (around 20) it would mean clicking the pen multiple times making sure I remembered how many. On one occasion I went out to dinner with some work friends and just before the food appeared I went into the toilets to inject. I remember hearing the characteristic click-click-click of an insulin pen from the stall next door and was surprised to discover that it was the technician who worked for me in my lab. I had known him for two years and I didn't know he was diabetic, nor he know that I was.

Again, my GP had a "hands off" approach: the treatment of diabetes was the consultant's responsibility, although I did find that when I occasionally went to my GP he would point out that there was a connection between the condition I presented and my diabetes (usually the fact that my blood sugar was too high). My only contact was the regular request for prescriptions.

A decade later, married with a child, I moved house to follow my job. I registered with the local GP and at my first appointment I asked to be referred to the local hospital. "We don't refer patients to the hospital clinic: we have our own diabetic clinic". I had registered at a fundholding practice although I did not know what this meant. At the first diabetic clinic the doctor told me that he had just been on a course about diabetes. Was this supposed to reassure me by telling me how up-to-date his knowledge was? I don't know, but his next statement dismissed that reassurance: "... but since you've had diabetes for 17 years I think you know more about diabetes than me!" Oh dear.

The practice was a new build and close to my home. However, I worked half an hour's drive away (coincidentally, where I worked was a ten minute walk to the local hospital). Since diabetic clinics were during my working hours it meant that if I had a diabetic clinic I would have to take the morning off work. From memory, appointments were prompt, possibly because it was a new venture for the practice and they had given it more than enough resources. Since I did not see the doctor other than for my diabetes (at this point my control was much better due to the modern insulin I was taking) I do not know how long a patient would wait for a GP appointment.

To be fair to the doctor in the GP clinic, he did notice when there were changes in my eyes and he immediately referred me to the local hospital for laser treatment. This was like going back in time: the hospital was pre-war and some of it was Victorian. My memories are of long waits sitting on plastic chairs in corridors. The eye clinic did emergency work so often I would see someone lead in (or pushed in on a wheelchair) with bandaged eyes and then told my appointment would be delayed as they treated the emergency case. The clinic was just ten minutes walk from where I worked, but the long periods of time I spent waiting for appointments meant I would have to take an afternoon off work. Treatment during week days have a knock-on effect. I taught week long courses and it was not convenient for me to take a morning off halfway through the course, but if I was given an appointment for treatment I had no option, I had to attend on that particular day for fear of not being able to get an alternative date.

Then I changed jobs and moved house (now with another child). The town had two GP practices with surgeries 100m of each other. Both were modern buildings and since there was not much difference between them, we chose more or less at random. At my first GP clinic I told the GP that I wanted to be referred: this time I decided that I was not going to accept just the GP clinic. The GP said "that's fine, we will put you down as shared care".

So now I was seen by the local hospital clinic and the GP clinic. The contrast was marked. The hospital was largely pre-war and the outpatients was in a large 80s extension that had not been completed. The clinics were crowded, (mostly elderly people) and I never had an appointment on time. In those early days at some point during the afternoon a nurse would announce that the doctor had been called away to attend an emergency and so our appointments were delayed (a diabetic clinic for me was always a case of turn up at 2 and be seen after 5).

Although the outpatients department was new it was still tatty: I guess it had not been repainted since I had been built. The older parts of the hospital were worse. The hospital was made up of several building of various ages and there was a long corridor (a covered walkway) between them. For years it seemed that the hospital had no money to replace broken ceiling panels, so occasionally when walking along that corridor you could see the pipes and wires that were the very guts of the hospital. The eye clinic I attended was in the old part and it was cramped with patients waiting on chairs along a narrow corridor. There was one positive memory: whenever I attended the diabetic or eye clinic I had to take my diary because after my appointment I could make the next appointment and was given a specific time and date. This meant that there was even a possibility of ensuring that the appointment would not be when I was away on holiday, although I rarely got the appointment within the three or six months that the consultant requested.

The GP diabetic clinic was very different. In those early days the GP made a double appointment at a time when they did not have a surgery. These were very relaxed and concentrated more on how I felt I was coping with living with diabetes rather than the obsession with numbers shown by the consultant at the hospital. Conveniently, if the hospital required a blood test I could have the blood taken at my GP rather than the hospital. At the hospital there were always long waits and I would have to pay for parking. The GP surgery was a short walk from where I lived and the queue for blood tests was always short.

