"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Thursday, 28 January 2010

Conservatives NHS Autonomy and Accountability Proposals

It is clear that if the Conservatives gain power they will make changes to the structure of the NHS. The Conservative 2010 "Draft Manifesto" on health gives some clues, as does their policy paper called the Health Improvement Plan. In this blog post I will gave another source of information about what the Conservatives plan for our NHS. In 2009 the Conservative party published the NHS Autonomy and Accountability white paper which is essentially the first draft of the first NHS bill that a Cameron government would present before Parliament. Team Cameron regards the NHS as a moving target, they focus group regularly and use this to make reassuring noises to the Press. However, underlying their public pronouncements are the real Conservative policies for the NHS: a vast expansion of the private sector, financed by the "ring fenced" NHS budget. In this blog post I will provide more evidence of this privatisation plan.

We know that the Conservatives have a dislike for NHS providers. We know this because the "Draft Manifesto" avoids pledging any commitment to existing NHS providers while at the same time it is enthusiastic about the "new providers" that will be created. In a time of austerity (and probably economic depression caused by Conservative mismanagement of the economy) what business will want to start up in Britain? Well, if the business is guaranteed contracts from the NHS, and backed by substantial amounts of public money from the "ring-fenced" NHS budget, any business will be able to secure capital funding from the money market. This guarantee of business for such private providers is given in the Conservative white paper:

3.1 Patient choice needs to be supported by a powerful system which offers rewards to the best providers. We believe that the best way this can be achieved is by allowing money to follow the patient to the provider of their choice.

This statement does not say NHS provider of their choice, as is the case at present. This means that NHS money will go to the private sector, with the corollary that NHS providers will not get this funding. This sentiment is reiterated later in the document:

5.5 Alongside NHS Foundation Trusts, which are public benefit corporations, we will enable any willing provider, who is able to meet NHS standards within NHS tariffs, to offer services to NHS commissioners.

I should make it clear here. The NHS is already under budgetary constraints and Cameron's "ring-fence" will not change this. The NHS is efficient, but it does rely on a regular income. If some of the budget is diverted to the private sector, it could have a catastrophic effect on existing NHS providers. Cameron knows this, yet he continues with his plan to allow NHS budgets to be spent on private care (note that these are not only existing private providers, but are new providers, that is Cameron expects the private sector to increase). The only conclusion that can be drawn is that Cameron wants NHS providers to fail and wants top see a shrinking of the public providers. His rationale is given in the following statement:

4.1 Allowing money to follow the patient to the provider of their choice – as under payment by results – will help to drive improvements in the responsiveness of services to patients.

The Conservatives are obsessed with the idea that by taking money away from a service you will improve it. It is very clear that if you take money away from a service the service will fail. The service users, if they are lucky, will have to obtain the service from elsewhere. The problem is this attitude of "if the hospital has problems close it down" is a very blunt tool, especially when there are better, more efficient and less costly ways to improve NHS services.

We know that information about hospitals is already published. There is the NHS Choices website for patients' reviews, and the CQC website for official healthcare quality reviews. In addition, there is also third party analysis available from Dr Foster Intelligence. So patients already have information about the NHS provider that they will use. However, the Conservatives want more, they even want hospitals to advertise how good they are:

2.31 Though simply allowing patients to choose where they are treated will drive improvements in the information provided to them – for example, hospitals will unilaterally seek to highlight to prospective patients why they should be chosen over other hospitals – we recognise that this process may not go far enough, fast enough.

This clearly says that under the Conservatives' plan that providers will advertise highlight the reasons why patients should choose them. Imagine how this will develop. Hospitals will have to create marketing departments (and a marketing budget – money that should go into healthcare). Our newspapers will have adverts from all the hospitals in your area, and local TV and radio will have adverts from the larger hospitals. This really is the creation of a market in healthcare.

So what sort of services will David Cameron's NHS deliver?

4.32 Alternative contractors, if they are able to demonstrate to the PCT that they can provide the necessary combination of primary medical services and commissioning skills to deliver the highest standards of care for NHS patients.

That's right, Cameron intends to allow NHS money to finance so-called "alternative medicine". I should now point you towards what Tim Minchin says about alternative medicine:

"Do you know what they call 'alternative medicine' that's been proven to work? Medicine."

Please, Dave, give us medicine, not unproven, placebo quackery.

Further, where will patients have these treatments? The first indication is given in this statement:

3.10 We support the return of powerful, clinician-led commissioning in primary care – like that engendered by GP fundholding in the 1990s.

Studies of the disastrous scheme of GP fundholding in the 90s have shown that GPs who have fundholding are less likely to refer patients to specialists (note that word: specialists, the people who best know how to treat you) than those GPs without fundholding. It is concerning that the Conservatives want to return to a system that was designed to prevent patients from being treated by specialists. Specialists are hospital-based, so this again shows the lack of commitment the Conservatives have to NHS hospitals.

But the Conservatives go further:

4.35 Patients will be entitled to exercise choice in elective care, in community provision where possible, and in respect of treatment options where appropriate – provided that the options are cost- and clinically- effective.

This, yet again, indicates that the Conservatives do not want patients to be treated in NHS hospitals. Expect that under a Cameron government your local NHS hospital will close.

So what do the Conservatives have planned for existing NHS providers: your local hospital?

5.13 However, such partnerships will be strengthened if NHS Foundation Trusts can offer their own assets as security on loans, together with sound long-term business plans based on the stable framework of regulation outlined above.

This is very concerning. NHS hospitals will be expected to pawn their property to obtain capital funding. Can you imagine what will happen when a hospital, forced by falling income due to Cameron's any willing provider policy, defaults on its bank repayments? Yup, the bank repossesses the hospital. A frightening prospect. The sentiment is given elsewhere in the white paper:

5.4 To maximise the freedoms of NHS Foundation Trusts, we will lift the restrictions on borrowing secured against their assets and remove the prohibitions in the NHS Act which restrict their capacity to secure private income.

This gives another worrying policy: the Conservatives say that NHS hospitals should take private patients. This can only mean that there will be a two tier system, otherwise why would private patients pay extra, if they are not getting something extra for their money? NHS investment should be solely for NHS care, private patients should not benefit from public money.

The future of the NHS is very bleak under David Cameron. The Conservative white paper reads as a recipe for privatisation: NHS hospitals will have to advertise their services, they will only get funding by pawning their assets, they will provide private care which heralds a two-tier system. If you value the NHS, the quality and equality of its services, then the answer is clear: vote for a Labour government.

Monday, 25 January 2010

Conservative Green Paper on Health Outcomes: Part 3

The Conservatives policy is to replace "targets" with "outcomes", their Policy Green Paper No 6 explains the rationale behind this policy. This is the final part of my analysis.


Sadly, no article including the words Conservative and NHS can avoid the word privatisation. Let's start with what appears to be the default phrase from David Cameron's Conservatives:

"[Our strategy involves] giving patients a choice of provider so they can use published outcome information to get the care they want"

Patients already have a choice of which NHS provider they will use. The difference with the Conservatives is that they want patients to use private providers. This is obvious from the fact that throughout the green paper the Conservatives fail to give a commitment to existing NHS providers, but they enthuse about "new providers". I have written elsewhere that the Conservatives intend to force privatisation upon the NHS by excluding NHS providers from the new contracts for healthcare provision. The "choice of provider" that the Conservatives will give will be any provider except for an NHS provider.

"introducing payment-by-results within the system, to reward those doctors and hospitals that achieve good results and to incentivise improvement amongst those whose standards are falling behind."

Don't you just hate that horrible American word incentivise? It just goes to show where the Conservative thinking comes from.

