More on NHS Privatisation

The government is now looking at privatising NHS Professionals the agency that provides temporary staff. So if your local hospital needs extra staff to cover sickness cover for its staff they usually look to NHS Professionals first. The organisation currently manages 50,000 staff who provide two million shifts a year. According to Karen jennings of Unison:

Ms Jennings said the move risked undermining the original purpose of NHS Professionals - "because private agencies were ripping off hospitals by charging them outrageous fees for recruiting or finding staff for shifts".

She added: "It makes no sense at all to bring back private companies who will want their slice of the action in return. This proposal is purely about Tory plans to promote privatisation and hive off parts of the NHS to private companies, regardless of the consequences on patient care."

At the moment the government wholly owns NHS Professionals and since the current Conservative government regards the organisation "as a business, not an agency" it is ripe for privatisation and so they are investigating into ways that private companies can "invest" in the organisation. The result, as ever, will be higher costs to pay for profits. Money that should be going into healthcare will nbe paying dividends for shareholders.

However, the plan may be illegal. A website, chiefofficers.net, that says that it is "written by senior business people, for senior business people", ie people who are in favour of privatisation, says:

"[a] question arises as to whether this is a lawful activity under securities laws [governing the public sector in Europe]. The general principle is that it is illegal to seek investment in a company except in very limited circumstances. A public offering that does not fall within those exceptions will often result in serious penalty for those who are convicted of the various offences related to the conduct."

It shows the incompetence of this Conservative government when a website like this is saying that they are privatising in a way that is illegal.

More NHS Cuts

A week ago I wrote that I was worried that our democracy was in danger because Commissar Lansley was pushing through his changes to the NHS without parliamentary approval. Now it appears that UNISON is to request a judicial review to halt the NHS cuts that David "I will cut the deficit, not the NHS" Cameron has fully endorsed.

"The government's white paper will change forever the NHS as we know it. These sweeping changes were not part of any party manifesto and it is outrageous that these changes are being brought in without consulting the public, patients, staff and unions," said Karen Jennings, Unison head of health.

"The NHS constitution enshrined in law the right to consultation and yet, in writing to NHS managers, Sir David is working on the premise that the consultation is only about the best way to achieve pre-determined outcomes - this makes it nothing more than a paper exercise and a sham.

In a frighteningly autocratic and politically-motivated response to Unison Sir David Nicholson said

"he was unwilling to reconsider his position and that he intends to carry on with his proposals"

Make no mistake, this is a civil servant saying that changes to the NHS must be started now, before proper public consultation and before parliamentary approval. This autocratic civl servant, no doubt under pressure from the extreme right-wing forces in the government, are changing our country in an authoritarian and non-democratic way. What else will these right-wing extremists do?

What about our democratic right to withdraw our labour? During the election, aware that Cameron would head the most right wing government we have ever seen, one of the themes of my campaigning was that I was sure that the only way that Cameron could push through his changes was to ban public sector strikes. Since Osborne was using the term Emergency Budget I was sure that Cameron would accompany it with a bill to restrict public sector strikes. I was a little premature, since the main cuts are due in the public spending review due to published in the Autumn. However, the government's vast army of spin doctors are at work persuading employers that they need these new changes. The BBC are reporting that a ban is imminent:

"Mike Emmott, CIPD employee relations advisor, said: "It is also incumbent on the government to consider the policy options open to it for reducing the risk of disruptive and damaging industrial action by public service employees, such as banning strike action of those involved in the delivery of essential services.""

Prescription Rationing

Yes, it is coming. The most vulnerable in our society - the sick - will find that in David Cameron's Big Society they are too expensive to be kept alive.

I have type 1 diabetes, I have had the condition for 35 years, ever since I was a boy. It is not my fault, it is a genetic condition. I am kept alive by regular injections of insulin. I take two, a short acting one (about £2 per ml) and a long action one (about £1.80 per ml). Without the insulin I would be dead in a few days, or maybe a couple of weeks. If I have too little insulin, or the wrong type, then it leads to complications. Insulins have changed a lot in 35 years, and understandably my control was not perfect when I was younger when I took the older, less effective, insulin. I am paying for that now. Five years ago I lost the sight in my right eye, but an operation from a skilled NHS surgeon restored my sight. The operation clearly cost money, and this is the cost of the poor control that the old insulins offered. Keeping your sight is a big incentive to look after yourself.

Insulins have changed over the years. Some have given improvements, others have not. Different people are suited to different insulins. I use human insulin - produced commercially by genetically engineered yeasts - and these suit me. They are not perfect, but my control is good enough to reduce the likelihood of complications. The human insulins I take are very common and are the cheapest on the market. Inevitably, when new insulins become available they will be more expensive and the drug companies will try to get as many people to use them.To do this their marketing people will tell doctors how wonderful the insulins are, and while this maybe true for some people, it is not necessarily true for all. 

