Slippage

In August Ali Parsa went on a PR campaign to try and get the media to think that Hinchingbrooke and Circle were doing well. He succeeded, the compliant media reported what Parsa said rather than report what was actually happening (Hinchingbrooke was behind plan financially and Circle had to beg for extra capital from its shareholders telling them it was insolvent).

In an interview with the Today programme Parsa was asked about the finances at the trust (4:30):

Justin Webb: and you're still on course? my interest is when you expect to begin to be able to take some profit from your activities at Hinchingbrooke?
Ali Parsa: we are still on course, we think the hospital should balance its books next year, it should finish this year on a balanced book, that is what we are working on

Parsa is saying that by next April the trust will have a "balanced book". Webb, unfortunately, didn't have the then recent July finance report which said that the trust was doing badly financially, and so didn't challenge Parsa on this point. (It's not Webb's fault: the quality of research in the health section of the BBC news department is extremely poor, as we have seen during the passage of the Health and Social Care Act. BBC health journalists have little knowledge of the NHS or what is happening to it.)

On Thursday Hinchingbrooke gave its finance report for quarter 2 and their finances are no better than before. HSJ report that a spokeswoman for Circle said:

"We’re confident that we're now on track to reach a sustainable break-even position by the end of the next financial year."

That's the next financial year, Parsa said that the "balanced book" would be achieved this year. So Circle are now saying that their plan has slipped by a year.

Filed under "Interesting"

I'm working through the various documents that FTs have submitted to Monitor and I came across the following in the Forward Plan (next year's plan) for Cambridge University Hospitals Foundation Trust.

In the section "Goals and milestones to deliver vision" and under "Financial strategy and goals for the the three years" it says:

Developing a mutually beneficial relationship with Circle Health, with CUH providing and/or supporting a number of services either on the Hinchingbrooke site or CUH campus.

and later on under "Strategic Position"

Hinchingbrooke Hospital The Trust is committed to seeing a sustainable future for Hinchingbrooke as part of the regional family of healthcare organisations and to this end we will develop a mutually beneficial relationship with Circle Health, with CUH providing and/or supporting a number of services either on the Hinchingbrooke site or CUH campus.

CUH runs Addenbrooke's which is local to Hinchingbrooke and, depending on your point of view, is either a partner in delivering healthcare to the local community, or a competitor.

The phrasing of the statement is important. First the "beneficial relationship" is with Circle, not with Hinchingbrooke Healthcare NHS Trust. The hospital is owned by the trust, not Circle. Circle are merely management consultants brought in to run the hospital for the next 10 years. Any relationship should be with the trust. Instead CUH has decided to have a relationship with Circle.

The second point is the statement "providing and/or supporting a number of services" does not name the services and doesn't even indicate the site for the "services" (it says, either your place or mine). That shows that the services are unimportant. It is the "beneficial relationship" that is important. Since Circle Holdings is bankrupt, it is difficult to see what could be beneficial to CUH in a relationship with Circle.

Finally, the Health and Social Care Act says that Monitor has to act to prevent "anti-competitive behaviour". Two neighbouring trusts striking up a "beneficial relationship" does not sound competitive. Monitor have had three months to look at this plan and as yet have not complained. remember this if/when Monitor comes down heavy on your local trust for being "anti-competitive" and ask why CUH and Circle are allowed to have a cosy relationship and your trust isn't.

AQP Nonsense

As part of the government's NHS privatisation plans they have produced a policy called Any Qualified Provider. They "sold" this to the electorate by saying it is "patient choice" it isn't, it is commissioner choice. And what's worse, the government are forcing it upon commissioners by telling them they have to provide at least three community services via AQP.

This is having stupid effects. The Forward Plan for Berkshire Healthcare FT (BHFT, a provider of community health services) says this:

"NHS Berkshire is extending patient choice during 2012 by offering some audiology services and podiatry services through the Any Qualified Provider initiative. Audiology services will be offered from September 2012, and podiatry services in the autumn 2012. BHFT is mitigating the potential loss of business by focussing on enhancing service quality, and patient outcomes and satisfaction levels. The Trust will also apply for AQP status to offer services in new geographical areas where the Trust can offer high quality accessible services with minimal risk."