The payments by results system already exists, it is the name of the scheme that pays hospitals for each procedure that they perform. The Conservative policy writers should know this, and using this name for their policy either means that their policy writers do not know how the NHS currently pays hospitals or it is a deliberate attempt to mislead. The current system is to pay an NHS provider for each procedure they perform. Each procedure costs money and the NHS provider needs to cover that cost, so the Primary Care Trust of the patient pays the provider for the service. The Conservative policy is radically different because the provider will be paid only if the procedure is deemed to have a successful outcome. This has a myriad of problems, not least because medicine is complicated and a patient could have health problems unrelated to the condition being treated which could affect the outcome.

The results of the Conservative payment policy will be to promote the private sector. Any healthcare provider will not want to perform a procedure where they are not guaranteed payment. There are some procedures which have very high success rates and private providers will target this market, taking funding away from NHS providers. David Cameron will skew the market to make private suppliers more likely to be used through the politically appointed (but unaccountable) super-quango, the NHS Board who will determine commissioning policy (ie, which providers are allowed to deliver the care). The NHS Board will be mandated to increase the amount of work performed by private providers, but paid out of NHS funds. The result is that NHS providers will find that the more successful (and potentially profitable) procedures will be performed only by private providers under a Cameron government.

Private providers will not perform procedures that will not have a guaranteed successful outcome. NHS providers, already underfunded because of the removal of services to the private sector, will be left with the complicated procedures where success is not guaranteed. David Cameron's diktat about payment depending on the outcome will mean that NHS providers left with the more complicated procedures will find that their funding will be cut even more. The ultimate aim will be for NHS providers to run out of money altogether, and consequently NHS hospitals will close. The more complicated procedures will then be only available via private providers for payment with cash.

It is worth pointing out that one underlying theme of this document is the phrase "already used by healthcare organisations like BUPA". It is always a good idea to learn how other organisations perform their work, and it is important to learn from them. But the underlying theme in this green paper is that according to the Conservative policy writers private healthcare providers are the gold standard for healthcare in this country. There are two points to make: first, they are not the gold standard, and second, if a Conservative government will base payments according to the way that private healthcare providers work, doesn't this mean that they will have an unfair advantage in the "health market" that the Conservatives plan?

It is almost as if the Conservatives are saying that the current private healthcare providers are their favourites and that NHS providers have to be more like the private providers or cease to exist. Certainly there is no explicit commitment to NHS providers in the document, but there are plenty of places where the private providers receive an enthusiastic endorsement.

Conservative Green Paper on Health Outcomes: Part 2

The Conservatives policy is to replace "targets" with "outcomes", their Policy Green Paper No 6 explains the rationale behind this policy.

Measurements and Publishing Results

The Conservatives obsession with outcomes is manifest in two ways. First, payments will be based on outcomes. As I mentioned earlier someone has to evaluate the outcome and determine from this how much the hospital will be paid. Second, outcomes have to be collated and then published, and these league tables of outcomes, in and of themselves, will magically improve the hospital.

So what data will be published? Hopefully, the information will be aggregated data and not specific information about an individual's treatment. The policy document says:

"We start from the position that all data should be published unless it can be shown why this will cause harm."

On the surface there is nothing wrong with this policy. But as anyone who has ever tried to make head-nor-tail of a spreadsheet will tell you: if you have too much data you cannot see the overall picture. It is a case of not being able to see the wood for the trees. By all means publish all the data, but experts should also provide an analysis of the data to provide an overall assessment from that data. The problem with this approach is that raw data is rarely instructive and people can make bad choices by not being able to interpret what the data means. Further, some people may appoint themselves 'experts' and interpret the data in a way that fits in with their political views. Such data is best collated, interpreted and published by an independent organisation, like the Office for National Statistics. The Conservatives give no clue about how they think outcomes will be published.

Another comment must be made. Collecting all this data is not simple. It involves administrative staff. The Conservative draft manifesto on health says that they will cut NHS administrative costs (ie staff) by a third. The Conservatives charge that targets require huge numbers of bureaucrats to gather metrics, so will the collation of outcomes be any different? It is unlikely that hospitals will be able to provide all the data the Conservatives say Hospitals will provide if the Conservatives make the administrative cuts that they promise. Indeed, the Conservatives admit this:

"Providers already have capability for the collection, collation and publication of outcome measures. Any transitional costs in areas such as IT and staff training will be minimal, if apparent at all,"

The Conservatives are suggesting that they will not cut the numbers of administrators to gather metrics, so where will their cut of a third come from? Further, this is saying that there will be no cost for NHS providers to change from collection, collation and publication metrics for targets to collection, collation and publication of outcome measures. While it is reassuring that there will be no money spent on the transition, doesn't it make you wonder if the reason why there will be no additional costs is because the NHS administrators will actually be doing exactly the same thing?

The interesting thing is that the same part of the green paper suggests that by scrapping targets the NHS can save money, but the statement above suggests that the same personnel and equipment will be used to collate data for the outcomes. If the savings are not from the actual process of collecting metrics for targets, where will the savings come from? The only conclusion is that the Conservatives expect that simply the change from measuring for targets to measuring outcomes will instantly make the NHS more efficient. This is an unsubstantiated claim.

The same section in the Conservative policy document suggests that targets cause "clinical distortions resulting from activities aimed purely at meeting government targets". Distortions are, of course, changes, so when is a change an improvement, and when is it a distortion? More significantly, the Conservatives make no mention as to how they will prevent the measurement of "outcomes" causing "distortions". (As I have mentioned in a previous blog, since payment will be based on outcomes, there will be a lot of pressure for clinicians to make sure that the outcome that is reported – not necessarily the actual outcome – is as successful as possible. I am not suggesting falsification here, merely that there will be a subconscious suggestion to be optimistic.)

The problem with the policy of publishing data is that the Conservatives do not say how it will improve standards, and they do not say what will happen if a provider has poor outcomes. The only explanation to how a outcomes will improve providers, is that when patients stops using a provider it will improve:

"We believe these results, … should be made publicly available to help patients … choose the right care provider."

It should go without saying that there is no healthcare market, and that a market cannot be created because the size of the investment required centralises treatment in a few providers (principally NHS providers). While patients do have choice, most patients choose a provider that is local to them, above other criteria. Consequently, improvements in healthcare are unlikely to occur due to patients' right to choose.

Outcomes will also, apparently, be the responsibility of the patient:

"developing outcome measures which patients with chronic conditions themselves provide, reflecting their needs and what matters most to them;"

This statement is unclear. We already know that the Conservatives will only pay NHS providers according to outcomes, yet in this statement they say that patients will suggest what the outcomes will be, and consequently, patients will have the power to determine whether providers are paid at all. This is worrying, not least because providers will become reluctant to treat patients if they will not have a guarantee of payment for that treatment, and hence providers are likely to be more reluctant to treat patients who have chronic conditions.

The Conservatives explain further how they will help patients with chronic conditions:

"We would consider using EQ5D – a 2-page patient questionnaire, developed and by EuroQoL. EQ5D been used in population studies over the past decade. The patient conducts a self-assessment that covers five dimensions: mobility; selfcare; usual activities; pain/discomfort and anxiety/depression."

Does this sound like something that most people with chronic conditions will want to participate in? Someone with a long term heart condition will have different needs and priorities than someone with diabetes. Indeed, someone with type 2 diabetes will often have different needs and priorities than someone with type 1 diabetes. Yet the Conservatives are offering a one-size-fits-all questionnaire for all patients with chronic conditions. What is the incentive for the patient to fill in this form? Will treatment be refused if the questionnaire is not returned? Indeed, if there are few patients willing to complete the questionnaire, will this result in an unrepresentative outcome being used?