About a decade and a half ago insulin analogues became available on the NHS and these were supposed to be the wonder drug for diabetics. I tried one short acting insulin analogue for a year (current price of this £3.20 per ml, so 50% more than my current insulin) and my control went haywire. I could not manage my blood sugar and I put on weight. I decided to go back to the human insulin and my control returned. So I was back on the cheap, but suited-to-me, human insulin.

Sometimes the drug companies use less acceptable methods to persuade you to move to their new products. Five years ago the manufacturer of the short acting insulin I take said that they would no longer produce it. (Interestingly, I can still find it sold online at £2.40 per ml.) Can you imagine how I felt? This was a drug that kept me alive and I was given just 2 months notice of it being withdrawn. Luckily I had a scheduled appointment with my diabetic specialist before that deadline. The recommendation from the drug company was to use their short-acting insulin analogue (current price £5 per ml). This was equivalent to the one I had tried five years before and with which I had problems. So my doctor put me on another short acting human insulin from another manufacturer (current price £2 per ml), and it turns out that I am suited to that. The drug company wanted the NHS to pay two and a half times more.

At the same time the doctor thought he could improve my control by changing my long acting human insulin to a long acting human insulin analogue. When I got home I looked up the new insulin on an internet pharmacy and found that it cost four times as much as the human insulin I was using before (current price £7.50 per ml as opposed to £1.80 per ml). Is the cost a problem? Well not really, if you consider that better control could mean that I avoid costly treatment for the complications of diabetes.

It turned out that I was not suited to the expensive long acting human insulin analogue. And after three years of battling with my blood sugar I took another unilateral decision and changed back to the cheaper long acting human insulin.

Why do I mention this? Well today I see that the National Prescribing Centre have issued cost-cutting guidelines to GPs and the long acting insulin analogue that I was using until the beginning of last year is on the list.Voluntarily my body had saved the NHS some money and cut my costs of long acting insulin usage by a quarter. However, it worries me how far this cost-cutting will go.

The figures I have give above are from here, of course, you cannot buy insulin without a prescription. If you want to know how much my insulin costs per day, here are the figures.

3 x 0.24 ml @ £2.00 per ml = £1.44

0.70 ml @ £1.80 per ml = £1.26

Total = £2.70

There's no NHS ring fence

I have railed about this before, but I think I have to keep repeating it until people start to listen: there is no NHS ring fence.

The NHS is the public service, publicly owned, paid out of general taxation. The funding for the NHS, the publicly owned service, is being severely squeezed by this disgracefully dishonest government. And then mantra of this government is that what is a loss for the public sector is a gain for the private sector. NHS hospitals are being purposely pushed towards bankruptcy by Lansley's plans while with the other hand he is handing public money over to the private sector and opening up the system to co-pay.

Take for example this news story:

"Up to 600 jobs are to go at Reading's Royal Berkshire Hospital (RBH) by 2015 to save £60m, the BBC has learnt. Chief executive Edward Donald said the hospital still needed to save millions even though funding for the NHS as a whole was being ring-fenced."

So what we are seeing here are cuts to an NHS hospital and the wheeling out that bizarre statement that NHS funding is "ring fenced"? If it is "ring fenced" then why are the cuts necessary? Why does RBH have to cut £60m and where will that money go?

Oh and who could take seriously a Chief Executive who makes such a glaring grammatical error as this?

"Mr Donald said the hospital would be looking at what it could do differently "to get through the same amount of work but with less people"."

I know it is pedantic, but it is a basic rule of English grammar: if you can count it, then use fewer. If he does not know that, then no wonder he's been hoodwinked into thinking that there is a "ring fence".

It's all about pensions

Think about it.

A social enterprise is a private company, which means that its employees are not NHS employees. When an NHS trust becomes a social enterprise it will take its employees out of the NHS. Those employees will take their NHS pension with them and they will continue to contribute to their NHS pensions. But new employees will not get an NHS pension, they will have to start a private pension. And if an employee moves from one "social enterprise" trust to another they will be moving from one private company to another. This means that if they had a right to contribute to an NHS pension in their previous place of employment they won't in their new one. The result of this is to slowly wipe out the government's responsibility for providing pensions in the healthcare sector.

Social Enterprises: It's all about pensions. I do hope the unions catch on soon, because once they do all hell will break loose.

Risk Pool

I missed this during my read of the NHS White Paper.

"[Monitor will have] powers to levy providers for contributions to a risk pool;" (4.27)

The reason for this is that Monitor will have

"powers to protect assets or facilities required to maintain continuity of essential services; [and] authorising special funding arrangements for essential services that would otherwise be unviable" (4.27)

in effect, Monitor will demand a payment from every provider and this will be used only to provide essential services should a provider goes bankrupt. In effect this means that if your local hospital goes into debt (which will become more likely under the new funding plans) then Monitor will be able to step in and save A&E and nothing else.