So BHFT fear that they will lose the income for audiology and podiatry because NHS Berkshire (the commissioners) will use another provider via AQP. Like many NHS organisations they cannot afford to lose this income so they intend to register as an AQP themselves are supply these services elsewhere!

What a load of bollocks this policy is.

Leader's Speech

In spite of a slight wobble on Saturday (which was more due to a misunderstanding than anything else), the overarching theme of the Labour conference is that the next Labour government will stop the marketisation of the NHS that the Coalition government is introducing.

This is an apt time because the government have just announced the third phase of Any Qualified Provider (AQP): 398 services will be opened up to private providers. It is now that private companies will be making the decisions whether to seek the investment so that they can become an AQP provider.

Incidentally AQP has nothing to do with patient choice as was touted at the last election. It is commissioners’ choice. CCGs will be allowed to commission any provider, and in some cases will have to use private providers since the government regards a choice for the NHS to be an invalid choice. The investment providers ill make is not insignificant. Yes, there are some that are relatively low risk investments (for example audiology, where there are already providers in the private sector, who will presumably seek to expand their business by providing NHS services). But other services, for example MRI and CT diagnostics, there are significant investments needed.

Ed Milliband’s conference speech said that the next Labour government will repeal the Health and Social Care Act, and significantly, it would stop the marketisation of NHS service: the NHS ill be the preferred provider. Private companies invest to make a profit and profit depends on gaining business. In the environment of flat funding it is even more difficult for a private provider to make a profit. To make a return on their investment they will need a sustained profit over a long period of time, and that includes the time after the next election. Ed Milliband said that when a Labour government is elected that profit is not guaranteed. It is possible that Ed’s statement could curtail the number of companies willing to become an AQP and could limited the policy.

Citizen Coders

This article is interesting:

Speaking to Government Computing, [Tim] Kelsey [Director of information at NHS Commissioning Board] said: "We want to help people to innovate and make best use of the data that is running through the veins of the health service, taking a leaf out of the very accessible and brilliant campaign launched by Code for America."

As a software developer and someone who has spent 20 years writing books, magazine articles and training courses (and spoken at conferences and given hands-on courses) on how to programme, I have some interest in this area. I am a C++/C# programmer and before the .NET framework was released I developed Windows applications using the Windows SDK (which is a library that gives you access to just about every feature of Windows). At conferences there would always be a discussion, either officially (as a panel discussion as part of the conference), or unofficially (in the conference hotel bars), of which was better: VB (Visual Basic) or C++. Clearly C++ is better, but I was always willing to take part in a good natured discussion with VB developers to prove them wrong.

There was always one point that I would concede: VB3 was the reason why Windows 3.1 became popular. VB3 was a drag and drop environment where basic components of a program (visual controls like buttons and list boxes, or functional collections of code like timers or database access) were packaged as visual objects that you could drag from the toolbox of controls and drop on the window (or Form) that you were developing. You then wrote a small amount of code to connect the objects together: handle the user clicking on the button to read data from the database and put it in the list box. In C++ I would have tens or hundreds times more code to write to do the same thing because the Windows SDK gives fine grain access to functionality. This makes SDK development very flexible, but you had to write a lot of code.

When VB3 was released it became very easy to write software for Windows, and almost overnight huge numbers of applications appeared as shareware or freeware. Business were also keen to use VB since it was easy to teach developers and it took much less time to develop a VB application than a C++ application. At that time (93/94) I taught both VB3 and C++ courses. The VB3 courses were three days to learn both the language and the objects that you could use. The C++ courses were two five day courses: one course to learn the language and the other to learn the library (Windows SDK or a C++ library called MFC). The cost per day was also cheaper: the company I worked for charged two thirds the C++ daily rate for me to teach a VB3 course. Consequently, for every C++ course I taught I taught five VB3 courses.

VB3 meant that there was a huge number of applications and this meant that somewhere, if you could find it, was one that did exactly what you wanted. The problem was that, as a hobbyist language, the quality of most applications was poor. They were bug ridden and the user interfaces were not designed with (dare I say it) any taste. Since it was so easy to make a form background shocking pink and all the text italic putrescent green, people did.