It is clear that the Conservatives intend to keep a target culture in the NHS except that they will rename targets to outcomes. The Conservatives will maintain the same numbers of administrators to collate outcomes as are being used to collate target data, yet the Conservatives claim that they will cut administration in the NHS by a third. The Conservatives will publish raw outcomes data and hope that patients choosing alternative providers will improve a provider with poor outcomes, something that is unlikely to happen.

Friday, 22 January 2010

Conservative Green Paper on Health Outcomes: Part 1

The Conservatives policy is to replace "targets" with "outcomes", their Policy Green Paper No 6 explains the rationale behind this policy. This is the first of three blog posts about this policy paper.

Targets and Outcomes

The Conservatives are on potentially shaky ground here. They know that metrics are important since how can you improve quality if you do not make measurements, and pledge to improve performance? It was the Conservatives who introduced SATs tests and school league tables; SATs, of course, define a level of achievement that every child should obtain, and this is a target. Targets are ingrained in Conservative thinking (some people may wryly remark that is why Tony Blair was so keen on them). The problem is that some targets have got a bad press and Cameron's focus groups have flagged up targets as a potential subject for them to use to attack Labour. The Conservatives have attacked targets with gusto, claiming that they are politically driven.

But if the Conservatives remove targets how can they monitor quality in the NHS and how can they ensure year-on-year improvements? The answer is simple, you just need to rename targets and tell people that they are something new: outcomes. Simples!

Green Paper No 6 (physically more blue than green) starts by saying:

"[Our strategy involves] phasing out Labour's process-driven targets"

This is a hollow statement, as we will see later the Conservatives simply want to provide their own targets. The Conservatives repeatedly complain about process targets and then promote outcomes as if the two are not related. The so-called process targets like the 18 week referral to treatment target have proven to drastically cut waiting lists, and given real benefits to patients. The Conservatives have no tangible answer to improving waiting lists, instead they say that:

"waiting times and other measures of service and patient satisfaction will still be collected, but instead of servicing government bureaucracy and paperwork, they will be made publicly available to patients, so the incentive for achieving low waiting times will be stronger"

The language is suggestive, you are made to think that the metrics for targets have nothing to do with patients, they are merely for the pleasure of bureaucrats and paper pushers. To someone waiting for an operation the guarantee that the waiting list will be no more than 18 weeks is far more important to them than simply "servicing government bureaucracy and paperwork".

The implication in the previous quote is that under the Conservatives waiting lists will be allowed to grow unabated. The only mechanism for waiting lists to fall is for patients to use a different provider. The Conservatives are returning to the idea of league tables. If Hospital A has waiting times longer than Hospital B how will the Conservative policy improve the waiting times of Hospital A? All that will happen is that Hospital A will come beneath Hospital B in the waiting list league table and those patients that can travel to the better provider, Hospital B, will use it instead. Patients who cannot travel will still be subject to the waiting lists of Hospital A.

This is a nonsense policy. For a start, you have a choice of provider already, but most people want to go to their local hospital: they want their local hospital to be high quality; they do not want to shop around. But this is what Cameron is promising us: GoCompare or SearchTheMarkets for hospitals. Guess who had a career in marketing?

In one place in the document the Conservative policy writers even give an example saying that if a hospital under performs:

"Patients and professionals move away from lower quality provision, incentivising low performers to improve and take on best practice"

(Ugh, there is that horrible American word, used frequently in US business circles, incentivising. This clearly shows the pedigree of these policies. Please Mr Cameron change it to to provide an incentive for.)

The problem with this statement is that it does not address the issue. If there is a quality issue with a provider then the cause could be the ability of the staff, or the level of funding, and there is no indication in this statement how achieving poor results could change the situation. Their only explanation appears to be:

"With process targets abolished and patients exercising greater choice based on information about results, a whole new culture will emerge within the NHS."

So they expect that there will be a new "culture"? We will see a bit more about culture in a moment.

The Conservatives say that they will make providers measure outcomes and not targets. So what is an outcome?

"The technical definition of an "NHS outcome" is the recorded result from the care that a patient, or a group of patients, experiences, for example long term survival rates from cancer."

So there are no expected values for the "long term survival rates from cancer"? If not then how will patients be able to interpret the values for their provider? Of course there will be some expected values, but if there are expected values, aren't these targets?

So what are these, outcomes that the Conservatives wish to be achieved?

"Five-year survival rates for cancer in excess of EU averages by 2015
Premature mortality from stroke and heart disease below EU averages by 2015
Premature mortality from lung disease below EU averages by 2020
Year-on-year improvement in patient-reported outcomes for patients living with long-term conditions
Year-on-year improvement in patients' satisfaction with their access to, and experiences of, healthcare
Mortality amenable to healthcare brought down to the level of comparable countries
Year-on-year reduction in the number of adverse events"

All of these are laudable, but can you, hand-on-heart, say that these are not targets? Of course they are! Not only are they targets, but there is a milestone for most of them, either a date that the target has to be achieved, or there is the demand that there are year-on-year improvements.

Some of these statements say that the Conservatives want us to compare our outcomes with those in other countries. Again, this already happens, but let us see what the policy document says about this:

"publishing those results, so we can see where we are making progress relative to other countries and where we lag behind, and can ensure continuing improvement in results;"

This is Orwellian double-speak: so the Conservative intend for the NHS to measure the outcomes of treatments in the NHS and then they will compare the results with other countries? What is the point of the comparison? Well, it is to see if those outcomes in the NHS are as good as or better than in other countries. So doesn't that mean that we have an aim to produce outcomes similar to other countries? That's a target, isn't it? I think by now you should be convinced that a Labour target is a Conservative outcome.

So who will measure the outcomes?

"The quality of outcome measures – and therefore of the decisions about future treatments and resource allocation taken on the basis of those measures – are dependent on the accuracy of the data provided by clinicians. The best person to report on a treatment episode is the clinician responsible for the care."

The new payment system that the Conservatives plan to introduce (I will call it payment for outcomes so that it is not confused with the current payment system used in the NHS: payment by results) will not pay a provider for the actual work done, but only for the outcome of the work. The Conservatives say that the best person to measure this outcome is the "clinician responsible for the care" so isn't there an incentive for this clinician to say that the procedure was successful? A less than successful outcome means not only less payment for the provider, but it also means more treatment for the patient to remedy the treatment that was not successful. There is even a possibility that patients could receive less treatment than they need due to optimistic measurement of outcomes. This is the culture that was mentioned above and it is a culture that we do not need.

However, David Cameron (in a speech to mark the sixtieth anniversary of the NHS at Trafford General Hospital, on the 2 January 2008) said that this is the culture that he wants:

"It should be a basic rule of social policy that you don't pay for what you don't want more of. Money should attend success, not failure. So, for instance, I don't think hospitals should be paid – or paid in full – for a treatment which leaves the patient with a hospital-acquired infection like MRSA. … GPs can spend the money that they save in this way to improve care elsewhere."

If there is a problem with hospital acquired infections then this means that the provider needs more investment to tackle infections and not a cut in funding. Curiously soon after quoting David Cameron's speech the green paper says:

"The tariff regime, where providers are only paid for the procedures they deliver, will reward success and encourage under-performing providers to improve."

The "tariff regime" is more accurately called Payments by Results and is the current system used to pay NHS providers. But note the phrase "are only paid for the procedures they deliver", this does not say that the provider will be paid according to outcomes. This clearly contradicts what David Cameron said.

Finally, note that the Conservatives regard targets to be bad because they are political, but the green paper says:

"We want the success of the NHS under a Conservative Government to be judged against how it improves health outcomes in seven key areas…"

So no "politically-motivated process targets" then?

