According to Monitor the memberships of Foundation Trusts at 31 March this year were 1,236,132 public members (opt-in) and 516,361 staff members (opt-out). According to the BBC political party membership in 2011 was Conservative 177,000, Labour 190,000, and Lib Dem 66,000. So the political parties with 236k members (the Coalition) are making laws that will affect the trusts which have 1.2m public members.
There's more of us than there are of you, perhaps you should ask us (FT members) what we want before you make changes?
Wednesday, 19 October 2011
Friday, 14 October 2011
Monitor and CQC: unfit for purpose?
The report yesterday from CQC about dignity and nutrition at NHS hospital trusts raises several questions. Clearly it is unacceptable that people are not fed. However, one question that has not been asked is: why did these trusts get into the this situation?
The report lists trusts that they categorise as raising "major concerns and those that raised "moderate concerns". Interestingly the media give the aggregate of these two – 20 trusts – rather than reporting that there were just two that raised "major concerns". These two worst trusts are NHS Trusts, that is, they have not yet achieved Foundation Trust status. Of the 18 that raised "moderate concerns" nine are Foundation Trusts.
When Foundation Trusts were introduced the initial criteria were financial: if a trust showed that it had the financial skills to keep in the black (indeed, to make a surplus every year) then it was awarded FT status. When the Mid Staffs scandal blew up, the Foundation Trust regulator, Monitor, initially suspended all applications and then changed the authorisation criteria so that a trust has to show that it fulfils clinical as well as financial criteria. After authorisation a FT must continually prove that it meets the authorisation criteria (listed here, pdf) or else it will be in breach of its authorisation. Monitor has a range of powers varying from requesting that changes are made, to interventions like replacing board members, to the ultimate sanction of de-authorising a trust. (Of course, after the Health Bill is passed de-authorisation will not be an option since there is nothing a trust can be de-authorised to.)
Monitor states that FTs boards must continue to show that their trust complies with their authorisation criteria including:
- delivering healthcare services to specified standards under agreed contracts with their commissioners;
- maintaining registration with the Care Quality Commission and addressing conditions associated with registration;
- complying with healthcare targets and indicators
- cooperating with the Care Quality Commission and a range of NHS and non-NHS bodies which may have a remit in relation to the provision of healthcare services
This says that to remain as an FT a trust must show that it provides high quality healthcare. CQC inspects all FTs and reports their findings to Monitor who then issues notifications of breaches. Monitor says that:
"In cases where the Care Quality Commission indicates that it has material concerns regarding an NHS foundation trust’s registration with Care Quality Commission standards, Monitor will work with the Care Quality Commission to establish the most appropriate course of action to return the trust to compliance with those standards in a suitable timeframe."
So it is quite clear that between them CQC and Monitor have a responsibility to ensure that FTs have high standards of clinical care. If a trust's standards fall this should be picked up by CQC, who will then inform Monitor. Monitor then determines the intervention that is needed.
Monitor lists nine FTs where an intervention was necessary, most of these interventions were due to poor financial governance and only one was listed in the CQC nutrition and dignity report. Monitor also lists 12 hospitals in breach of their authorisation, none of which are in the CQC report. CQC lists on its website the trusts that it has concerns about. This gives just three acute hospital FTs and none of which were mentioned in their report on elderly care.
Why didn't CQC notice before that there were nutrition and dignity issues at the 20 trusts? Monitor exists to ensure that FTs are high quality. CQC has a responsibility to report on poor care. CQC and Monitor exist solely to ensure that Foundation Trusts are high quality, and any perennial failure in quality of FTs indicates that these two regulators are not fulfilling their responsibilities. There are serious questions that needs to be answered about whether these two regulators are actually fit for purpose. Finally, when the Secretary of State removes his own responsibility for the NHS bear in mind that we will be left to the mercy of these two organisations, there will be no one to take leadership over any failings in quality.
