NHS White Paper Part 1

1. Liberating the NHS

Odd phrase that: "liberating" implies releasing from shackles. Since the emancipation of slaves, and the (near) abolishing of slavery, the shackling that most people experience is economic: a lack of money. Yet the NHS gets one sixth of all tax revenues, over £100bn of tax payers' money, what does the NHS need liberation from? Unfortunately, it is us, the taxpayer.

Under Lansley's plans public accountability will go. As a result, an unaccountable quango, the NHS Commissioning Board, will direct the operation of the NHS with its strings being pulled by private healthcare corporations who want a bigger share of taxpayers money. (Bear in mind that 5/6 of healthcare spending in the UK is on the NHS and the other sixth is on private health. This ratio has remained constant for a couple of decades. Private health corporations have been frustrated for years over this intransigent ratio.)

The NHS today

The first point to make about this section is how much it praises the primary care delivered by GPs, it describes them as being "world-class". This ignores the fact that the main role of GPs are to restrict expensive treatments, not promote them.

Let me explain. In international comparisons of healthcare systems, British GPs are known as gatekeepers: the idea is that the only way to get specialist care in England is through referral by a GP. In other countries, for example the United States, patients can visit a specialist without a clinical referral, but they have to pay for the consultation, of course. (If medical insurance pays the bill, then the consultation has to be approved by the insurance company, and sometimes this contravenes the clinical advice.) GPs are very effective as gatekeepers, they make sure that expensive treatment, equipment and expertise is only used on patients who really do need that care. Otherwise the GP can provide cheaper treatments themselves. Hospitals are expensive, their treatment is expensive and GPs, using clinical judgment, make sure that the most deserving gets that treatment. No wonder the white paper raises GPs to a level of sainthood, they save the NHS so much money!

The problem is that the white paper goes too far. It treats hospitals as if they are the enemy and the source of all that is wrong in the NHS. This is the premise where they start, and as you'll see through the paper, the conclusions they draw are anti-NHS hospital.

Our vision for the NHS

The thrust of this section is about "liberating" the NHS from central political control. But is this possible? The NHS Commissioning Board will be providing commissioning guidelines from London under the instruction of their political masters and with only rudimentary scrutiny from Parliament. Is this really the model that we want? Even if the new NHS has greater "liberty" there is another factor. With liberty there always comes risk. The "monolith" that is the NHS shares risk. If one NHS hospital runs a deficit and makes cuts, patients can go to a neighbouring hospital and the Department of Health will take measures to make sure that the failing hospital reforms its finances. The failing hospital will usually get additional support from the DoH so that patients can continue their treatment. This shared risk means that there has to be one large provider. When there are many, smaller providers the risk is divided between them, and the consequences of the risk born by each one individually. As a patient in such a fragmented system you have to hope that you do not choose a provider that will go out of business.

To this end, have a look at what they say in section 1.22:

"We are very clear that there will be no bail-outs for organisations which overspend public budgets." (1.22)

This means that if your local hospital has a deficit then it will close. No ifs, no buts, there will be no "bail-out". In some cases hospitals generate deficits due to mismanagement, so should a local community be punished by losing their hospital because of this? Why not monitor the financial governance of a hospital and if they show incompetence then replace the management? In other cases hospitals generate deficits because of underfunding due to changing demographics and so the fault is the government's for miscalculating the necessary funding. Should a community be punished for this?

This statement (1.22) is very serious and you should bring it to the attention of your local MP.

Improving public health and reforming social care

The white paper says that public health responsibilities of PCTs will transfer to local authorities. Section 1.10 says that the government wants to make the NHS "free from frequent and arbitrary political meddling". Yet we know from our experience of social services that different local authorities implement them differently – some charging scandalous amounts of money for personal care – yet here the government is saying that public health responsibility will be handed from public, non-political, expert led bodies to organisations that are politically charged and frequently corrupt. So section 1.16 contravenes section 1.10.

It is important at this point to direct you back to what I wrote on the 19 January 2010 about the Conservative green paper on public health. In this document they say:

"To encourage a new market in innovative public health solutions is opened up in every part of the country, we will require local public health directors to ensure that an increasing proportion of contracts are awarded to providers from the private and voluntary sectors."