It is clear, the Conservatives will still have a target driven culture in the NHS, but now the targets will be called outcomes and if hospitals do not achieve expected outcomes from a treatment on a patient then the hospital's funding will be cut. Can anyone explain how this fits in with David Cameron's oft quoted "ring fence". And how can these cuts to hospital funding be reconciled with his pledge that he will "cut the deficit, not the NHS"

Tuesday, 19 January 2010

Conservative Public Health Green Paper: Part 3

Last week, I wrote about the Conservative plans on the NHS, including their plans for public health. This is the last blog post on the series where I cover some of the other notable policies that I have highlighted from the Conservative green paper on public health.

Other Public Health Policies

First, the one good policy:

"We will provide a health visiting service and provide an additional 4,200 Sure Start health visitors, based in Children's Centres, who will help families provide support from before birth to primary school."

Health visitors are vital because they are in the community and hence they have first-hand experience of the public health issues. The care that health visitors can provide is important on its own, but also important is the advanced warning that health visitors can give when there is an imminent health issue within the community. The Conservatives should put in force some mechanism for health visitors to feed back valuable (but confidential) epidemiological information, but sadly there is no sign of such a policy.

Now let's have a look at some other policies. These are largely unrelated, but it is interesting to see what the Conservatives plan to do and the effect such plans will have on us. Let's start with a policy that will not affect us because they have no intention of implementing it.

"there will be a significant increase in single rooms across the NHS specifically reserved so that patients who have, or are suspected of having, a hospital infection"

David Cameron has already said that the Conservatives will not be able to do this, that the pledge is merely an "aspiration". It is wonderful. Isn't it, that the Conservatives can make such a fuss about a policy and then as soon as they are pressed on details their commitment to the policy crumbles. I suspect that as the election gets closer many of the Conservative policies will crumble.

Now let's have a look at another policy that won't be implemented because it will have no effect at all.

"We will work with the drinks industry to improve labelling so that people are more aware of amount of alcohol in drinks (rather than the misunderstood 'units' system) as well as guideline limits."

This is rather farcical. It is simple: a unit is 10ml of alcohol and the guidelines are that the daily consumption for men should be less than 3 to 4 units and for women it should be less than 2 to 3 units. (Previously the guidelines were that men should drink no more than 21 units per week and women should drink no more than 14 units.) The health spokesman, Andrew Lansley indicated that the "misunderstood 'units'" should be replaced with "centilitres of pure alcohol". The farcical aspect of this policy is explained by the simple equation:

1 cl = 10 ml = 1 unit of alcohol

So the new innovation that Lansley is suggesting is to replace the phrase "units of alcohol" with "cl of alcohol" and everything else will remain the same. A pure waste of airtime.

"For two generations, we have seen too much urban space designed around the needs of motorised transport. It is now far too easy not to walk and cycle. A Conservative government will make these activities feel safer and more desirable than other forms of transport."

This seems to be at odds with the Mayor of London who has shown his dislike of schemes to discourage car use (and axed the extension of the congestion charge) and who has raised the price of public transport above the rate of inflation which clearly discourages people from using public transport. If people don't have public transport they use cars.

"We will treble duty on alcopops, we will significantly increase tax on super-strength beer and we will more than double tax on super-strength cider."

This is from a party who say that they will tax us less. This is a policy that will clearly affect moderate drinkers of these beverages.

Finally, there is this rather obscure statement:

"This is one reason why we believe that greater personal control of health records could lead to significant benefits, by helping people to take more responsibility for their health through sharing information with third parties if they choose to do so."

The "draft manifesto" says:

"we will put patients in charge of their own health records, with the ability to choose which providers they share them with"

Who are these "third parties", what do they want with our data, and why would we want them to have our health records? Health records are personal and confidential. They should only be available to the clinicians who treat us, so who do the Conservatives want to have our confidential health records? The green paper is rather coy about this and the only section that seems to cast light on this is an example from Unilever:

"Unilever measured the difference in productivity between its healthy and unhealthy employees and found that those who had a poor score on their health risk assessments also performed at a lower level over time. The company offered interventions to a group of staff to manage stress, cope with pain and sleep more soundly."

This implies that healthier workers means more profits for corporations, hence it is in the interest of corporations to make their workers healthier. This seems to be where the "third parties" come in: your employer has a vested interest in making you healthy. They also have a vested interest in not employing you if you are not healthy and they can get valuable information about this from your confidential health records.

The green paper encourages businesses to share in the health costs of their employees and this statement appears to suggest that employees should share their health records with their employers. The effects of this policy on privacy are significant. An employer who is responsible for the health of their employees will give the employee the "choice" to either share their health records with the company's doctors, or not be employed. If this is the case then it is no wonder the Conservatives are coy about what this policy means.

In this short series of blogs on the Conservative Green paper on public health I have given you a taste of what the Conservatives plan for us if they get into government later this year. I encourage you to read the green paper yourself and their draft manifesto on health and make up your own mind. My opinion is that under the Conservatives the NHS will be privatised and the incidental costs of healthcare to patients will be significant.

Conservative Public Health Green Paper: Part 2

(Poster template from mydavidcameron.com.)

Last week, I wrote about the Conservative plans on the NHS, including their plans for public health. This is the second part of my analysis of their new public health policy.

More Evidence of Cameron Privatising the NHS

Any policy from David Cameron's Conservatives will always have a substantial amount of privatisation built in. This is the case with their policy on public health. Public health should be about benefiting the public, but the Conservatives just cannot help making sure that their friends in the private sector get the biggest benefits.

Early on in the policy document they give a fairly innocuous statement.

"Local directors of public health will manage budgets and will be obliged to commission local bodies, like schools, businesses, councils and GPs, to promote healthy living. With money behind them, they will have the power to recruit and pay innovative local organisations, whether businesses or charities, to start to implement new ways of promoting healthy choices and behaviour."

Reading this more carefully, note that public health money will be going to "businesses or charities" but not to existing NHS providers. Yet again, this indicates the lack of commitment that the Conservatives have in existing NHS providers. When the budget is restricted (a "ring-fence" does not mean unlimited cash, in fact, it means the opposite) it means that increased funding to "businesses or charities" means less funding for existing NHS providers: a cut.

So these "businesses", what will they be responsible for?

"Whenever possible, we will ensure that national public health initiatives funded by public money are paid for on the basis of the results they achieve. … By paying organisations running national campaigns by the results they achieve, we can encourage such innovation and improve the value we get from the money spent on public health."

From this statement it appears that these new private providers will be in charge of national campaigns, and hence since the responsibilities will be large, they will receive substantial amounts of public money: substantial amounts of public money going to private providers.

The Conservatives also intend to devolve some public health responsibilities to local authorities. Of course, since most local authorities are Conservative this means that the decisions that will be made will be those sanctioned by the Conservative Party's working party on health. In other words, the same policy as the Conservative Secretary of State.

"Local directors of public health will manage budgets and will be obliged to partner with local bodies, like schools, businesses, councils and GPs, to promote healthy living. And with real money behind them, they will have the power to recruit and pay innovative local organisations, like businesses and charities, to design new ways of promoting healthy choices and behaviour. 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."

There is that phrase again, "businesses and charities", and no mention of existing NHS providers like hospitals. The intention is very clear from the statement "To encourage a new market" that the private sector is welcome, but the public sector is not. But note the last sentence: "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". If you were not convinced before about the Conservative plans for privatisation of public health provision then you should be now, since it is here in black and white. Not only a "proportion" of contracts would be awarded to private providers, but an "increasing proportion", a proportion that will presumably rise to 100%. In my previous blog on this topic I identified that this section of the NHS currently has a budget of £3 billion. The Conservative plan is to hand over £3 billion to the private sector, which is £3 billion less funding for the NHS. So when David Cameron claims that he will "not cut the NHS", it is a bare-face lie, he is planning at least a 2.5% cut from day one.