Update: Community Care have an article today about the reaction from Action on Elder on the CQC report. AEA say:
Update: Community Care have an article today about the reaction from Action on Elder on the CQC report. AEA say:
"These inspections suggest CQC has little or no sense or urgency in terms of its regulatory activity, often leaving very vulnerable people in neglectful or abusive settings while waiting for 'action plans' to be delivered by a care provider. In our view this is a major failing in its 'duty of care'."Remember that CQC has not yet taken over the responsibility for inspecting primary care: GPs, opticians, dentists etc. If CQC are failing now, what will it be like when their workload increases due to these extra duties?
Wednesday, 12 October 2011
Silver lining?
I am a pessimist (some would say a curmudgeon) so the votes in the House of Lords does not surprise me, especially since many of the Tory peers who voted probably had not been in the chamber for years and were voting out of mere loyalty to a political party.
The Bill:
One could argue that if Labour had won the election last year the NHS would have faced tightening finances too. Labour promised the same flat funding and also promised the £20bn "efficiency savings". However, Labour did not promise a £2bn re-organisation, but whether this extra £2bn of funding would have been enough to avert the financial crisis the NHS will suffer is something we will never know. The forthcoming financial crisis and the rationing inherent in the Bill will mean that the NHS will be the main issue at the next election.
The government know that there will be a financial crisis in the NHS, and they know that if it is not averted we will see patients on trolleys in corridors. Currently, Lansley is backtracking on NHS finances. At the Health Select Committee yesterday he said that the "efficiency savings" were "up to £20bn" rather than strictly £20bn. This will allow him to relax the "Nicholson Challenge" diktat when it becomes apparent that either the NHS cannot achieve a 4% cut every year, or that cutting so deep will push the service into crisis. Further, Lansley is also suggesting that some hospital trusts may be bailed out, something that the white paper last year said the government would not do.This is being done to make sure that there are not too many trust bankruptcies before the next election. Further - to try and persuade Lib Dem and Crossbench peers to vote against the Owen amendment - the government has conceded that the Secretary of State will have responsibility for the NHS (although we have yet to see the actual details, in particular, whether clause 10 will be removed).
So is there a silver lining? On a purely political basis, there is. From this point on the government cannot say that the state of the NHS is the fault of the last government: by passing this Bill they are making the NHS work their way. If this bill is killed then the Conservatives can say that the NHS that Labour bequeathed was wasteful and inefficient and say that this is why it is suffering a financial crisis.
When the Health and Social Care Bill is passed, the NHS will be Lansley's NHS and any ensuing financial crisis will be entirely the government's fault. At the next election Labour will be able to say to the electorate: look at what the Tories have done to our NHS. And hopefully, Labour will promise to fix the postcode lottery and raise funding to curtail healthcare rationing. We will all benefit.
The Bill:
- will not save money, quite the opposite, it will cost billions to implement and the bureaucratic structures that have been created will slow down any re-configuration that is needed and will cost a pile of money in the process;
- will produce a postcode lottery on a scale that England has never before experienced and as a consequence, health inequalities will increase;
- will mean that rationing will be rife and people will find that they have no recourse;
- together with the financial squeeze and the wasteful bureaucracy created by the Bill will result in a financial crisis
One could argue that if Labour had won the election last year the NHS would have faced tightening finances too. Labour promised the same flat funding and also promised the £20bn "efficiency savings". However, Labour did not promise a £2bn re-organisation, but whether this extra £2bn of funding would have been enough to avert the financial crisis the NHS will suffer is something we will never know. The forthcoming financial crisis and the rationing inherent in the Bill will mean that the NHS will be the main issue at the next election.
The government know that there will be a financial crisis in the NHS, and they know that if it is not averted we will see patients on trolleys in corridors. Currently, Lansley is backtracking on NHS finances. At the Health Select Committee yesterday he said that the "efficiency savings" were "up to £20bn" rather than strictly £20bn. This will allow him to relax the "Nicholson Challenge" diktat when it becomes apparent that either the NHS cannot achieve a 4% cut every year, or that cutting so deep will push the service into crisis. Further, Lansley is also suggesting that some hospital trusts may be bailed out, something that the white paper last year said the government would not do.This is being done to make sure that there are not too many trust bankruptcies before the next election. Further - to try and persuade Lib Dem and Crossbench peers to vote against the Owen amendment - the government has conceded that the Secretary of State will have responsibility for the NHS (although we have yet to see the actual details, in particular, whether clause 10 will be removed).