During this time my treatment changed again: I was changed to analogue short acting insulin. This was a disaster. My control went haywire and I put on about 15Kg. Eventually my wife told me I had to change back to the human insulin. I did and my control returned, but I was still somewhat wary since I had changed my treatment without the consultant's permission. In fact, at the next appointment the consultant merely said "no one else seems to have had a problem" and that was it.

In the new millennium things changed. The hospital started to be better funded and it got a loan from the Department of Health so the outpatients department was completed and the whole hospital redecorated. There was a new A&E department and the eye clinic got a new waiting room, and had had contrasting paintwork and signs in letters large enough to read when your eyes are dilated. The hospital was no longer dilapidated.

Since that time I have never sat in a full waiting room and appointments are always prompt. It has been a decade since I last heard a nurse explain that appointments are delayed because of an emergency case. Yet during this time I have been an emergency case myself - I phoned the eye clinic having suffered a haemorrhage in my eye and was told to go immediately to the clinic where I was seen.

But there are other differences. Now I cannot book an appointment at the clinic, instead the appointment is sent to me. I guess this is in response to the 18 week target so that the hospital can change clinics quickly. However, it is a real pain because you cannot guarantee that the appointment letter will get to you before the appointment: one housebound neighbour got an appointment through the post two hours after the appointment time. If you need to change an appointment then you have to phone up and inevitably you get an appointment later than the original, extending the time between clinics. The hospital also seems to regard appointments as easily moveable and often I will get a letter saying that "due to unforeseen circumstances, your appointment has had to be changed". During the time my eyes were unstable (I was told they could haemorrhage at any time) the consultant said he wanted to see me every three months, but the appointment system never took this into account. On one occasion I had three letters changing the appointment, the final one giving me a date 14 months after my last appointment (I phoned, and was given a "cancellation", but the system should not allow an appointment to be made that contradicted the clinician's opinion by so much).

My treatment also changed. First, I was put on an ACE inhibitor by the hospital. Next my long acting (basal) insulin was changed to an analogue, and after using it for twoi years I changed it back to the human insulin, again, because my control had deteriorated on the analogue. In addition, my GP put me on statins, and at a later stage, a calcium channel blocker when my blood pressure had shown it was rising from the recommended value. The ACE inhibitor, calcium channel blocker and statins are all preventative medicines. My cholesterol and blood pressure have been normal for most of my life (sometimes, from their reaction, I used to think that this disappointed the clinicians) but latterly my test results have veered off the recommended range for a diabetic and so I was prescribed the medicines.

With the appointment system aside, the hospital has improved immensely over the last ten years. The GP clinic has gone in the opposite direction. First to go was the ability to have blood taken for a hospital clinic. I was told that since the GP paid for the phlebotomist they would only draw blood for the tests the GP ordered. This now meant that for the blood test for the hospital (to be done two weeks before an appointment) I would have to travel to the hospital. Since there was no co-ordination between the GP and hospital, I would sometimes have a blood test for both within a few weeks - they would not share the results.

Then the diabetic clinic changed to a single appointment during surgery time, so now I had longer waits because my diabetic appointment was treated like any other GP appointment. After a while the diabetic clinic changed again, this time it was the practice nurse took them, not a GP. I learned fairly early on not to ask questions, because if I did, the nurse would say "you should make an appointment and ask the doctor". This surprised me because the diabetic nurse at the hospital was very knowledgeable, she knew far more about living with diabetes (including the various insulin pens and blood testing kits) than the doctors. The GP practice nurse was there merely to measure me.

This coincided with my GP (who ran the original clinics) taking time off for a lengthy illness, and then taking early retirement. However, when I went to another GP about a diabetes related issue he told me that none of the GPs were now specialised in diabetes telling me: "I really should do something about that". As I write this, the GP clinic still hasn't got a doctor who specialises in diabetes. Finally, at my last GP diabetes clinic, the practice nurse told me that they have lost a member of staff (I assume this means a cutback) and so rather than seeing me twice a year (to monitor my condition) they would see me once a year.

This tale has shown a progression of the treatment over time. Initially my diabetes was treated by a hospital consultant and both my GP and I never wanted to contradict what he said. Then during the fundholding period my GP wanted to do everything he could. After that I moved to split care and I found a level of assertiveness about my care. During this time my hospital care got better, but my GP care got worse. First my GP wanted to see me, then she was replace by a practice nurse, and now I am seeing the practice nurse less often, the next stage is surely me not being seen at all by my GP practice.