Another policy is targeting funding for "deprived communities":

"So the public health funding we devolve will – subject to the results achieved - work in such a way as to give relatively bigger future funding streams to deprived communities, where health problems tend to be much worse: this is our 'Health Premium'."

Note the "subject to the results achieved" proviso, in other words, there is no guarantee of a "Health Premium". This means that providers will be reluctant about the amount of work they are willing to do, because if they do not have a guarantee that their costs will be covered they will not be willing to do the work. It is unclear how private providers will handle this situation. Private companies are always reluctant to perform work where there is no guarantee return on investment, so it is possible that this proviso "subject to the results achieved" will be watered down (and perhaps removed altogether) to encourage private providers to bid. One thing is clear, such a kid-glove approach will not be given to NHS providers because the intention is to squeeze NHS providers out of the public health "market" entirely (that is what the phrase "increasing proportion" of contracts to private providers means).

The policy document further explains what the "Health Premium" means:

"To incentivise local communities and providers to engage in improving the health of the people who live in each area, we will first establish a picture of the health of a community. The incentive system will then reward communities and providers which make progress improving public health against a set of outcomes."

Ugh, first try and get past that horrible America business-speak: "incentivise", it is the sort of phrase commonly used in US healthcare corporations, and it does give you a clue about the pedigree of these policies. So the Conservative policy "will first establish a picture of the health of a community" which presumably will establish some "objective" that local public health providers will have to achieve to get their "Health Premium". So there will be some "objectives" or "benchmarks" or maybe we can call them "targets"? Remember, this is the party that says they will "scrap all of the politically-motivated process targets", and yet here the Conservatives are saying that they will create their own targets.

From my analysis of the draft manifesto we have already seen that the Conservative policy is to re-introduce the failed GP fundholding scheme, but for public health, their policy document gives an interesting statement:

"we will develop the system that determines GPs' income, including fee-for-service and the Quality and Outcomes Framework, to align incentives with preventative health interventions, aiming to reduce people's need for more serious treatment"

What does "fee-for-service" sound like to you?

Also, think about what the phrase "aiming to reduce people's need for more serious treatment" means in practice. When a patient has a condition they need treatment, and the choice of treatment should be made solely on clinical grounds. The last time the Conservatives introduced GP fundholding the outcome was that fundholders referred fewer patients for specialist treatment than non-fundholders. It was clear at the time that if you needed specialist treatment it was better for you if your GP was a non-fundholder, than if they were a fundholder. The Conservatives want us to return to a system where referrals to specialists will be rationed.

"We will want the providers engaged by the Department to undertake such activity to be paid by results"

There is that hint of wholesale privatisation that flows throughout the Conservative health policy, these "providers… paid by results", who are these providers, again?

"we will go further by publishing the results of all public health programmes online, along with tools which allow people to compare and benchmark performance … spurring new providers to take over or replace failing programmes."

Note again the "new providers" phrase who will "take over or replace failing programmes". Presumably these "failing" providers are the NHS providers whose budget have been handed over to the "new providers". This is a bold statement. Elsewhere in their health policy documents the Conservative have been coy about how the "new providers" will get their business. However, here is a bold statement saying that they will be "spurred" to "take over or replace" NHS providers. This is the wholesale privatisation that infects Conservative health policies. Yet again, there is no commitment to existing NHS providers, if the Conservatives were committed to NHS providers they would have a plan to help them improve. There is no such plan in any of the Conservative policy documents.

"We want to harness all this innovation to revolutionise our public health approach and we will use payment by results to ensure the adoption of programmes which have been successful elsewhere. This will be one of the driving forces through which we will ensure all our activity is focused on achieving real benefits for people: national public health initiatives commissioned by the Department of Public Health funded by public money will be paid for on the basis of the results they achieve wherever possible."

The glaring problem with this approach is that it is the "new providers" that the policy document is so very keen about, who will be rewarded; it is not people and patients who will be rewarded. So rather than "real benefits for people" it will be real profits for businesses.

The Conservative policy document cites an example: "health and life insurers offer free gym membership to increase their customers' fitness". This is clearly a benefit for the customer. However, look at the plan from the Conservatives, "payment by results" (note the deliberately misleading use of the term that is the name of the current funding mechanism for hospitals) does not provide benefits to people (ie tax payers), instead it channels financial benefits from the NHS budget into private providers.

Finally, there are worrying signs that a Conservative government will force some levels of privatisation by making employers responsible for the health of their employees:

"Any economic incentive scheme needs to recognise this by helping employers to see the benefits more immediately, or by splitting the costs between all parties who benefit - the employer, the individual, and the (NHS)"

Note that these healthcare costs are split three ways. They are not free-at-the-point-of-delivery healthcare; they are healthcare where the employer and the employee will be expected to contribute. This will effectively put a tax upon employers, who in response will covertly choose not to employ people who have existing healthcare problems, or less healthy lifestyles. Conversely, once an employee has found an employer that will contribute, it will mean that the employee will be reluctant to change employer, curtailing movement in the jobs market.

The Conservative Green Paper on Public Health is important because it is one of the few documents from the Conservative party that admits that their intention is to privatise large portions of the NHS. This document shows no commitment at all to existing NHS providers. Furthermore, it brazenly says that the Conservatives will "encourage a new market in innovative public health solutions … 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". This openly admits that the private sector will be used in preference to NHS providers to the point that NHS providers will be squeezed out. Finally, the Conservatives say that their policies are intended to "[spur] new providers to take over or replace failing programmes". This is privatisation, pure and simple.

Monday, 18 January 2010

Conservative Public Health Green Paper: Part 1

Last week, I wrote about the Conservative plans on the NHS, including their plans for public health. The "draft manifesto" is a little sparse on details and the 2009 health policy document from the Conservatives offered little help in explaining some of the new policies. The Conservatives have now provided more information in what they call their Policy Green Paper No 12. In these next three blog posts I will examine in more detail what the Conservatives plan for us.

The Department of Behaviour Change

The big announcement in the policy document is:

"The Department of Health … will be renamed the Department of Public Health and its role will be focused much more strongly on the prevention of disease, rather than just its cure."

The Conservatives think that changing the name of a department will have an effect on public health. To be fair to them, changing the name of government departments is nothing new, New Labour has been doing this during their term in office, although usually the name changes have been due to the amalgamation of departments (for example, the Department for Children, Schools and Families) or the devolving of responsibilities to new departments (for example the new Department of Justice).

Changing the name of an existing department is an interesting concept, however. I suggest that the new name is not correct, for the reasons I will give in a moment. The sentences above indicate clearly that the Conservatives intend an expansion of the nanny state. Of course, nannies are usually employed on a private basis, and this is the case with the new nanny state planned by Cameron:

"Whenever possible, we will ensure that national public health initiatives funded by public money are paid for on the basis of the results they achieve. … By paying organisations running national campaigns by the results they achieve, we can encourage such innovation and improve the value we get from the money spent on public health."

This is clearly indicating that a Conservative Government will franchise public health responsibilities to new private corporations: these are private super-nannies who will tell you what you should eat and drink: "public health initiatives funded by public money".

However, as usual, it is the citizens who are at fault because any corporation that affects our health, but also makes a profit, will be gently allowed to decide if they want to participate:

"We will work together to extend to all media voluntary restrictions on marketing to children to all media, including online advertising, and also support industry-led initiatives to promote better health, such as reducing food portion sizes and reformulation." [sic]

(So they will "extend to all media … restrictions … to all media"? Editing of policy documents ain't what it used to be!) While it is clear that advertising has a significant effect on purchases (otherwise, why do corporations have such large advertising budgets?) this says that the industry will "voluntarily" apply restrictions, ie they will be allowed to be let off the hook. So what will be done to persuade people to change their lifestyles to be more healthy?

