Responsibility

The Spending Review is a depressing document, but the sections 1.86 to 1.90 are the most depressing. This is a section titled "Sharing Responsibility". On first sight you would thing that this means you, that you should share responsibility for your health, your environment, your community. To a certain extent I agree, you do have some responsibility for all of those things; but that is not what the section is about. The responsibility here is that of the government. Cameron thinks that it has no responsibility to provide public services.The Spending Review 2010 document says:

The Government believes that while it should continue to fund important services, it does not have to be the default provider. (1.87)

That is pretty clear, isn't it? What it is saying is that the government should not be regarded as the provider of last resort of any service: education, health, police, fire fighting, welfare, ambulances. Think I am going over the top here? No. Frances Maude has said as much, as reported in the Guardian.

Ambulance drivers, paramedics and firefighters could be given the right to breakaway from the national rescue service to form for-profit groups and run their services themselves, the Cabinet Office minister Francis Maude has said. The government is to unveil a white paper that will give nearly all public sector workers a right to "mutualise" services, along the lines of a John Lewis model whereby employees own the service they work for, and can profit if it makes money. Maude said that almost all public services – bar the police and the armed forces – could be mutualised. One ambulance service had already expressed an interest and he would also look at options for the fire service, he said.

Notice that Maude says "bar the police and armed services". That has been inserted to keep the retired colonels happy, but we already know it to be untrue. There are many so-called Private Military Companies (mercenaries) and these were used extensively in Iraq and Afghanistan. Governments like PMCs because their casualties do not contribute to the Allies body count (and so it appears that our military action has been far more successful than it has because fewer of our soldiers have been killed) and that the PMCs are not subject to the same rules of engagement as our military. Have a look at the companies listed here: there are a lot of them, aren't there? PMCs are big business.

As to police, well every nightclub has bouncers, every shopping centre has security guards, every warehouse and factory has night watchmen, we have never had a comprehensive system of state provided policing. There certainly is a plan to move more policing into the private sector. After the Spending Review indicated that there would be vicious cuts in local authority funding (which includes the police) my town was inundated with PR from a private security company that was offering a "service" of checking that your house had not been broken into for a fee of £10 per month. (That PR guy was very good: there were articles about the company in all the local newspapers and a piece on the local TV news, and the company paid not one penny for that publicity.)

The Spending Review continues:

the Government will look at setting proportions of appropriate services across the public sector that should be delivered by independent providers, such as the voluntary and community sectors and social and private enterprises. This approach will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services, and early interventions for the neediest families. (1.87)

A proportion of services will be provided by anything other than a public provider. This will be the law. The last time the Tories did this was with the 1990 Broadcasting Act that mandates that 25% of TV and radio production broadcast by the BBC had to be from non-BBC suppliers. When this was introduced undoubtedly it shook up the system. A lot of new production companies appeared apparently from nowhere and there was a distinct improvement in the BBC output that still had a 70s feel to it. However, this was at a time when there was money to innovate and all the Act did was to push the BBC into spending it on innovation. And, of course, this is a creative industry, they don't need much of a push to be creative. But significantly, the BBC is a service that we can do without (though many of us would not want to): if the experiment had failed then we would still be alive and well, just slightly culturally deprived. However, the long term result is not so rosy. The plethora of small, brash, edgy and innovative companies coalesced and merged and were taken over by the big beasts. So now we see that the "independent production" is from the new establishment of Talkback-Thames, Endemol, Granada etc. It can be argued that the BBC spawned baby-BBCs producing much the same stuff as the matriarch. We are back to 1990.

We are in a different situation now. First, there just isn't the money to allow people to make mistakes, so we cannot afford a Plan B. Secondly, the services being played with are vital, we cannot afford for them to fail. Health, ambulances, fire fighting: these services were provided by the state precisely because they were too important to let them be subject to the vagaries of the market. The state took the responsibility of providing these services so that we could be assured that we would have access to them. When Conservatives talk about Sharing Responsibility they mean offloading the responsibilities that they have taken on. Basically we have elected a bunch of shirkers who are telling us: we do not want the responsibility, we just want the power. The next few years are going to be very unpleasant.

Administration

Coalition Agreement:

We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.

Where does all of that administration come from? Well David Cameron will insist that it is targets. Lansley has now abolished the 18 week target (well, abolished performance monitoring hospitals against it, the NHS constitution gives you a right to treatment within 18 weeks) so surely the NHS administration problem has been fixed? No, of course not. The Tories are not that logical.