VB3 applications only ran on Windows so people bought Windows computers and, for the fairly reasonable cost of the VB development environment, they could be creating applications within days. Or, if they did not want to develop code themselves, people could find somewhere on bulletin boards or in the classified ads of computer magazines, a VB3 application that would do what they wanted. The popularity of Windows 3.1 came from VB3.

Tim Kelsey's idea is similar, he plans "to launch a 'mass training programme' in basic data coding across health and social care with the aim of creating thousands of applications to open access to NHS data". He does not say what language or framework will be used, nor how the "mass training programme" would be carried out (hint: I can recommend an excellent developer to author and delivery the training). However, I am somewhat cautious. Developing useful apps comes in two parts: having the idea and developing the code. As a developer I am skilled at the latter. The thousands of "doctor, manager or patients" that Kelsey identifies, are skilled at the former.

I am always in favour of training people new skills (hint: and looking for a job right now!) but it has to be done in an economic way. If a surgeon had an idea of a robotic surgical instrument would he go back to university and take an electronics degree so that he could design the device himself? No, the surgeon would find someone who could design the device and explain the idea to the engineer. The important point is to get the new, innovative ideas to the people who have the skills to implement them. The implication that you can teach anyone to programme an innovative idea is also rather demeaning to skilled developers: it implies that there is no skill in development. However, as with VB3 applications, it will fairly rapidly become apparent that there is a lot of skill in developing and this will show in the quality of the applications created. I suspect that the idea to train thousands of people in "basic programming" will result in thousands of very basic, buggy applications and the challenge would be to trawl through them all to find the one that does something innovative and is reliable.

A more powerful idea would be to get the ideas people to connect with the coding people. Create a virtual "dating agency", a website where a "doctor, manager or patients" can post their ideas and developers can take up those ideas and produce a working application. I would go one step further. I think such a website should also include a toolkit that developers would have to use. Such a toolkit would ensure that all the applications had the same look and feel and would be compliant with standards of reliability and accessibility. This would ensure that all patients (regardless of their disability or their mother tongue) could use any application created with the toolkit.

And just in case I've been too subtle: I am available at reasonable rates to help design such a programme.

Rat-arsed

Joe Farrington-Douglas tweeted last week an article on Lib Dem Voice posted at the time that Norman Lamb  took over the Lib Dem health brief. Lamb wrote a paper about his thoughts and followed up with interviews with newspapers. In particular Lamb said:

"If you get rat-arsed on a Friday night and get taken to A&E where you are foul and abusive to staff, is it right for the taxpayers to fund your life-saving treatment?"

The implication being that it isn't and we shouldn't and hence there should be a charge for A&E in these circumstances. The Guardian said:

He called for wide public debate on whether the community should pay for the excesses of the individual. There was a strong case for charging drunks for stomach pumps or treatment of injuries, and pubs and clubs should also be made to contribute if their complicity could be proven.

This is not only wrong, but it is very unliberal. Lamb was suggesting that we create a concept of deserving patient and undeserving patient. Under Lamb's plan the undeserving patient has to pay for their treatment. Where does it stop? Do we charge smokers for their treatment? Do we charge drunk drivers for the injuries they receive, or the injuries they cause?

What happens if someone is foul and abusive but sober? Is Lamb concerned with people's behaviour, or their condition? If a person does something illegal (they are foul and abusive to A&E staff) then the legal system can be used: they will be punished for their behaviour. But what if they are drunk but polite, do those drunks get a discount, or get the treatment free? Who decides what is foul or abusive, will there be national standards or will some areas be allowed to be more sensitive? What if the patient has mental health issues which is the cause of the abusive behaviour and is unrelated to the alcohol they consumed?

The whole idea was poorly thought out.