No mention of the public sector (NHS) there. In fact if there is an increasing proportion then that means that the public sector will be squeezed out. Furthermore, the language implies that the intention is to move to a point where public health provision (vaccination and screening) is a wholly private sector service. This is in spite of the glowing endorsement that they give in section 1.6 ("Other countries admire NHS delivery of immunisation programmes") to the work of public providers. If it ain't broke (or is doing an excellent job) then don't fix it!

Public health currently takes up £3bn of the NHS budget, so the government intends to privatise £3bn of NHS services.

The financial position

Since the government regard us to be "all in this together" when it comes to austerity, there has to be an application to the NHS. Therefore, in section 1.20 the white paper says:

"It is now even more pressing that we implement the reforms set out here in order to increase productivity and efficiency in the NHS." (1.20)

It is always easy to say that you will increase productivity and efficiency, but it is very difficult to do in practice. In spite of the claims of "ring fencing" the only effective way to save money is to cut the budget. This is stated in section 7.v of the executive summary:

"The NHS will release up to £20 billion of efficiency savings by 2014, which will be reinvested to support improvements in quality and outcomes."

The point is that the extra £20bn of funding is needed because of increasing demands on the health service, and the only way to get that funding is through "efficiency savings". In effect this means that the government will cut the budget by £20bn and expect providers to find the money elsewhere. (And it was imposed on the NHS by the last Labour government too.)

So where are these cuts going to come from? We have been promised that frontline staff will not be affected, but the RCN already notes that 10,000 nursing posts have been axed. Section 1.21 says that the savings will come from:

"Large cuts in administrative costs ... increasing productivity ... the NHS will employ fewer staff at the end of this Parliament" (1.21)

These are ephemeral. Administration is about getting you an appointment according to your need, or rescheduling the appointment if you decide that you cannot make the original appointment; it means having your test results placed in your notes and getting your notes on the consultant's desk at exactly the time that the consultant needs them. If you make an arbitrary cut in administration then you are in danger of notes going missing, or patients not getting appointments soon enough and quite apart from the detrimental effect on patients this will ultimately result in less efficient and more expensive system.

Implementing our NHS vision

The phrase our vision goes to the heart of this white paper: it is ideological. But note what section 1.24 says

"In the next five years, the coalition Government will not produce another long-term plan for the NHS." (1.24)

That is, take it or leave it there is no alternative. Yet this is a plan which was not discussed at the election. No one debated this plan. Furthermore, the Conservatives who formulated this plan did not even get a majority, so the government has no mandate to implement this plan. This is a thoroughly undemocratic action.

Conclusions

These are the important issues to note from the first section of the white paper:

• These are untested, ideological changes and no other plan will be accepted by this government. There will be no pilot, no trial, it is the case of all or nothing, take it or leave it. The government is experimenting with the NHS, which is extremely risky thing to do.
  
• Public health will be a responsibility of local authorities which are under political control. This will increase political meddling in public health provision.
  
• The "liberation" will be liberating the taxpayer from the NHS, not liberating the NHS from political control. The paper says that there will be "no bail-outs" of hospitals, which mean that you may lose your local hospital.
  
• These plans were not publicised during the election and the public did not debate them. In fact the public did not know what the Conservatives were planning. There is no mandate for these changes.
  

NHS White Paper

The NHS White Paper is now available on the Department of Health website. In the next few posts I will go through these plans and put them into perspective. There are five main sections so I will devote a post to each one. These sections are:

Liberating the NHS

The Conservatives have always hated the NHS, the reason is that they really do not understand the reason for it. They see healthcare as yet another profit making business opportunity and yet the NHS is based on the principle of treating people without making a profit - what, they say, is the point of that? The very phrase "liberating the NHS" is highly offensive because it implies enslavement, and yet it is the principles of the NHS themselves that are liberating, liberating people from the constraints and enslavement that comes about from ill health.

Putting patients and public first

This should be a given with any healthcare system. My concerns here, as always, is that private health by law has to put the shareholder first (company law says that a company is run for the benefit of the shareholder, not the customer). I would say that the best way of putting patients first is through advocacy where a trusted professional representing only your best interests helps you to get the best care possible. However, the government says that in their view you have to do this. They say that this will be achieved "through an information revolution and greater choice and control". The choice and control will be yours, but how will you know what the choices mean?

Here is the key point:

Patients will have choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment. We will extend choice in maternity through new maternity networks.