The government tell us that an important part of their "reforms" is self treatment. This is a nonsense. If you are a diabetic you cannot live without self treatment. It is a 24x7 condition and if you do not treat it, you die. The government implies that I, as a diabetic, am not treating my diabetes well enough, presumably because I am costing them too much. They do not understand that my incentive to have good control of my condition is to feel well. I do not even want to live longer, I just want to feel well, and because of that I am proactive in my own treatment. However, I know why the government wants to involve me more in "self treatment": they want to cut costs. The government does not have a measure of how well I feel, but they do have a measure of how much I cost them.

Self treatment is a natural end point in the relentless journey that is to "move care from hospitals to the community". The "community", ultimately, is the patient. The question is whether the move to self treatment will result in diabetics losing their control and costing the NHS more.

Cost of diabetes

2011-08-24T17:24:00.000+01:00

I am incubating a monumental rant over the government's policy to blame sufferers of long term conditions for the current problems with the NHS (problems which have actually been caused by this government). This rant will have to fester a little more before I will let it out. Until then let me just explain about the cost of diabetes.

IT IS NOT THE COST OF THE DRUGS!

There you go: simple isn't it? Complete idiots think that the cost of diabetes is in the drugs. It isn't, and it only takes a little thought to realise why. When diabetes is well controlled - whether type 1 or type 2 - the patient is a fully functioning member of society, no one will know that they have the condition. Indeed, many colleagues do not know that I have type 1 diabetes. The only visible sign of the condition is me injecting insulin before I eat and I have become adept at doing the injection surreptitiously under the table in restaurants (all you need to do is wait for the food to appear - people naturally spend a couple of minutes inspecting what's on their plate and not at you).

A well controlled diabetic is no different to a non-diabetic when it comes to contributing to GDP. The cost of diabetic drugs is fairly small. NHS Information Centre says that last year it was £725m. There are 2.5m people with diabetes (10% are type 1), so that means less than £300 per person.

I have written before that the cost of the drugs I take is small - a few quid a day. However, I only listed the insulin that I must take. I also take other medicine which are preventative: statins and two types of hypertension drugs one of which I am told protects me from kidney damage. These drugs cost pennies per day. The fact that they are preventative is very important because the real cost of diabetes is the cost of the complications from poor control. Long term high blood sugar leads to blindness, nerve damage (leading to amputations), kidney damage (needing dialysis or transplant) and cardiovascular disease. This is where the cost lies. Secondary to this cost of treatment is the monitoring once you show signs of a complication to determine when intervention is needed.

For example I have retinopathy where the blood vessels on my retina are weak and liable to burst. Since this was diagnosed 20 years ago I have had retina clinic appointments every 6 months. I have also had many tens of thousands of laser burns on my retinas to try and prevent vessels growing too big and when one did, and burst, I had an operation where the gel in my eye was removed, my retina cleaned of the bleed and the vessel sealed. That operation lead to me getting a cataract, so I have had cataract operations too. These interventions cost many tens of thousands of pounds: as I said, it is the complications that cost.

Incidentally, for the last 5 years I have been subject to "patient choice". Every six months my GP and my local optician send me a letter telling me that I need to have my retinas screened. Every six months I politely phone them up and tell they to take me off their marketing lists because I am seen every six months by a consultant at the hospital retina clinic. (I don't want to upset GPs or opticians, but honestly, do you really think you know more about my retinas than the specialist at the hospital?) Neither the GP, nor the optician, have shown any sign of removing me from their marketing list. Beware, AQP will open the floodgates to far more companies touting for business like this.

Today the NHS Information Centre published figures of the cost of diabetic drugs. Inevitably these figures have been misreported.

Diabetes prescriptions now account for 8.4 per cent of the entire NHS net bill for primary care drugs in England.

These drugs - if used correctly - will prevent a large range of complications and hence reduce demand on the NHS in the future. We should not focus on the cost of these drugs now, and instead we should focus on the cost of diabetes if we didn't spend this money.

Choice and Competition

2011-08-24T13:31:00.002+01:00

Can choice and competition work in the NHS?

NHS funding is being cut so is it economic to have a choice over everything? Choice costs. For example, if you choose the exact day (and time of day) to have your cataract replaced, the provider has to have a timeslot available for you to choose it. The provider cannot guess what time you will choose and consequently to plan ahead (and ensure there will be the staff and theatre time) they have to provide over-capacity. They also have to have over-capacity to accommodate patients who switch providers, again, something they cannot accurately predict. This over-capacity means that more facilities and staff will have to be available than is actually needed, and this has a cost.

In their evaluation of the London Patient Choice project, Picker Institute says:

"Choice is dependent on the availability of beds and staff, so providers were encouraged to expand capacity and improve the management of existing resources to enable patients to exercise choice. Funds were made available for this purpose and several treatment centres specialising in elective surgical procedures (e.g. hip and knee replacements or cataract operations) were established."