Undoubtedly targets do add to administration, but they are not the source of excessive administration. Anyway, targets deliver benefits, notably that patients actually get the treatment within an acceptable amount of time. Since targets deliver a benefit, then surely we should be willing to pay something for it?

I am currently reading a rather depressing book: NHS plc by Allyson M Pollock. Great book, but you get a sinking feeling as you read it (buy it, I do not know Prof Pollock nor do I have any financial gain from you buying the book). Anyway, in the context of this blogpost Prof Pollock says:

The number of general or senior managers in the NHS rose from 1,000 in 1986 to 26,000 in 1995, and the proportion of total NHS spending consumed by administration more than doubled, from 5% to 12%.

The Internal Market was introduced in 1991. Get the message? The rise in administration is due to the marketisation of the NHS and fuckall to do with targets.

I cannot find a table of the cost of administration since the 80s (which would prove the point conclusively) but the nearest I can get is this from Hansard:

	96–97	97–98	98–99	99–00	00–01
Admin costs	2,020	1,963	1,935	2,158	2,166
NHS Budget	32,997	34,664	36,608	40,201	43,932
Adimin %	6.1	5.7	5.3	5.4	4.9
	01–02	02–03	03–04	04–05
Admin costs	2,565	n/a	3,345	3,412
NHS Budget	49,021	54,042	63,001	69,706
Adimin %	5.2	n/a	5.3	4.9

It certainly looks like Labour had got administration under control.

It is interesting to see that Prof Pollock also cites some evidence about the US system (remember, a system that is based on competition). She said that in 1994 administration was 22.9% for public sector hospitals, 24.5% for independent not for profit hospitals and 34% for for-profit hospitals.

Marketisation clearly puts up admin, so will the pledge to cut admin by a third be yet another Coaltion Agreement pledge to be boken?

PCT Functions

When the NHS White Paper was first published and announced that PCTs were going to be abolished (incidentally, against what the Coalition Agreement said would happen, but as we all know that piece of paper was a sop to LibDem party members, it was never intended to be actual policy) many people said "huh? who are they and what do they do?".

So the Department of Health and the NHS Confederation produced a document that listed the responsibilities of PCTs. This list came to 211 items and it took 14 pages just to list them. This may sound like bureaucracy, but when you look closer you see that these responsibilities include making sure that money is spent in a cost-effective way, that healthcare is equitable, that strategic planning is done to ensure that facilities are available for expected population changes.

The laws that they have to be compliant with are: NHS Constitution, European Convention on Human Rights, Race Relations Act, Equality Act, Sex Discrimination Act, Disability Discrimination Act, Equality Act (Sexual Orientation) Regulations, Mental Health Act, Coroners and Justice Act.

Now I am sure some right-whingers will complain about all of this, but the country is not a majority of ignorant right-whiners, the rest of us want to make sure that healthcare is equitable, that steps are taken to make sure that everyone gets equal access regardless of their race, sex, sexuality or disability.

Many commentators have pointed out that GPs do not have the skills to provide all of this, and hence they will have to employ former PCT commissioners. Lansley see the PCT commissioners as the problem, not the solution. So how does he make sure that GPs do not have to emply PCT commissioners? Easy, get rid of the PCT responsibilities.

HealthcareRepublic report:

Dr James Kingsland, DoH national clinical director for practice-based commissioning in England, said much of a 283-point list compiled by the DoH and the NHS Confederation PCT Network was unnecessary. ‘This is what PCTs used to do. They are being abolished, and their functions are gone,’ he said. ‘We have to rewrite this list and it has to be radically different.’

Since much of the list is about making healthcare access equitable, and about keeping the NHS cost-effective and improving performance, it seems bizarre that the Department of Health will want to abolish most of the responsibilities.

Quoting PCT Network director David Stout:

‘Work was being done to ‘downsize’ the list of functions but none would be easy to abolish, he said. ‘I suspect it will be quite difficult to do as just because they are less important it doesn’t mean they just don’t need to happen,’ Mr Stout said.

The NHS under Lansley will be very different than we are used to.