The "any provider" will mean private hospitals. Since private providers cannot provide treatment at the rates of the NHS we have to wonder how the government will enable this. The previous government's ISTC programme was an attempt to privatise services, but it failed because ISTCs could not match the NHS on price or efficiency. As a consequence the New Labour government had to apply hidden subsidies to make it appear that these providers were efficient. It is very important that we scrutinise the government's plans for any hidden subsidy to the private sector.

The pledge for "consultant-led team" is vital. The result of the last Tory experiment ion GP fundholding resulted in 7% fewer patients being referred for specialist care, in other words GPs had a financial incentive to perform treatments that should have been performed by consultants and consequently patients did not get the best care. If these plans are implemented then it is vital that patients always demand a consultant-led clinic.

For example, when you compare hospital diabetic clinics with GP diabetic clinics, the hospital diabetic clinics are always consultant-led, whereas GP diabetic clinics are always practice nurse led. The monitoring that GP diabetic clinics provide are vital when it comes to diabetic control, but they should be in addition to, rather than a replacement for, hospital diabetic clinics. We will have to monitor the situation very carefully and make sure that the government's plans are not simply a case of cost-cutting and intended to downgrade the role of hospitals in  healthcare.

The "choice of treatment" is an interesting one. At the moment NICE approves treatments on their clinical effectiveness. Sometimes - but not always - cost comes into it, but the decision is mainly made on clinical effectiveness. It will be interesting to see if the government allows non-NICE approved treatments, or whether they will allow patients to have quack treatments like homeopathy or chiropracy.

Improving health outcomes

No government wants bad health outcomes, it is how you achieve them that is important. New Labour believed that performance targets were the answer (interestingly, the current government have not abolished the targets, they have simply stopped performance testing based on hospitals achieving the targets). Every healthcare professional will tell you that there have been huge improvements in outcomes over the last decade, the political issue is whether targets are the most effective way to achieve better outcomes.

The focus of the Department of Health appears to be to treat health providers like roofers. If you need a tile replacing you contract a roofer and after they have replaced the tile you check. If they have not replaced the tile, or they dropped the old tile on your conservatory roof cracking a window, then you do not pay the roofer for the work. Simple? Well we will see. The problem is that patients will have to know what the expected outcome will be and how to complain. This is fine for the pushy middle classes, but it is unclear now the non-pushy patients will benefit.

"Providers will be paid according to their performance. Payment should reflect outcomes, not just activity, and provide an incentive for better quality."

This seems like nonsense. The fact is that activity (the treatment) can be very expensive. Imagine the cost of major organ transplant, like a liver. Imagine the follow up treatment involved, the anti-rejection drugs that suppress the immune system which result in patients suffering greatly from what would be trivial infections for a healthy person. How do you determine the outcome here? How do you determine what proportion of the outcome is due to poor treatment or due to the patient? How do you determine what proportion of the payment is withheld due to a less favourable outcome?

Why should we wait for outcomes to be determined before we find out that a treatment is not being performed correctly, surely constant monitoring of procedure (oh dear, there is that process-led target phrase again) would reduce the chance of there every being a bad outcome?

Finally, all treatments have a chance of failure, but some treatments are very risky. Innovation means trying out new procedures and there is always a risk that the new procedure will fail. If a hospital will not be paid for this activity if their is a bas outcome then surely this policy will restrain innovation, perhaps even remove it altogether.

Autonomy, accountability and democratic legitimacy

This is the worrying part. This is where the p-word comes in: privatisation. Interestingly, the executive summary for this section includes a lot of policies on the autonomy point, a weak sop to the democratic legitimacy point and nothing on accountability. The Conservatives like to talk a lot about accountability, but they never implement plans where they are made accountable. (For example, moving to five year parliaments makes the Conservative less accountable because as voters we now have just one chance every five years to hold Conservative MPs accountable. Allowing dissolution during this five year period means that they would be far more accountable because at any one point during that period a Conservative MP could lose their job.)

This section seems to have some inconsistencies. For example, this phrase:

"local authorities will promote the joining up of local NHS services, social care and health improvement."

This means vertical integration and is what I think the NHS should be doing: one organisation responsible for end-to-end care. But this conflicts with the fragmentation of the health service that is promised in the "any willing provider" policy.

"We will establish an independent and accountable NHS Commissioning Board."