The important point here is that hospitals taking part in this programme were given funds to create the extra capacity. Patient choice is not possible without this capacity, nor the funds to provide it.

The LPCP is used as"evidence" that patients want choice because in the project two thirds of patients offered chose took up the offer. However, when you look at the details, it is more surprising that a third did not take up choice. The reason is that in the project patients were given access to Patient Care Advisers (these are not available to current NHS patients) to help them have all the information they need to make a choice; they were also given free transport to the alternative hospital (one patient even chose to go to an overseas hospital). But crucially, the patients who took part in LPCP were had already waited over six months. It is rather surprising that anyone would not take up the offer to join a shorter queue, but a third did.

Two facts: the patients involved had waited more than 6 months and the hospitals involved in the pilot were given funds to increase their capacity. This raises the question: if the hospitals had been given the extra funding before the pilot, would this have prevented patients waiting more than 6 months and hence removed their desire to choose to use another hospital?

In a totally free market there are ways to fiddle such a system to make it more efficient. I used to work in computer training and when I started the job I looked at the company's brochure and noticed that the week-long courses I gave (I was the only trainer of those subjects) were often in two cities on the same day. I pointed this out to my manager and he replied that I would give the course that had the most customers, the customers who had booked for the other city would be told that "their course was full" and be given a discount to attend the course in the city where I would be. This system meant that during the year I worked for that company I never had a week when I was not training (from the numbers of people I trained, I estimate that the company took in £250,000 training fees; not bad considering that by the time I resigned I was on £23,000).

The problem is that the free-at-the-point-of-use system is not a free market, so it is not possible to use a discount to persuade a patient to choose another time. So if we have real choice of providers those providers must run at excess capacity. The cost of this over capacity is money that could be spent on more healthcare, and as we suffer more rationing (that no one voted for) there will be political pressure for providers to cut costs. My guess is that commissioners, recognising that the unpredictability of patient choice is a major source of inefficiency and will quietly remove patient choice.

[On Twitter I suggested using bed occupancy as a measure of this over capacity. Unfortunately health policy wonks misunderstood the point I was making and veered off in another direction saying that the number of beds in NHS hospitals are reducing. So what? AQP has not started in earnest yet and this reduction is being driven by NHS cost cutting.]

It is also often stated that "choice" improves quality. Again, I think that this is not possible. Looking through the board papers of my local hospital I see that a consultant has been asked to leave. The reason is the high number of letters of complaints about his attitude to patients (interestingly, not his clinical ability). The hospital did not count the number of patients using that clinic and use that data to decide whether to sack the "low quality" clinician. Of course not, there is a waiting list so that means there are already too many patients (d'oh!). Patient complaints raised the quality of that clinic, not patient choice.

If I get a poor service from, say, my GP and I decide to register with another GP, will that raise the quality of my previous GP? No, of course not, I am merely one patient. Do I now want to raise the quality of my previous GP? I have a new GP who I am happy with so the quality of the old GP is of no interest to me - why should I care? Of course, over time there may be other patients who decide to move away from that GP, but the important point is that it is over a length of time. It may take months or years before a threshold is reached when the practice realises that that particular GP is simply not popular. During this time more patients will get a poor service. Is it acceptable to allow patients to have a poor service over a long time?

The Competition and Co-operation Panel produced a report earlier this year on Any Willing Provider. In this they give the following graph as their "proof" that choice raises quality:

They say:

"adverse news about the quality of care at a particular hospital can also have a significant short-term impact on patient referral patterns. For example, in early 2010, shortly after the CQC’s findings of ‘systematic failings’ at Basildon and Thurrock NHS FT was publicly reported, there was a short, sharp decline in patient referrals for routine elective care"

Fine, there was a "short, sharp decline" but this is no proof that quality has changed at Basildon and Thurrock: after a couple of months patients returned! Why did they return? Well the CCP tells you clearly in the title of the graph "change in patient referrals for routine elective care following adverse publicity over quality standards", that is, once the publicity stopped, the patients returned, they didn't return because quality improved.

During those few months when the referrals declined staff will still have been employed, adding to the trust's costs, and since many electives are paid through payment-by-results there would be no income for the lost patients. So the hospital will make a loss due to this bad publicity. This is hardly the best way to invest in better quality.

Competition and choice are extremely blunt tools. When it comes to healthcare we are right to demand the best, and to get this every provider must be of high quality. Do we really want to stake our lives on blunt, largely ineffectual mechanisms to raise quality? I think not.