Prof Maynard at Health Policy Insight has this to say about the situation:

Monitor – the provider insurer of last resort
Monitor is also to tax all providers, public and private, to create a risk pool which can be used to bail out failing trusts. What will be the basis of this taxation?


If the greater risks are taxed more, these marginal entities will be driven further into insolvency. Or are the best endowed to be taxed more, to keep the marginal and often badly-run trusts in business?


Why should Plain Crap FT be bailed out by Staggering Along FT? And if this is judged right and Plain Crap cuts its quality to stay in business, how will Monitor and CQC reconcile their anxieties about patient safety?


Remember Mid Staffs?!

Further, if the hospitals who perform the most risky procedures will be taxed more, then wouldn't this be an incentive against performing those procedures?

A similar situation occurred at Mid Staffs, and I recommend that you read the Francis report for more details. Volume 1, Section G, paragraph 50 says:

The latest figures for Mid Staffordshire show an astonishing apparent recovery. The HSMR from the Dr Foster Unit for 2008/09 was 89.6. In the Good Hospital Guide 2009, produced by Dr Foster Intelligence, the hospital is now in the top band as one of the top 14 hospitals with a patient safety score of 93.83 against the top performer (100) and the lowest of 0.00. This is, of course, a different measure than mortality, though the patient safety score does include it. The figures were announced during the period when the Inquiry was holding oral hearings in Stafford and were touched on by witnesses at the Inquiry. Mr Sumara told me that:


"I think there are four elements in why Dr Foster is different… which I have no evidence for and I can’t give you any detail. One is that the coding is just better now. The second one is we don’t do strokes any more. The third one is we don’t do MIs [myocardial infarctions] any more and the fourth one is actually because we have improved that emergency care pathway, your chances are you will get to see the right doctor quickly if you are medically ill. I think that will make a big difference to outcomes eventually. But I have got no evidence to say that has done the trick. In many ways do I care because all I am interested in is can I get it right every time? It is a bit of reassurance."

The HSMR figure for April 2007 was 127, but this fell to 89.6. What does this mean? Well HSMR is essentially a measure of greater mortality at the hospital. The expected mortality is indexed at 100 so 127 means that mortality is 27% greater than expected (I caution you against regarding this to mean that those 27% more people died "needlessly").

So what caused the fall? Look at the items I have highlighted in Mr Sumara's reply. The hospital have stopped doing two types of work which have high risks of death - those patients are now someone else's problem. Mid Staffs had to do something about their HSMR figures, especially since the dumber-than-dumb tabloid press were making out that the hospital was some kind of charnel house killing 400-1200 people (a nonsense figure that the Francis Report dismisses). So they simply stopped doing risky work. Problem solved.

If Monitor's tax on a hospital is too high for the hospital to pay then won't they have the incentive to stop doing risky procedures to reduce their "risk pool tax"? If so then where do those sick people go?

What's the value of your reputation?

And how much would you sell it for? This is an interesting issue and it is being debated by GPs and accountants. Currently the Government owns a brand called the NHS. It has an immense reputation not only here but also abroad. How much is that worth?

Companies often buy and sell reputation. Mergers and takeovers may be to take over a product or intellectual property, or it may be simply to purchase a company name, and hence the reputation that goes with the name. Reputation is clearly an asset and has a value. Professionals often buy and sell reputations, it is called goodwill.

Since the inception of the NHS in 1948 selling the goodwill in GP practices has been illegal, but the Blair government relaxed this in 2004.The rules say thata practice with a list of patients cannot sell goodwill, but a practice with no list of patients (for example a Alternative Provider Medical Services - APMS - contractor) can sell their goodwill. Also out-of-hours, additional and enhanced services are not covered by the ban.

Goodwill is valuable and solicitors and accountants are used to the concept of buying and selling it. Laurence Slavin at healthcarerepublic says that "a goodwill valuation of 50 per cent of turnover is not unusual". Slavin also gives an example where if the ban on the sale of goodwill is repealed then  hypothetically the partners in a GP practice (the doctors) could sell the goodwill to an APMS and become employees of the new practice on a salary but also eligible for profit share. The APMS then runs the practice as a private enterprise. Andy Cowper, the editor at Health Policy Insight, says that the value of the goodwill of GP practices is around £8bn and currently it is owned by the Secretary of State for Health, Andrew Lansley. Cowper asked Lansley recently:

"who will own the goodwill and intellectual property in GP commissioning consortia, and will there be an asset lock on these?
"

Lansley replied,

"I see no basis on which consortia could realise and distribute goodwill".

 According to Policy Exchange

"The prohibition of the sale of goodwill on GP practices further adds to market distortion by preventing the sale GPs practices at true and fair value."

and they recommend:

"As part of the process of introducing fundholding to GP practices [ie GP Commissioning], restrictions on the sale of goodwill in GP practices should be lifted. This will enable high performing GP practices to take over poorly performing practices."

It would be interesting to see how long Lansley thinks he can resist allowing GPs to sell goodwill.