So is there a silver lining? On a purely political basis, there is. From this point on the government cannot say that the state of the NHS is the fault of the last government: by passing this Bill they are making the NHS work their way. If this bill is killed then the Conservatives can say that the NHS that Labour bequeathed was wasteful and inefficient and say that this is why it is suffering a financial crisis.
When the Health and Social Care Bill is passed, the NHS will be Lansley's NHS and any ensuing financial crisis will be entirely the government's fault. At the next election Labour will be able to say to the electorate: look at what the Tories have done to our NHS. And hopefully, Labour will promise to fix the postcode lottery and raise funding to curtail healthcare rationing. We will all benefit.
Monday, 10 October 2011
AQP and Commissioning
On the surface AQP (patient choice) and commissioning are antithetical since commissioning is carried out for a population, whereas patient choice is for the individual. However, the two can be combined. The House of Lords constitutional select committee report on the Secretary of State's duties outlines this:
The government's policy document Making Quality Your Business: A guide to the right to provide says:
Once AQPs have been licenced (and hence meet the criteria of CQC, Monitor and the CCG) they will be put on the list of providers from which the patients can choose:
The remaining "commissioning" part of CCGs is determining which services the NHS will pay for. This is clause 10 of the Bill and is also described in the Making Quality your Business policy document:
12. Clause 10 of the Bill amends section 3(1) of the NHS Act 2006. As amended, section 3(1) would provide as follows:In the 2006 Act it is the Secretary of State who has this responsibility. If this clause survives into the Act then CCGs will decide "to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility" the medical services in the area. That is, the CCG determines which services the NHS will pay for. So when GPs in Haxby offer private procedures to their patients they are merely jumping the gun: this is what it will be like in most areas after the Bill is passed. The CCG determines the services the NHS will pay for and private providers (including GPs themselves if they have a private business) can offer the services that are not paid by the NHS as private services.
(1) A clinical commissioning group [CCG] must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility—
(a) hospital accommodation,
(b) other accommodation for the purpose of any service provided under this Act,
(c) medical, dental, ophthalmic, nursing and ambulance services,
etc
The government's policy document Making Quality Your Business: A guide to the right to provide says:
To qualify as an AQP, providers will be subject to a qualification process. They will be required to show that they can meet the conditions of their licence with CQC and/or Monitor (if necessary), provide safe quality services to the contractual standards set by the NHS Commissioning Board and meet NHS prices – either set nationally or locally.This is where the Q in AQP comes in, once a provider has met the conditions of CQC and Monitor it becomes an AQP. However, CCGs do have some leverage, the same document goes on to say:
Commissioners (PCTs and consortia) can set reasonable additional contractually binding quality standards to meet the needs of particular communities or patient groups. This could include referral protocols and thresholds to manage demand and support integration with local services. Providers will be expected to work within and as part of the local health system.(Note that this pre-dates the introduction of the term CCG.) This says that CCGs can insist that AQPs meet the specific needs of their population and hence this is is another part of the Q in AQP and is part of the commissioning that the CCGs will do.
Once AQPs have been licenced (and hence meet the criteria of CQC, Monitor and the CCG) they will be put on the list of providers from which the patients can choose:
Commissioners cannot refuse to accept qualified providers once qualified, unless providers fail quality standards, reject the agreed price or refuse to comply with any reasonable, additional, locally set standards.GPs cannot tell patients which AQP provider to use and they cannot refuse to add an AQP provider to the list of providers patients can choose from, so any talk of GPs "protecting" NHS providers is fanciful because Monitor will force them to add AQPs to the providers list.
The remaining "commissioning" part of CCGs is determining which services the NHS will pay for. This is clause 10 of the Bill and is also described in the Making Quality your Business policy document:
It will be for commissioners to decide which services are best delivered through an AQP approach or tendering but the presumption will be that for most services patients will have a choice of Any Qualified Provider.This says that the government says that there should be a presumption that most NHS services will be AQP, but note that the commissioners (CCGs) decide which services are provided.