NHS Funding

Michael Blastland from the BBC gives some graphs which show how the pledge that the Conservatives are protecting the NHS budget is basically a lie. (The Riddle of the NHS Budget). I have downloaded the data myself from ukpublicspending.co.uk and applied some colouring to make the situation clearer. Here is my version of the graph of NHS funding as a percentage of GDP:

The blue are Tory years, Red are Labour years and the dotted line is the expected spending outlined in the CSR. The reason that the line goes down is because in real terms NHS funding will fall by on average 0.1% every year (a fall of 0.54% between the 2010/11 and 2014/15 figures) yet GDP is expected to rise over this period. remember this poster? Complete and utter lies, and the graph above prove it.

Bloody Blairites

I suppose they don't have to allow me to comment on the articles on their website. but it does smack of cowardice. I mean, all I am is a moderately lefty amateur with a passion for the NHS, and ProgressOnline are a well funded website edited by professional politicians who should be able to put up a cogent argument against my comments. (To be fair to ProgressOnline, I think the main problem was that I was posting a long comment - see below - but once I had chopped it into two, then got past the Captcha - after about 10 tries - I was given a reply that said because there was a URL in my response - there wasn't - it would have to be moderated. This means that my comments are not on the site. That either indicates incompetent, badly thought out website software, or censorship. Which would ProgressOnline prefer?)

Progress have an article called "Labour can seize on this reckless NHS reform" written by Ralph Michell who is described as "head of policy for a charitable organisation but is writing in a personal capacity". I'll let you know which charity at the bottom of this post, when you'll go, "oh, that makes sense". Anyway, since the Blairites won't allow me to comment on what is frankly a disgusting article, I have posted by comments here:

I had to check to make sure this was not a posting on Conservative Home.

"Labour should mount a bold attack on the government's policy of ringfencing NHS spending"

While I agree that the "ring fence" was political expediency, only Tories (and that would appear to include Ralph Michell) actually believe that any "ring fence" exists. Please, before you spout right wing nonsense can you first look up some of the statistics? The Kings Fund (like, umm, independent experts on the NHS) say that the NHS needs to have a 5% to 6% real terms increase every year to take into account the aging population and healthcare inflation (which is typically TWICE CPI). Therefore any responsible government would agree to real terms increases. As we know from the CSR we do not have a real terms increase because £1bn a year is to be taken from the NHS to pay for social care that has NEVER been their responsibility. Since this social care commitment is being done to make up (only partly) for the massive cuts in local authority funding (and hence their social care funding) it means that it is a real cut in the so-called "ring fenced" budget. The NHS "ring fence" does not exist: does that make you feel happy?

"The NHS consumes more than £100 billion a year of public money, and there is patently scope for it to be more efficient and make a significant contribution to reducing the deficit."

Where on earth have you been for the last ten months? In the 2010 NHS Operating Framework, published at the beginning of the year, Andy Burnham, said that the NHS must make £15bn to £20bn "efficiency savings" by 2014. That's about £5bn of efficiency savings every year. Let's see: that would be the entire public health budget, or most of the NHS training budget, or half of prescribing costs. What would you do, cut public health in the first year, then most of training in the second year, then half of prescribing costs in the third year, and then the remaining prescribing costs in the final year?

Oh right, you would actually make the NHS more *efficient*. The evidence is that there is not much fat to be trimmed. Even the Tories admit this, the Guardian reports that a Tory "health insider" says that "a fifth of everything the NHS does today will have to stop". That means cuts. That means that patients will have to go to the private sector to get the treatment or (I guess your "solution") beg a charity for it.

These "efficiency savings" are wreaking havoc in the service right now. In my county the PCT has stopped all "non-urgent" treatments. (The only treatments that are being done are: cancer - everyone's favourite disease, it is a pity if you have a non-cancerous heart condition - A&E and fractures. EVERYTHING else is non-urgent!) Do you know what that means? An elderly woman needing a hip replacement will be told that she will have to be in pain and immobile for another 6 months (at least) because first Andy Burnham, then Andrew Lansley (and presumably now Ralph Michell) think that it will be "more efficient" that way. What utter and obscene nonsense!

"Arguing that the NHS is different ... will not wash", says who? Someone who knows nothing at all? The fact is that the NHS is the bottom line. It is the last line of defence, there is nothing to protect you after the NHS. The NHS has to pick up the pieces and repair the consequences of failures in every other service. You mention social care, yet the first thing that social care providers do when there are any problems is pass the client on to the NHS. It is frankly disgusting that anyone could argue for a cut to the NHS.

"Second, Labour should attack the government's economic incompetence on the NHS."

I don't know if you have noticed, but the NHS is currently running under the policies of the last Labour government. Any attack on the NHS now will be an attack on Labour.

