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

Wednesday, 14 July 2010

NHS White Paper Part 1

1. Liberating the NHS

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

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

The NHS today

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

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

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

Our vision for the NHS

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

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

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

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

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

Improving public health and reforming social care

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

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

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

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

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

The financial position

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

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

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

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

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

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

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

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

Implementing our NHS vision

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

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

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


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

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

1 comment:

  1. I'm an NHS employee who works within the provider arms that provides community health services, it feels like we are going to be sold to the highest acute hospital bidder. We were told that becoming a community foundation trust was not an option or setting up a social enterprise scheme. I think this has caught our commissioning and provider senior mangement teams on the hop otherwise the plans to become a foundation trust or set up a SES would have commenced in 2006 when the PCTs underwent reconfiguration.
    I dont believe any consultation was held over this white paper - yet within my PCT it feels like fait accomplait and morale is extremely low. I feel that the Government has kicked us all in the teeth and wants to punish the employees because of previous government actions. I work extremely hard 60 hours plus many weeks and am proud of the services my PCT offers to the community. The acute hospitals to which we will transfer have no idea of community nursing issues; they also have their own performance problems and may sideline community healthcare because of ignorance of how it operates.
    If there is another general election next May due to electoral reforms the conservatives certainly wont get my vote.