This is another area where the policy is inconsistent and we will have to scrutinise the proposals. On the one hand the government says that they will "devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia" which means that the decisions are made at the local level. But at the same time the government will create the super-quango the NHS Commissioning Board. In earlier Conservative policy documents they say that this board will produce commissioning guidelines, so will this mean that the NHS Commissioning Board will determine services or GPs? Further, Conservative policy documents say in many places that they want to create a healthcare market of private providers paid with NHS funds. The question here is whether the sole responsibility of this new NHS Commissioning Board is to force GPs to commission private providers.

Cutting bureaucracy and improving efficiency

Bureaucracy is an interesting concept. No one likes it, everyone thinks that bureaucrats are there to do non-jobs that get in the way of us doing our work. Governments always say they want to cut bureaucracy because it is popular. the problem is that if you allow people to do whatever they like, they start to do things that you do not like, so then you have to bring in regulation and monitoring and bureaucrats.

For example, in the section above we are told that the government wants to pay providers based on outcomes. Where do we get these figures of outcomes? Who decides the proportion of payment according to the outcome? Who enforces this outcome based payment system> The answer is administrators and hence this will result in greater bureaucracy.

"The NHS will release up to £20 billion of efficiency savings by 2014, which will be reinvested to support improvements in quality and outcomes."

This is a pledge from the previous government and few NHS providers know how they will achieve it (it is a saving of 20%). In fact, the "efficiency savings" being made at the moment have resulted in the loss of 10,000 nurses jobs (source: RCN). New Labour made this wild claim, and the Conservatives are making it too. Making claims in absolute terms like this is very risky. What happens if, in September 2013 there have only been £11bn savings, will there be a sudden rush over 6 months (to the end of the financial year April 2014) to cut £9bn from somewhere, anywhere?

"The Government will reduce NHS management costs by more than 45% over the next four years, freeing up further resources for front-line care." 

Again an arbitrary absolute figure. Where does 45% come from? (See my later blog post on this.) The fact is that managers should be there to free-up clinical staff from any managerial responsibilities, but this government wants to push more managerial responsibility on clinicians, which means that they will be doing less clinical work. By all means make management more efficient, but do not make clinicians treat fewer patients.

The Civil Service Are The Enemy

Well, that appears to be the point of view of the government. This article from the Observer is interesting, though clearly from just one point of view. It is interesting to read the comments. A minority are from the extreme right, the tea party types who think that, as Reagan said "the government is not the solution, it is the problem". We can safely ignore them as being nutters: anarchy (the lack of government) is not a solution. But read some of these comments:

lightacandle:

Say goodbye to what was once a country envied throughout the world for its education system, its health system, parliamentary system and democratic state structures and say hello to what will be an empty shell of a country with it's infrastructure in ruins, it's people either destitute or living elsewhere and it's hope and enlightenment gone never to return. Think I'm being sensational and over dramatic - no - just you wait and see the first signs are already there. Last one out turn off the lights - if there are any lights left to turn off.

CptAnguish:

BTW I understand from a colleague, who attended Civil Service Live that members of the audience walked out when the Deputy Prime Minister gave his speech - interesting times ahead methinks.

This last comment really gets to the nub of the problem:

AmberStar:

BTW - Who did you vote for at the General Election? Just asking.....

Decline

Just before the budget the OBR thought that growth for 2011 would be 2.6 per cent.

Then, for the budget, the OBR revised the growth figure to 2.3 per cent.

Now the IMF have produced its forecast for the UK and they reckon that growth will be 2.1 per cent (down 0.4% on its previous forecast).

See a trend? As a country we are in decline, and the Conservative policies are the cause.

UPDATE: Stephanie Flanders has more to say on her blog:

Back in April, the Fund was expecting the UK economy to grow by 2.5% in 2011. In today's update that prediction has fallen to 2.1%. The forecast for 2010 has been nudged down as well - from 1.3% to 1.2%. This is at a time when the global growth prediction for 2010 has been revised up by 0.4 percentage points, to 4.6%. The Fund doesn't spell out why it is now more gloomy about the UK, but I am assured that last months' Budget is the reason. 

Constituency Sizes

In an earlier post I wrote about the Conservative government's policy of gerrymandering. Now I come across this article from last year. It gives the conclusions from two academic studies about cutting the number of MPs and changing the sizes of constituencies. The conclusions are that it is being done to make Tories feel that something is being done.