"One hundred and fifty-two primary care trusts and 10 strategic health authorities will be wound up"

Not an expert on the NHS I see. The SHAs were due to be wound up anyway. When an NHS Trust becomes a Foundation Trust it is take out of SHA control, so under Labour SHAs were getting more and more irrelevant and would have been reformed, or maybe abolished when the NHS Trusts in the SHA's area became FTs. As to PCTs well Labour's plans were to hand commissioning over to GPs through Practice Based Commissioning, which is not quite the same as GP commissioning, but not far off. And if you were paying attention you'll see that the Kings Fund says that consortia need to be at least 500k people and most commentators agree: there will be about 80 consortia. The 500 figure was an initial estimate by some newspapers based on PBC. It is clear that such consortia would be far too small and would not have financial stability.

Of course, you may have noticed that 152 PCTs will be replaced with 80 consortia and largely staffed by PCT commissioners. You may also have noticed that the NHS Board cannot do its commissioning work from London, and will need regional officers, and some people (Sir Philip Green, for example) suggest that there should be 10 regional offices. Is this "re-inventing the wheel"? Yes it is. But that has happened frequently in the NHS.

You casually mention Foundation Trusts, but this is the main area where Labour can get a popular campaign against the Tories. The problem is that you spoil it by making exactly the same argument as Lansley does.

"It should look to make greater use of organisations outside the NHS (including community groups, or peer support groups like those run by third sector organisations)"

No! No! No! This is NOT the attitude to take. The reason is quite simple: this is EXACTLY Lansley's plans (have you actually read the White Paper? it does not appear so). Now let's see. An elderly woman has ulcers on her legs and needs the dressings changed frequently. So let's ask a "community group" if they could give it a go, I mean all you have to do is take the old dressing off, throw it away and stick a new one on. What's difficult about that? No need for a trained nurse, eh? Oh right, it does need a trained nurse, but you don't want to pay him/her? The fact is that the vast majority of the work being done by the NHS needs highly skilled, trained staff. You simply cannot shunt that work onto untrained volunteers. What about if something goes wrong? Who is responsible?

"It should argue clearly for shutting inefficient hospitals."

And who will do the hip operations, cataract replacements, cancer treatments? Oh let me guess, either 1) voluntary "poor house" hospitals paid for by charity contributions by rich people with a conscience (doesn't it just make your heart sing that there are such lovely people around?) or b) private hospitals where the exorbitant costs are paid using a co-payment by the patient. Nice. Point me to an "inefficient NHS hospital", then have a look at how much it costs to perform their procedures (say, a diagnostic test, or an operation). I will accept your assertion only if you can find me an alternative that is safe and of equal quality, but costs less. Please do not spout Lansley's propaganda.

I would argue that in some places, for historical reasons, there are too many hospitals and that there is an argument to close the excess hospitals. But equally so, there are some areas with too few hospitals and they need a new one built. Over all, the NHS is very efficient compared to just about any healthcare system you could mention.

"The National Care Service which Labour started to articulate in government, free at the point of need, could form the basis for such a vision."

Now we can finally agree on something. But the NCS is NOT and alternative to the NHS. We need BOTH. And the NHS needs new funding, it MUST NOT be funded from NHS funds (like Lansley is trying to do now).

OK so who do you think this Ralph Michell is? Other than the lame talk about attacking Conservative policies, he does sound like a wet Tory, doesn't he? (Read the original article, if you can stomach it.) He says that the NHS wastes money (heard that somewhere? perhaps in a Tory election leaflet?). He says that NHS services should be done by the voluntary sector (again, where have you read that before?). OK so I went a little over the top about DIY community health services, but it is the natural conclusion of his ludicrous plans.

So Ralph Michell's Twitter profile says he is

Head of policy at the Association of Chief Executives of Voluntary Organisations (ACEVO), interested in third sector, charity, politics 

Let's remember what the "third sector" really is. They are charities (who have staff that need to be paid) and "social enterprises" (ie, not for profit, but still private, companies, that have staff to be paid). These charities and "social enterprises" have boards of directors and chief executives on very generous salaries. They have also got rather fat on the funding from New Labour.None of these charities and "social enterprises" would stand up to the financial scrutiny that the NHS suffers. None of these charities and "social enterprises" could withstand the Conservative government instigated, media bile that has been throw at the NHS. They feel that they are untouchable because they have a cuddly image. But they really are the bad guys.

