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

Monday, 19 January 2015

Fill in the gaps

This is my response to Bill Morgan in a blog on the Spectator. Bear in mind that Morgan was a Special Advisor to Lansley so there is a whiff of the Mandy Rice-Davies about his post.
You rightly start by saying that the 2010 winter was affected by a flu outbreak. However, you then go on to say that 2011, 2012 and 2013 were uneventful. This is not true. There was more flu and norovirus at this point last year compared with now. Last year the NHS could cope (just) with the flu, this year the NHS cannot cope even without flu. It is this problem we have to address. The run up to Xmas was mild - just like it was the year before - so why wasn't 2014 like 2013?
It isn't a small dip in A&E performance. Every winter you will find that *some* trusts will fail to meet targets (the usual suspects), but what is characteristic about this winter is that *every* trust has been effected, even the best performers. Since the dip (you claim "small", well on the front line it isn't seen that way) is universal, so there must be a universal reason for it. You're right to say that Labour have jumped upon the Lansley "reforms" (well, fragmentation of the NHS) without explaining why it has affected A&E performance. The problem is that most trusts will say that they really don't know - the problem started in the summer when we had winter activity all year with no lull. As you rightly say, no trust, nor NHS England can explain why, but the facts are clear - there are large numbers of frail elderly people, who are sick with multiple conditions and these are the reason for the drop in performance. 
People from different parts of the health service and different political persuasions, will have their theories, but it is rather silly to blame it on the GP contract because the performance problems is not due to the people who would have otherwise gone to a GP. You dispute the cuts in social care, which I think is brave since many social services are close to collapse. (My theory, is that it is community health services, that has failed. I think we have got to the limit of treating people "in the community", at home or in nursing homes, certainly at the level of funding there is now. Nursing homes are a particular problem, there isn't enough NHS medical care in those homes (which is their right), so people are deteriorating unseen. You *can* blame GPs for that. Consequently people are being admitted from care homes in a poorly state. But I can be wrong, just like anyone else.)
You say "the reforms – largely focussed on making doctors responsible for long-term NHS planning", which is a statement from a politician, not from someone with any experience in how CCGs run. Most GPs will tell you that they have no more control or say in how local services are planned. GPs are inherently independent and most of them want to remain so. A few GPs have got involved in CCGs, but this happened with PCTs too. GPs joined the PCT and became managers and those few GPs who have joined CCGs have now become managers too. Analysis I have carried out on CCGs show that less than a third of CCG boards have a GP majority (and mostly, that is the limit of GP involvement). Plus ca change, plus c'est la meme chose.
In fact the fragmentation of commissioning has been a disaster, which is why things are changing now and with co-commissioning CCGs are starting to look just like PCTs. For my condition - type 1 diabetes - there was one commissioner of all the NHS services I use in 2010. Now there are three different commissioners, one for the GP services, one for the hospital services and (bizarrely) another one for the monitoring of my diabetic eyes. None of these commissioners talk to each other. Whenever I ask them why such-and-such service is not integrated with the other services (like it was in 2010) I am told "we don't commission that". It's a mess, and the mess was predicted when Lansley came up with his plans in 2010.
You talk of the timing "why would a set of reforms cause short-term problems in our A&Es two-and-a-half years after most of them were in place". This is a valid question (except your calendar is wrong, the reforms came into place in April 2013, 20 months ago, not 30 months ago). However, I think you are saying "look over there". We know that social care has been viciously cut in the last four years (NAO says a 7% cut in spite of a £1bn from the so-called ringfenced NHS budget every year), and four years of cuts are enough to put that service to the edge. Four years of a deteriorating service is more likely to have an effect than a 20 month old policy, however cracked-pot that police was.
Your Wales argument is a red herring. Wales is mostly rural, it has higher levels of deprivation than England and is arguably too small and too dispersed to be an effective health system. The problem in Wales is not Labour, it is Wales, and maybe we should accept that devolution of the NHS to Wales was a mistake.
Bear in mind that Morgan works for a public relations company and its a fair bet that they have a contract with someone or other connected to the Conservative party, so the piece is more PR than anything else. I thought I would fill in the gaps in the PR piece.