It didn't matter that this policy was unworkable because Lamb wanted to get a different message out to the public. The message came straight out of the Lib Dem's Orange Book. Lamb wants to deliberately break the cherished free-at-the-point-of-delivery principle of the NHS. Once you start charging for treatment, regardless of the reason, that principle has been broken and charges will spread throughout the NHS. Imposing charges will encourage the development of an insurance market. Insurance companies will produce products so that you pay a small premium every month (say, for the cost of 5 pints) and the insurance company will pay your A&E bill if you get injured when rat-arsed. Of course, this may backfire. Just as some people are rather "clumsy" with a paint pot "accidentally" knocking it over the carpet that they want replaced, or like some people foolishly put all their valuable electronic items in one bag which they lose "by accident" so that they are replaced with the latest models. Just as there are always people who will abuse insurance, there will be people whose behaviour will be worse if they have "A&E drunk coverage" because they know that whatever they do, whatever injuries they get, they will be covered. Indeed, since they have paid for the insurance they may well want to get their money's worth.

Such ill-thought-out policies are fine for a spokesperson for a party that will never be elected, but these were the policies of Norman Lamb, who was just appointed Minister of State in the Department of Health. It is a cause for concern for health policies in the future.

Independent

What is the point of being "independent" on a committee? Surely it is so that you can use your abilities, expertise and knowledge to form your opinions, rather than to simply parrot the opinions of the people who have appointed you?

The Future Forum is described as "independent". It isn't. It is appointed. Nick Timmins "Never Again" says

[Prof Steve Field said that Sir David] Nicholson told him "that the chancellor, the prime minister and the deputy prime minister had met and decided that because of the reaction in Sheffield and the noise in the system, they wanted to get a better understanding of what the problems were. He told me my name had been discussed about potentially chairing this Future Forum and that they were going to make a decision, but if I was asked by the minister would I do it?" He [Prof Field] said yes and was told to expect a call from Number 10, while the department worked hard on assembling names for four working groups

The Department of Health "worked hard on assembling the names" of the four working groups of the Future Forum meaning that they appointed the forum. Timmins goes on:

Finally on a train back to his home in Birmingham a call came through from Simon Burns, on behalf of Cameron and Lansley, formally asking him [Field] to chair the new Forum.

Hence Field was asked by Burns on behalf of Cameron and Lansley to be the Chair of the Future Forum.

The Future Forum (FF) is a committee appointed by the Department of Health. Even if the FF was not told what to think (and I have doubts about that) it is clear that the composition of the forum is important and if the department chose people that agree with the thinking behind the bill they would provide a report that agreed with that thinking. It is a classic move that could have been a plot line of Yes Minister: need an "independent" report that agrees with you? so appoint a committee of people who agree with you to write it and tell them they are "independent". The FF report only made cosmetic changes to the Bill.

Now we are told that Prof Field has been appointed to the National Commissioning Board as Deputy National Medical Director. But he is still the Chair of the "independent" Future Forum. How can the FF be independent when the Chair is Deputy National Medical Director?

What about NICE (the National Institute for Health and Clinical Excellence)? Its website says:

We provide independent, authoritative and evidence-based guidance on the most effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation.

NICE evaluates drugs and treatments, it uses evidence from peer reviewed papers to determine how effective the drug or treatment is. It is vital to the finances of the NHS that the service uses only those drugs that have been shown to be effective. The problem is that drug companies hate NICE. They hate NICE because the drug companies spend large amounts of money to create public demand for ineffective drugs which are then rejected by NICE.

It is vital that the experts who make the decisions on behalf of NICE are independent, they have a very difficult and important job to do. But now that independence is under threat, the following article is from Pulse:

Pulse has learnt that the Department of Health is set to table secondary legislation under the Health and Social Care Act so that the health secretary will personally approve all appointments to the panel of experts that consider appeals from drugs companies against NICE appraisals of drugs. The chair of the appraisal appeal panel will also have to be 'someone from outside NICE'.

Apparently, the Association of the British Pharmaceutical Industry wrote to Lansley and told him "Policy is made a long way from political accountability and the NICE Executive appears to have no remit or desire to challenge the decisions of independent academics." They were complaining that decisions were being made by independent academics! In the future the appeal panel members will have to be approved by the Secretary of State for Health (the completely, and totally incorruptible Jeremy Hunt someone who would never be influenced by large multinational companies).

If the 18th Century British politicians were anything like the current government it is no wonder that they fought a revolution to gain their independence.