Saturday, 8 October 2011
Fickle Patients
Earlier this week I wrote for UK Uncut an article about how I think that the government's Any Qualified Provider policy will be the main driver to privatise the NHS. My argument was that the policy will create thousands of new providers who will appear on the Choose and Book system, and when a patient chooses a non-NHS provider that will mean money for their care will go to the new provider (most likely profit making) and not to their local NHS hospital. The result will be that the service in the NHS hospital will close (through lack of patients), and this may well have a knock-on effect of closing other, more complicated, services in the hospital that are cross-subsidised by the simpler services. (Poly Toynbee takes up this theme in her column in the Guardian today. An article that deserves a read.)
My message in my UK Uncut article was this. It's our NHS: Choose it, or lose it.
The problem is that this depends on patient choice, and patients are fickle. Let me give you an example. A few years ago I attended the AGM of the hospital local to me and there was a talk by their consultant eye surgeon. The talk was about Age-related macular degeneration. Until recently this was an untreatable condition: if you suffered the condition then you would go blind. Then it was discovered that people with one version of the condition (the so-called "wet" version) who were treated for bowel cancer found that the macular degeneration was halted. These patients were treated with an expensive drug called Avastin. Studies showed that when tiny doses of Avastin are used, the "wet" macular degeneration can be halted.
The surgeon told the AGM that such a dose of Avastin cost £1. The problem is that the drug company realised that patients were desperate to save their sight and would pay accordingly. The drug company chemically altered Avastin to remove the cancer treating property, but keeping the macular degeneration properties, and called this drug Lucentis. For no other reason than the fact that it would make them loads of money, the drug company priced Lucentis at £1000 per treatment. The surgeon told us that on average ten treatments were needed.
Avastin or Lucentis: £10 or £10,000? The surgeon said that all evidence showed that there was no difference between the two drugs other than the price. However, the drug company only applied for a licence for Lucentis to be used to treat "wet" age-related macular degeneration. Remember that we are told by the government that the NHS is horribly "wasteful"? It isn't. The surgeon told the AGM that when a patient is referred to his clinic it is explained to them that the licenced drug and the unlicenced drug are the same clinically, but there is a factor of a thousand in the cost of the drug. The hospital has to get the patient agreement to use the unlicenced drug and save the NHS (on average) £9,990 when saving their sight.
Half of patients choose the expensive drug even though it gave them no extra benefits.
Patients are fickle. Even when they are given all of the facts, there are some patients who think "if it costs a thousand times more, it must be better". I am sure the hospital did not mention rationing because they are professional. However, the half of patients who chose Lucentis also chose to deny another patient of a treatment that could improve their life, since there is a limited amount of money and money wasted on a drug that is priced to be a cash-cow is money that cannot be spent on other treatments.
In the future, when patients are given an AQP choice between a private hospital and an NHS hospital there will be some patients who will say (without any evidence to support their view): "the private hospital must be better". I want patients to defend our NHS, but I fear that too many will be enticed by irrational arguments to use non-NHS providers and this will result in our NHS hospitals closing.
Patients are fickle. This is why we will lose our NHS.
Update:
My thanks to @DrPanik on Twitter for this link to the New York Times describing the Avastin/Lucentis issue in the US.
My message in my UK Uncut article was this. It's our NHS: Choose it, or lose it.
The problem is that this depends on patient choice, and patients are fickle. Let me give you an example. A few years ago I attended the AGM of the hospital local to me and there was a talk by their consultant eye surgeon. The talk was about Age-related macular degeneration. Until recently this was an untreatable condition: if you suffered the condition then you would go blind. Then it was discovered that people with one version of the condition (the so-called "wet" version) who were treated for bowel cancer found that the macular degeneration was halted. These patients were treated with an expensive drug called Avastin. Studies showed that when tiny doses of Avastin are used, the "wet" macular degeneration can be halted.
The surgeon told the AGM that such a dose of Avastin cost £1. The problem is that the drug company realised that patients were desperate to save their sight and would pay accordingly. The drug company chemically altered Avastin to remove the cancer treating property, but keeping the macular degeneration properties, and called this drug Lucentis. For no other reason than the fact that it would make them loads of money, the drug company priced Lucentis at £1000 per treatment. The surgeon told us that on average ten treatments were needed.