"people are powerfully influenced by the behaviour of others, in that they want (often unconsciously) to do what others do, particularly "influential" others."

This suggests celebrity endorsements: our televisions and newspapers, our favourite websites and even our mobile phones will be inundated with the images and messages being endorsed by the latest winner of the X-Factor. That's something to look forward to!

Clearly this "new" department will not be able to get industry on its side, so what will it do to promote public health to the rest of us? In the policy document there is a section marked:

"A new Department of Public Health focussed on evaluation and behaviour change"

"behaviour change"? What does that imply to you? Well, if that is the focus of this new department then clearly its name should be the "Department of Behaviour Change". Do you want your behaviour changed? Well apparently you'll get no choice, as we will see in a moment. First, however, what is the science behind this?

"We will want the providers engaged by the Department to undertake such activity to be paid by results; and we will insist that the methods used are linked to the recent advances in behavioural economics."

Here is yet another hint of wholesale privatisation that flows throughout the Conservative health policies: "providers … paid by results".

Now look at the Orwellian phrase "recent advances in behavioural economics". The new Department of Public Health clearly wants to tell us what to think and how to behave. How do you make people think differently, well apparently through "default options":

"Case studies from around the world have shown how it is possible to use default options to help people make better choices without restricting their options at all."

This convoluted sentence indicates that in future a Conservative government will choose what you will eat and what exercise you take, and make you think that it was you who chose. Clever! I wonder if they will apply the same science towards what we put in the ballot box? It makes you wonder, doesn't it? A nation who has been conditioned to accept the "default option" is then asked to vote in an election, without restricting your options at all.

What will this new department do? Well we learnt from the draft manifesto that it will hand over all of its NHS responsibilities to the unaccountable super-quango, the NHS Board. So will the Department of Public Health be an empty husk? No, it will grab responsibilities from formerly independent public organisations:

"we will put parts of the Food Standards Agency which are responsible for the nutritional content of food and a slimmed down Health Protection Agency into the Department of Public Health"

Government agencies are deliberately "hands-off" so that political interference is kept to a minimum. The Department of Public Health will be under the political control of the Conservative Secretary of State, which implies that the "nutritional content of food" and more worryingly, the functions of the Health Protection Agency (who are entrusted to protect public health from infections, chemicals and radiation hazards), will be under the direct political control of the Secretary of State. This is from a party who say that they want "less political interference" in health.

The new Department of Public Health is appearing to be more and more like a Big Brother organisation, and to cap it off, here is a delicious statement from the policy document:

"'Self-contracting' allows one fix preferences over time. Research by social psychologists has shown that self-contracting is highly effective in regulating individual and organisational behaviour in a non-bureaucratic and voluntary way."

Wow! What is all of that gobble-de-gook? I have no idea, but it certainly sounds like fun for someone! Get ready, because clearly this is the "behavioural economics" that we will see more of from the Department of Public Health!

The message is clear. Under a Conservative government the Department of Health will be renamed the Department of Public Health but we all know that it will really be the Department of Behaviour Change. This new department will use behavioural economics to tell us what to eat and drink and make us think that we chose to behave in that way. The private nanny state meets Big Brother.

Friday, 15 January 2010

Conservative Draft Manifesto 2010: Index

The Conservative Draft Manifesto 2010: Chapter One covers the Conservative plans for the NHS. David Cameron has tried very hard to reassure the public that the NHS will be safe under a Conservative administration. However, their draft manifesto shows that this is simply not the case, and they are quite upfront about their plans for moving much of treatment from NHS suppliers to private suppliers, a de facto privatisation of the service. Over the last couple of weeks I have gone through the "manifesto" point-by-point and analysed the effect of the policies. If you want one reason and one reason only not to vote Conservative it is their policies on the NHS.

The following is a list of the Conservative policies and a link to my blog post on the policy.


A Patient-Centred NHS

"We will scrap all of the politically-motivated process targets"

"[We will] set NHS providers free to innovate by ensuring they become autonomous Foundation Trusts."

"We will unleash an information revolution in the NHS by making detailed data about the performance of trusts, hospitals, GPs, doctors and other staff available to the public online... [we will] enable patients to rate hospitals and doctors according to the quality of their care."

"We will focus on the health results that really matter, like improving cancer and stroke survival rates or reducing infections."

"[We will] give everyone the power to choose any healthcare provider that meets NHS standards… open up the NHS to include new independent and voluntary sector providers"

"we will implement a 'payment for results' system throughout the NHS."

"we will give GPs the power to hold patients' budgets and commission care on their behalf"

"we will link GPs' pay to the quality of the results they deliver"

"we will be able to cut the cost of NHS administration by a third"

"we will create an independent NHS board to allocate resources and make access to the NHS more equal"

A More Accessible and Accountable NHS

"hospitals will not be paid in full for a treatment which leaves a patient with an avoidable infection."

"We will end the scandal of mixed-sex accommodation and increase the number of single rooms in hospitals, as resources allow."

"We will reform the way drug companies are paid for NHS medicines so that any cost-effective treatment can be made available through the NHS with drug providers paid according to the value of their new treatments"

"We will reform NHS Direct and introduce a single number for every kind of urgent care to run in parallel with the emergency number 999. We will give people access to a doctor or nurse when the local family doctor's surgery isn't open, and we will stop the forced closure of A&E wards."

"we will introduce local 'maternity networks' to ensure that mothers can safely access the right care, in the right place, at the right time."

"[we will] allow new providers to deliver maternity care - especially services like ante- and post-natal support."

"…allow us to give one million more people access to an NHS dentist and give every five year old a dental check-up"

"we will remove the rules preventing welfare-to-work providers and employers purchasing services from Mental Health Trusts so that many more unemployed people and at-risk workers can be helped."

Improving The Nation's Public Health

"we will turn the Department of Health into a Department of Public Health"

"we will provide separate public health funding to local authorities"

"we will weight public health funding so that extra resources go to the poorest areas with the worst health outcomes through a new 'health premium'."

"In the long run, we will introduce a new per-patient funding system for all hospices and other providers of palliative care so that proper support for sick children and adults can continue."

"[we will] give patients with chronic illnesses or a long-term condition access to a single budget that combines their health and social care funding which they can tailor to their own needs."

"we will allow everyone – on retirement – to protect their homes from being sold to fund residential care costs by paying a one-off insurance premium of £8,000."


If you want to see a well funded public National Health Service then the choice is clear, vote Labour at the 2010 general election.

Conservative Draft Manifesto 2010: Conclusions

Over the last ten days I have given a point-by-point analysis of the Conservative Draft Manifesto covering the NHS. In this final post of the series I present the conclusions that can be drawn.

Privatisation Agenda

The first thing that is extremely obvious is the Conservatives intend to have a much larger involvement of private suppliers in the NHS. The manifesto is littered with terms like "any willing provider", "choose any healthcare provider", "new independent and voluntary sector providers", "allow new providers" and "encouraging hospitals to compete for patients".

Where is the commitment to existing NHS providers? There is just one mention: "set NHS providers free to innovate by ensuring they become autonomous Foundation Trusts". Foundation Trusts are a Labour innovation and the Conservative party were firmly against them, voting to block their introduction during the passage of the legislation through Parliament. The Conservative party have suddenly decided that this Labour policy has merit, but do not acknowledge that they were wrong to try to block the legislation. Other than this single mention, the "draft manifesto" gives no other support for NHS provider, in fact, quite the opposite, they openly admit that they will cut the funding to NHS providers in situations when more investment is clearly needed: "hospitals will not be paid in full for a treatment which leaves a patient with an avoidable infection".