These charities and "social enterprises" are in competition with the NHS. They are in competition because they do the same stuff as the NHS (or they see a business opportunity in doing what the NHS does) and the only source of funding is the taxpayer. They want NHS money. That is why Michell is against the so-called NHS "ring fence" because he sees that it is a threat to his (and the other chief execs and directors) fat pay packets.

Their website congratulates the last government on neutering the "NHS as preferred provider". They are no friends of the NHS and as such no Labour supporter who supports the NHS should have anything to do with them.Sadly, these horrible people were pulling Blair's strings and are now salivating over Cameron's plans. They really make my heart sink.

By the way, if anyone from Progress is reading this, I allow ANYONE to post comments. I want to debate, it is a pity that you do not.

Basingstoke Rule

Last week I attended a meeting with the finance director of my local hospital. The meeting was called to outline the effects of the NHS white paper. It was frightening. As he went through the slides he pointed out substantial parts of the plans that will not work. Remember, this is a white paper, and essentially the first draft of the legislation, it is not a discussion paper. Lansley has said that the white paper will be implemented and that there is no alternative.

One of the points the Finance Director made concerned the debts of PCTs. He said that the GPs were relying upon the "Basingstoke Rule", and he explain thus: Andrew Lansley was on one of his tours touting his white paper to GPs, and in Basingstoke he was asked if GPs would have to take over the debts of PCTs. This issue is a frightening prospect for GPs because they run businesses, and as such they have to make sure that they at least break even. It is usual for businesses to owe money on an asset that they use (like premises, or equipment), but PCT debts are not for assets the GPs will own. (One could argue that some of PCT debt is created by GPs over prescribing or referring patients when they shouldn't.) Lansley's response to the Basingstoke GPs was that they would not inherit the PCT debts.

This is significant because some PCTs have huge debts. There is a lot of PFI debt, there are liabilities like leases on property and some PCTs have hidden debts where they have borrowed from other PCTs. Lansley's Basingstoke Rule means that GPs will not take on this debt. This does raise a question of where the money will come, but this is just one of a plethora of important questions that Lansley seems not to be able to answer.

Pulse gives some more details about this:

[Lansley] made clear the Government would not write off debts racked up by PCTs in their remaining two and a half years, and urged GPs to work closely with trusts during the transition period to ensure they don’t start off with huge financial millstones around their necks.

So clearly Lansley's Basingstoke Rule is that the debts PCTs generated until the government changed would be written off, but any debts that PCTs generate under his watch would be the liability of the GP consortia. This is quite clever since it means that GPs will have to get involved immediately in the process of taking over commissioning so that they can limit their future liability.

It means that commissioning that happen now is effectively the responsibility of GPs even though the actual commissioning consortia have not been created. After all, if PCTs are cutting patients' treatments now to protect GPs from a debt in two and a half years time, the PCTs are doing this for the benefit of the GPs and hence the GPs should take the responsibility for this.

Cuts, cuts, cuts

The Commons public accounts committee published a report today about the results of the last attempt at "efficiency savings". The New Statesman says:

The report warns that only £15 billion of the £35 billion of savings identified in the 2007 Spending Review have been achieved, and only 38 per cent of those were considered "legitimate value-for-money savings". The Communities department, for instance, which faces cuts of 51 per cent - the largest of any department - has made only £40m of savings against a target of £987m.

£15bn out of £35bn is 43%. Let's use the more optimistic 43% than their measly 38% (a little bit of illegitimacy can be excused).

The NHS is supposed to find £20bn of "efficiency savings" by 2014. We are told that the money saved will be re-invested in the NHS. The NHS needs a 5-6% real terms rise just to stand still and so some of this rise must come from the re-invested "efficiency savings". £20bn over four years is about £5bn a year, or about the 5% needed to stand still. That is why Osborne only gave the NHS 0.085% increase each year, the rest that the NHS needs has to be found in the money from "efficiency savings". The big if here is can the NHS get 5% more efficient each year for four years? The evidence from the public accounts committee suggests not.

43% of £5bn is £2.1bn a shortfall of £2.9bn. So if the 2007 spending review is replicated with the 2010 CSR it would mean that the NHS will have £2.9bn less each year. Hence this indicates that the NHS funding will be cut by about 3% every year. It certainly looks like we are heading towards the usual Tory situation of patients on trolleys in corridors. Bastards.