Avastin or Lucentis: £10 or £10,000? The surgeon said that all evidence showed that there was no difference between the two drugs other than the price. However, the drug company only applied for a licence for Lucentis to be used to treat "wet" age-related macular degeneration. Remember that we are told by the government that the NHS is horribly "wasteful"? It isn't. The surgeon told the AGM that when a patient is referred to his clinic it is explained to them that the licenced drug and the unlicenced drug are the same clinically, but there is a factor of a thousand in the cost of the drug. The hospital has to get the patient agreement to use the unlicenced drug and save the NHS (on average) £9,990 when saving their sight.
Half of patients choose the expensive drug even though it gave them no extra benefits.
Patients are fickle. Even when they are given all of the facts, there are some patients who think "if it costs a thousand times more, it must be better". I am sure the hospital did not mention rationing because they are professional. However, the half of patients who chose Lucentis also chose to deny another patient of a treatment that could improve their life, since there is a limited amount of money and money wasted on a drug that is priced to be a cash-cow is money that cannot be spent on other treatments.
In the future, when patients are given an AQP choice between a private hospital and an NHS hospital there will be some patients who will say (without any evidence to support their view): "the private hospital must be better". I want patients to defend our NHS, but I fear that too many will be enticed by irrational arguments to use non-NHS providers and this will result in our NHS hospitals closing.
Patients are fickle. This is why we will lose our NHS.
Update:
My thanks to @DrPanik on Twitter for this link to the New York Times describing the Avastin/Lucentis issue in the US.
Sunday, 2 October 2011
Hospital Closures and Catchment Areas
If patients behaved as consumers there would be no such thing as distinct "hospital catchment areas" because a patient would treat all hospitals in England as a candidate for their choice and consequently each hospital would have a "catchment area" of England. However, we know that patients do not want choice: they just want to use their local hospital. The most rabid governmental promoters of competition, the Cooperation [sic] and Competition Panel, say "on average patients travel around 12km to their chosen provider", the "chosen provider" is quite clearly a local provider. So hospital catchment areas are important.
Health Service Journal and the Financial Times have recently come out with lists of hospital trusts at financial risk. HSJ came up with a list of 22 trusts where their PFI payments are so large that they are unlikely to be able to meet the financial criteria required to be authorised as a Foundation Trust. The Financial Times list 17 trusts where their level of historical debt (which includes PFI) threaten their ability to be authorised as Foundation Trusts. There is some overlap between the two.
HSJ-22
Mid Yorkshire Hospitals
North Cumbria University Hospitals
St Helens and Knowsley
Sandwell and West Birmingham
University Hospitals Coventry and Warwickshire
Hereford Hospitals
Walsall Hospitals
University Hospital of North Staffordshire
Worcester Acute Hospitals
Mid Essex Hospital
Barts and the London
Barking, Havering and Redbridge University Hospitals
South London Healthcare
West Middlesex University Hospital
North Middlesex
Royal National Orthopaedic Hospital
Dartford and Gravesham
Maidstone and Tunbridge Wells
Buckinghamshire Hospitals
Portsmouth Hospitals
Oxford Radcliffe (+ Nuffield Orthopaedic Centre)
North Bristol
FT-17
Mid Yorkshire Hospitals
North Cumbria University Hospitals
Trafford Healthcare
Hinchingbrooke Healthcare
North Bristol
Royal United Hospital Bath
Winchester and Eastleigh Healthcare
Heatherwood and Wexham Park Hospitals
Buckinghamshire Healthcare
Surrey and Sussex Healthcare
Royal Cornwall Hospitals
North West London Hospitals
West Middlesex University Hospital
St George's Healthcare
Whipps Cross University Hospital
Barking, Havering and Redbridge University Hospitals
South London Healthcare
In the original Bill the government said that if a trust is not a Foundation Trust by April 2014 it would cease to exist (meaning, it would have to merge with an existing FT, or close). Such a pronouncement was simply bonkers: there just wasn't enough time to change the finances of trusts with extremely large debts. Lansley stuck to the ludicrous deadline until the Future Forum made it clear how daft this deadline is. The deadline has now been moved to April 2016 and there is talk of it being pushed further into the future.