The Conservatives say that they will "ring fence" funding for the NHS, so let us take this at face value, and assume that they are telling the truth. Since their manifesto shows no commitment at all to existing NHS providers, where is the ring-fenced NHS funding going to go? The answer is clear: it will go to the "any willing provider" that they mention time and time again in their manifesto.

The idea of "choose any healthcare provider" (not choose any NHS healthcare provider) is the tired old Patients' Passport that was the Conservative health policy at the 2005 general election. That policy was based on an idea that somewhere in the Department of Health there is a pot of money with your name on it and if you need healthcare you should be able to take that pot to any healthcare provider you wish. The original plan was to allow patients to have their NHS pot of money and add their own funds to it to get premium private treatment. This policy was interpreted, quite rightly, that the NHS would be subsidising private care, and that the long term effect would be the reduction of NHS providers until the only providers would be private providers and most patients having to pay for treatment. The electorate were not convinced by this idea and rejected it in 2005.

The Conservatives have tweaked this idea, they now say that they will "give everyone the power to choose any healthcare provider that meets NHS standards" and "if they can deliver a service that patients want, to a high standard and within the NHS tariff". In other words, the current Conservative policy will be the Patients' Passport without the option for patients to add their own funds for the treatment. However, there is no explicit guarantee that this embargo on top-ups fees will be permanent. The likelihood is that once this policy is in place patients will be allowed and encouraged to contribute extra. Indeed, it is easy to imagine that private providers will perform the bare minimum of the requested procedure at the NHS tariff while offering the patients "additional care" at an extra cost. Such "additional care" could easily be applied to the drugs used ("this drug is not available on the NHS, so you will have to pay extra to receive it"). Look at how the dual system of NHS and private treatment works in dentistry: dentists try to persuade patients to have additional, private treatment; this is what will happen in the future with hospital treatment. The result, of this policy, like the original Patients' Passport will be to remove funding from NHS providers, and lead eventually to the closure of NHS hospitals.

The Conservatives intend to create a super-quango called the NHS Board. In their health policy document in 2009, the Conservatives specifically say that the "commissioning of NHS services will be separate from healthcare providers and overseen by the independent NHS Board." In other words, the NHS Board will dictate which providers local commissioners are allowed to use and since the Conservatives say that "we will enable any willing provider, who is able to meet NHS standards within NHS tariffs, to offer services to NHS commissioners" it is clear that they expect the NHS Board to force local commissioners to use private providers. David Cameron will ensure that the NHS Board follows his privatisation plan because although the super-quango is described as "independent" the Conservatives' 2009 policy document says that "the NHS Board members will be appointed by The Secretary of State for Health" in other words they will be political appointees, and inevitably politically aligned to the right-wing Conservative party lead by David Cameron.

Apart from a general plan to provide NHS resources to "any willing provider" the "draft manifesto" makes specific promises. In maternity care it says they will "allow new providers", in terms of patient records they say they will allow patients "to choose which providers they share them [their patient records] with" and worryingly when it comes to mental health services, the Conservatives will "remove the rules preventing welfare-to-work providers and employers purchasing services from Mental Health Trusts" when clearly these services should be free-at-the-point-of-delivery and not purchased at all.

In addition, the Conservative "draft manifesto" has a rather obscure statement about public health. "we will provide separate public health funding to local authorities", what does this mean? Currently public health is carried out by a variety of NHS providers: Primary Care Trusts, hospital trusts and GPs and the current budget is about £3bn a year. The Conservative plan is to take this funding from existing NHS providers and hand it to local authorities, who have no experience of providing public health. This seems very odd and a clear recipe for disaster. However, notice that most local authorities are Conservative held, so this will be £3 billion of extra funding to Conservatives councils. Furthermore, a local authority with no experience of providing public health policies, particularly a Conservative council, will be naturally inclined to purchase that expertise from a private provider. This is the real reason for this policy from the Conservatives: a whopping £3bn of cuts to NHS providers and a corresponding £3bn cash injection into the private sector.

Interestingly, the Conservative spokesman on health, Andrew Lansley has received funding from a private health supplier. CareUK is one of the country's largest private healthcare providers and contributed £21,000 to the running of Lansley's office. (Originally reported by Paul Waugh.)

This lack of commitment to NHS providers and the zeal for using private providers heralds the beginning of a wholesale privatisation of the NHS.

New Funding Arrangements

Conservatives like the carrot-and-stick approach, the problem is that the way they make the rules means that the private sector gets lots of carrots and the public sector (in this case NHS providers) get lots of stick. This is apparent in their new funding arrangements.

First, let's make something clear: all procedures have costs and if a hospital is not reimbursed for those costs it will make a loss, get into debt, and eventually become a failing hospital. It is the responsibility of the Department of Health to make sure that funding arrangements are such that hospitals are reimbursed to cover their costs while providing good quality care and keeping a control on costs. The Conservatives will, of course, franchise the responsibilities of the Department of Health to the new super-quango the NHS Board. Then the Conservatives will apply a lot of stick to NHS providers under a new payments system called payment for outcomes (or payments for results, a term which is deliberately chosen to be confused with the much fairer system already in place called payment by results, I will avoid the confusion by talking about outcomes and not results). Under the Conservative system of payments hospitals will have no guarantee that they will be paid for the treatments they provide. The "draft manifesto" gives one example of how this will work: "hospitals will not be paid in full for a treatment which leaves a patient with an avoidable infection". Note that there is no offer of help to reduce hospital infection rates, no rewards for achieving low levels of infection. In fact, no carrots at all for NHS providers, just sticks, sticks, sticks. Mr Cameron must really dislike the NHS to threaten to continually beat NHS hospitals like this.

So who will get the carrots, and how? As the last section explained the overall theme of the Conservative "draft manifesto" is to bring in wholesale privatisation of services while maintaining, and even increasing, tax payer contributions; taxpayer contributions that are earmarked for the private sector and not NHS providers. How will the Conservatives do this? First, the NHS Board will be given a mandate to increase the amount of private sector involvement. Have you noticed that the "draft manifesto" does not say "existing independent providers" instead it says "new providers" over and over again? This shows the central theme of their privatisation plan. The Conservatives intend to create a plethora of new providers in a health market with the NHS Board providing the funding. The NHS Board, a super-quango with a £120 billion budget, has a hell of a lot of carrots to throw around, and the majority of these carrots will be thrown at new private suppliers. Expect that, when the details are produced, the NHS Board will be given a target of how much private involvement there will be. The resulting Conservative health bill will be similar to the rules imposed on the BBC by Margaret Thatcher under the 1990 Broadcasting Act. The Broadcasting Act says that 25% of the TV and radio broadcast by the BBC must be from independent producers. This had the effect of creating a large number of independent television producers. The Conservative plans for the NHS will be to create a large number of private healthcare providers, this is why the "draft manifesto" uses the term "new providers" so much.

The other main carrot for the private sector comes under the innocuous statement "value-based pricing". In practice this means that a Conservative government intends to pay drug companies more. They are not suggesting that they will do something sensible, like encouraging competition between drug companies by making more drugs generic; instead they will reward drug companies "according to the benefits the drug brings to patients". Call me cynical, if you like, but the NHS should only be giving patients treatments that they will benefit from, the NHS should not pay for treatments that do not have benefits. This new policy seems like a new way to turn more NHS money into profits for drug companies. The example that the Conservatives' 2009 health policy document gave describes exactly why this policy is wrong: the example was for a drug that was cheap to produce but since the drug saved the sight of patients the drug company priced it according to how much they thought patients would pay to keep their sight. The Conservatives endorse the sentiment in this drug pricing policy, and in effect it means that they want to hand more NHS funds over to drug companies.