However, the conclusion of both papers seem to be that the "Labour bias" is simply because of the spread of the vote:

Labour continues to benefit from electoral size but its real advantage currently stems largely from a better distributed vote – it acquires fewer surplus and wasted votes than its rivals. It is also benefitting more than other parties from the general decline in electoral turnout, requiring fewer votes for its victories.

Only time will tell whether the 50 MP cut will have any effect on the chances of Labour forming a government. What is clear, however, is that the motive behind this cut in representation is to gerrymander.

Gerrymandering

First, let's make this clear. It is desirable to have constituencies that are of equal size. Whether this is equal size of population, or of registered voters, is a debating point. The problem with using the number of registered voters for the constituency size is that doing nothing more than a localised public information campaign will increase the size of the constituency and so any "rebalancing" action would have to be repeated. While it is true that populations change by people moving from area to area, or by procreation, these are longer term changes. I am more in favour of basing constituencies on population size rather than on the number of registered voters.

The Tories, in a shameless attempt to gerrymander, said in their manifesto that they would reduce the number of MPs by 10%. At the 2005 election there were 646 constituencies and at the 2010 election there were 650 (more about that later), so a 10% cut would be a new Parliament of 585 MPs. Nick Clegg has decided on a figure of 600 (8%), which is at least a round number. I suspect that this is still more than coukld fit in the chamber, but then few of them bother attending debates, do they? It seems to me that the most sensible figure is to count how many seats there are in the chamber and have just that many MPs, but there is nothing sensible in Cleggy's plans. So where does the 10% come from. In truth, no one in the Conservative party will admit to saying where they got it from. Indeed, in 2004 Michael Howard said that the number of MPs should be cut by 20% to 525.

The issue that is highlighted by the more rabid Tories is that the average Labour MP is elected by fewer votes than the average Tory MP. This partly due to the habit of inner city constituencies voting for Labour MPs and that there has been a move in the last few decades from the inner cities to the suburbs. But this argument is specious at best. Have a look at this paper that examines electoral bias up to 1997. The following graph shows the bias in the system for the various political parties in terms of the number of votes per seat. Clearly in 1997 Labour had a distinct advantage, but in 1983 and 1987 the Conservatives had an advantage, In short, there is always some advantage in the system for one party or another, but you would not realise this if you listen to the rabid Tories who claim that Labour always has the advantage.

The Boundaries Commission for England is independent and has the responsibility to make constituencies equal. The problem is that this is a very lengthy process. For a start, people expect there to be some correlation between their Westminster constituency and their District of County council wards, so the Commission has to take this into account. To try and prevent gerrymandering the Commission performs extensive public consultation. Cameron's claim that he will make the constituencies "fair" by making them the same size is a nonsense claim, because this is what the Boundary Commission does anyway.

At the last election the Boundary Commission created 4 new seats. They also redrew the boundaries of the other 646 seats to make them more equal. You can download their results from here. The interesting figures are:

Total Registered voters 38,129,082
Average per seat (Electoral Quota) 71,537
Larges (Isle of Wight) 110,228
Smallest (Wirrel West) 55,152
Standard Deviation 5,884

The standard deviation gives the spread of values and it is usually regarded that 95% of values will be +/- two standard deviations from the mean. In this case it means that 95% of all constituencies will be between 60,000 and 83,000. It is interetsing that the smallest is 33% less than the mean, but the largest is 54% more than the mean. In fact Isle of Wight is an anomaly, but it does skew the results.

The skill of the Boundary Commission will be to create constituencies where the standard deviation is as low as possible. However, as I have mentioned above, this "rebalancing" will be out of date before the following election because people move and people are born (or die).


The standard deviation of the constituencies at the 2010 election was 8% of the mean, two standard deviations (96% of the seats) is 16%. In Nick Cleggs announcement in Parliament he said that the Boundary Commission should ensure that all the seats should be within 5% of the mean. I would be interested to see if this is actually possible, to get the standard deviation down to 2.5% of the mean. My gut feeling is that it will not be possible before the 2015 election and such a tight tolerance will mean that the constituencies out of date requiring a new "rebal;ancing" within a few years.

OBR

I urge everyone to follow @OtherTPA on Twitter. You know it makes sense, if only because of the following tweet:

Following @psbook's report, OBR gets a rebrand