Politically it was bonkers too because a deadline of April 2014 would have meant that the government would go into the next election under the shadow of closing hospitals. Voters like hospitals and it is a brave politician that says that an NHS hospital must close. So there is an important political aspect too. Last December I pointed out that Labour and Liberal Democrat areas have a higher number of Foundation Trusts than Conservative areas. Foundation Trusts in general are the hospital trusts with better finances, so my limited analysis from last year showed that Conservative and Liberal Democrat MPs would be more at risk than Labour MPs seeking re-election.
Since last December I have been working on this political aspect, but it is not easy. One way to look at the issue is to look at the constituency where the trust is located. However, since the average constituency size is about 70k and even a small district general hospital will cover a population of several hundred thousand, it is clear that more than one constituency will be affected by the financial issues at a single trust. There is also the fact that in urban areas the catchment of hospitals overlap, so in the overlapping areas (where patients have two or more hospitals that they can regard as "local") the poor finances of one hospital will have a lesser effect. Clearly, any analysis means taking into account several constituencies around the trust and making estimates to "weight" the effect of poor finances.
Even so, in June I created the following spreadsheet to try and analyse the political effect of hospital finances. This is an extract because I collated more information but I could not come up with a good conclusion from the data. If you take a figure of around 5% as a "marginal" then the figures (for the combined HSJ-22 and FT-17 list) show that three Labour marginals and five Conservative marginals are affected. If we assume the campaigning in these marginals will target the Coalition (and increase the Labour vote) then these hospital trusts will only affect five seats, and of these only two are where Labour came second (and could take the seat). I rejected this analysis because it is far too simplistic to assume that only one seat would be affected by the local trust's finances.
Over the last few months I have tried to get an idea of the catchment areas of trusts. It is not an easy thing to do. Some trusts list in their annual reports the populations they cover; some trusts list this in their descriptions on the NHS Choices and some list it in their descriptions on the Dr Foster Intelligence website. The problem is that not all trusts do this, so if you use data from these sources you have to do some guess work.
A better way to determine the catchment area is to look at the home addresses of the patients who use a hospital. Such information is collated by the Hospital Episode Statistics Online website. Home addresses are personal and it would not be ethical for this information to be made public. However, it is possible to convert a postcode into a local authority election ward and since each ward is about 10k - 15k such data will not have patient identification values but can still be used to determine catchment areas. Unfortunately HES Online do not provide this data by default, but can provide it on request (for a fee).
This is what the South West Public Health Observatory have done. They have analysed HES data which includes the home address of the patient and produced a series of maps with electoral wards colour coded according to the number of patients who use the hospital. Take for example North Bristol NHS Trust. This is on both the HSJ-22 and FT-17 lists. The SWPHO gives the following map for the catchment area (I have provided an extract to conserve space).
The darker the blue shading, the more patients use the trust (the circles also indicate the number of patients). If we ignore the cyan areas (since some patients choose to go to other hospitals in these areas) and concentrate on the three shades of blue, we can see that patients come from seven 2010 constituencies and partially from another constituency. These constituencies are:
Bristol East (Labour, majority: 8.3%, 3,722)
Bristol South (Labour, majority: 9.8%, 4,734)Bristol West (LD, majority: 20.5%, 11,366)
Thornbury and Yate (LD, majority: 14.8%, 7,116)
Bristol North West (Conservative, majority: 6.5%, 3,274)
Filton and Bradley Stoke (Conservative, majority: 14.3%, 6,914)
Kingswood (Conservative, majority: 5.1%, 2,445)
North Somerset - partially (Conservative, majority: 13.6%, 7,862)
If we use the simplistic analysis of looking at the constituency where the trust is located then only Bristol North West would be at risk. However, widening out the analysis to include neighbouring constituencies where many patients live, the figures show that if there is a backlash against the Coalition parties due to the situation at North Bristol NHS Trust then at least two Conservative seats (Bristol North West and Kingswood) would be affected.