Centralisation and Political Interference

The Conservatives' policy writers say many times that they want to end "political interference". They say that the unaccountable, super-quango, the NHS Board will "make sure the NHS is funded on the basis of clinical need, not political expediency". They say that they will "set NHS providers free to innovate by ensuring they become autonomous Foundation Trusts" (this is already a Labour policy). They say they will "give GPs the power to hold patients' budgets" (a repeat of the failed GP fundholding scheme). All of this seems to indicate a hands-off approach, a devotion to devolving healthcare decisions to patients and local commissioners. But that is not the case.

The NHS Board, of course, will be a huge, centralised body and "the NHS Board members will be appointed by The Secretary of State for Health", in other words, political appointees. The NHS Board will dictate commissioning rules to NHS commissioners, and these rules will be that they should use "any willing provider". They plan to interfere in the actions of NICE (who they call "unaccountable bureaucrats" who let "Ministers off the hook"). Furthermore, the Conservatives pledge to "stop the forced closure of A&E wards" which is more interference since decisions to rationalise A&E services should be taken at a local level.

All of these are actions of an authoritarian government who do not want to let go of control.

Existing Labour Policies

One of the interesting things about the Conservative "draft manifesto" is that about half of them are policies adopted from the Labour government but presented as if they are new Conservative policies. The following are a list of their pledges that are either exactly what are implemented already, or are planned to be implemented by the Labour government.

"[we will provide] detailed data about the performance of trusts, hospitals, GPs, doctors and other staff available to the public online"
[NHS Choices website, the CQC Website and independent websites like Dr Foster already do this.]
"[we will] give everyone the power to choose any healthcare provider that meets NHS standards"
[Government policy is to allow patients to use any NHS provider, but local commissioners may use private providers if they wish.]
"we will give GPs the power to … commission care on their behalf" [This is the same as the Labour policy of Practice Based Commissioning.]
"[we will] link GPs' pay to the quality of the results they deliver"
[GPs are paid extra for public health provision like vaccinations, performing cervical smears, testing blood pressures etc.]
"[we will] introduce local 'maternity networks'" [The RCM says this happens already.]
There is no acknowledgement in the Conservative "draft manifesto" that these are Labour policies, nor is there any indication why the Conservatives have reversed their opposition to many of these policies.

Unachievable Aspirations

Within the manifesto there are some pledges that are frankly unachievable. Why a policy writer would include something that cannot be achieved and can be easily proven so, is inconceivable. For example:

"[we will] cut the cost of NHS administration by a third"

A cut of a third in administration costs is a huge cut and it is inconceivable that this could be achievable without huge disruption and a breakdown of the service.

"we will allow everyone – on retirement – to protect their homes from being sold to fund residential care costs by paying a one-off insurance premium of £8,000."

To understand the problems with this policy you have to look at what it is intended to cover. Residential care costs at least £1000 a month (and easily more, depending on the location and the amount of care that is needed). So an insurance payment of a mere £8000 simply cannot cover the costs, it is a policy that cannot succeed due to lack of resources. The real reason for the policy is to highlight the Conservative support for inherited wealth.

Another pledge is:

"We will end the scandal of mixed-sex accommodation and increase the number of single rooms in hospitals, as resources allow."

The Conservatives originally promised an extra 45,000 single rooms at a cost of £1.5 billion, but on the 7 January when pressed on this figure David Cameron admitted that it was not achievable and said that it was simply an "aspiration". Here was Cameron admitting that the manifesto has at least one policy that could not be achieved, a Conservative lie

If we have learnt anything from the expenses scandal it is that the public want politicians to be honest and open. The fact that the "draft manifesto" includes policies that cannot be achieved shows that it is neither honest nor open.


There is very little of worth in the Conservative "draft manifesto" on health, but there is a lot to be worried about. First it shows the natural inclination in Cameron for centralising power, next it shows his zeal for privatisation and finally it shows dishonesty by claiming Labour policies as theirs and including unobtainable policies. It is clear that the only people who will benefit from these policies are the private healthcare providers. This is not a manifesto for the NHS it is a manifesto for private healthcare.

Conservative Draft Manifesto 2010: Dissection Part 14

An analysis of the Conservative Draft Manifesto 2010.

"we will allow everyone – on retirement – to protect their homes from being sold to fund residential care costs by paying a one-off insurance premium of £8,000."

Many people have pointed out that this policy has problems. The average annual fee for residential care homes is £18,000, where constant medical care is needed, then the care required is from a nursing home and the average cost is £25,500 a year. There are regional variations, of course, and in the last few years fees have exceeded the rate of inflation. A one-off payment of £8,000 looks like remarkable value-for-money. 

But that is the problem. It means that most people who pay this insurance fee must not go into residential care for there to be enough money to pay for those that do. Those that do not go into residential care will stay in their own home and will need care there. This scheme can only work if it includes provision for care in the home of the elderly. The Conservatives make no mention at all about care of the elderly in their own home. So we can only assume that the Conservatives expect that the elderly will have to pay for their own care. 

Update (18/2/2010): Even Andrew Lansley does not believe that £8,000 is enough:

The Liberal Democrat health spokesman, Norman Lamb, said that his Tory counterpart, Andrew Lansley, had accepted before going on a BBC political show this Sunday that Conservative plans would see people offered three voluntary insurance schemes.

One, which the Tories have already outlined, costing £8,000, would be for those who wish to be covered in the event they had to go into a care home. The second, said Lamb, was a new admission: a one-off payment of £10,000 to secure care for people in their own home. The third was a "cheaper, stripped down package for critical care at home". "Having options within a voluntary scheme has potential perverse consequences. What happens if you want to switch out from one scheme to another?" said Lamb.

There is abundant evidence that under the Conservatives the vulnerable will be forced to pay extra. The so-called Conservative Easy Councils, local authorities that have made savage cuts in council tax, have done so by increasing charges for services including social care. In effect, these councils have targeted the most vulnerable in our society to pay for the council tax that benefits the rich. So if the choice is for an elderly person to have to pay themselves for help in their own home or to get free residential care, they will have no choice at all: they will choose the latter. This is the fear of the Association of Directors of Adult Social Services and the Kings Fund who say that this policy from the Conservatives will mean that people will go into residential care too early.

There is also a philosophical issue. When I asked an elderly neighbour about care for the elderly she told me that she was brought up to save for her retirement, and so it was a natural assumption that any assets that she had – including her house – would go towards paying for her care if she needed it. In fact she, and those people of her generation, was very forthright about the issue: she did not want her children to be paying for her care, and her house was hers and so ultimately she know that this would pay for her care. But, she told me, if she didn't need care then she was happy for her children to inherit her house. This is the sort of self-reliance that should be encouraged.

The Conservatives, however, seem somewhat obsessed with the idea of inherited wealth. This has been clear time and time again when they argue somewhat unjustifiably for an increase in the IHT (Inheritance Tax) threshold. The Conservative obsession infantilises the adult children of the elderly, suggesting that they are not capable of living their own lives without the inherited wealth of their parents. This is nonsense, of course, but it is the only conclusion that can be drawn from the Conservatives obsession with enabling children to inherit as much as possible from their parents. The Conservative social care policy is more evidence of this Conservative obsession over inheritance because the justification is "to protect their homes from being sold to fund residential care costs". The whole point of a policy on social care should be to ensure that the elderly retain their dignity and receive the care they need; inheritance should have nothing to do with the policy.