Saddly, other Public Health Observatories have not carried out the same analysis (or if they have, they do not make it publicly available). So to do a complete analysis of the effects of the HSJ-22 and FT-17 work will need to be done using HES data to map the catchment areas of these trusts.
Catchment areas are important.
MHP is a consultancy agency that have recently got some publicity over an article they wrote about the political aspect of the financial situation of trusts using the new constituency boundaries. Unfortunately they have rather lazily taken the approach of looking at the constituencies where the trusts are locate (an approach which I rejected - see above). Their "analysis" that caused a bit of a stir amongst the health policy twitterati says
So why haven't I done a more complete analysis? Money. Currently I am unemployed and I cannot afford to pay for the data. A tailor made dataset from HES Online that lists the patients using a hospital broken down into the wards where they live will cost between £348 and £773. I do not have that sort of money to spend. Also, the analysis will take time and if I get offered a job I will stop that work immediately. If someone is willing to pay me, say, a month's work (plus the expenses of getting the HES data) then I am willing and able to do the work.
I am surprised that MHP didn't do this work correctly, since their analysis shows that they really do not understand catchment areas of hospitals.
Health Service Journal and the Financial Times have recently come out with lists of hospital trusts at financial risk. HSJ came up with a list of 22 trusts where their PFI payments are so large that they are unlikely to be able to meet the financial criteria required to be authorised as a Foundation Trust. The Financial Times list 17 trusts where their level of historical debt (which includes PFI) threaten their ability to be authorised as Foundation Trusts. There is some overlap between the two.
HSJ-22
Mid Yorkshire Hospitals
North Cumbria University Hospitals
St Helens and Knowsley
Sandwell and West Birmingham
University Hospitals Coventry and Warwickshire
Hereford Hospitals
Walsall Hospitals
University Hospital of North Staffordshire
Worcester Acute Hospitals
Mid Essex Hospital
Barts and the London
Barking, Havering and Redbridge University Hospitals
South London Healthcare
West Middlesex University Hospital
North Middlesex
Royal National Orthopaedic Hospital
Dartford and Gravesham
Maidstone and Tunbridge Wells
Buckinghamshire Hospitals
Portsmouth Hospitals
Oxford Radcliffe (+ Nuffield Orthopaedic Centre)
North Bristol
FT-17
Mid Yorkshire Hospitals
North Cumbria University Hospitals
Trafford Healthcare
Hinchingbrooke Healthcare
North Bristol
Royal United Hospital Bath
Winchester and Eastleigh Healthcare
Heatherwood and Wexham Park Hospitals
Buckinghamshire Healthcare
Surrey and Sussex Healthcare
Royal Cornwall Hospitals
North West London Hospitals
West Middlesex University Hospital
St George's Healthcare
Whipps Cross University Hospital
Barking, Havering and Redbridge University Hospitals
South London Healthcare
In the original Bill the government said that if a trust is not a Foundation Trust by April 2014 it would cease to exist (meaning, it would have to merge with an existing FT, or close). Such a pronouncement was simply bonkers: there just wasn't enough time to change the finances of trusts with extremely large debts. Lansley stuck to the ludicrous deadline until the Future Forum made it clear how daft this deadline is. The deadline has now been moved to April 2016 and there is talk of it being pushed further into the future.
Politically it was bonkers too because a deadline of April 2014 would have meant that the government would go into the next election under the shadow of closing hospitals. Voters like hospitals and it is a brave politician that says that an NHS hospital must close. So there is an important political aspect too. Last December I pointed out that Labour and Liberal Democrat areas have a higher number of Foundation Trusts than Conservative areas. Foundation Trusts in general are the hospital trusts with better finances, so my limited analysis from last year showed that Conservative and Liberal Democrat MPs would be more at risk than Labour MPs seeking re-election.
Since last December I have been working on this political aspect, but it is not easy. One way to look at the issue is to look at the constituency where the trust is located. However, since the average constituency size is about 70k and even a small district general hospital will cover a population of several hundred thousand, it is clear that more than one constituency will be affected by the financial issues at a single trust. There is also the fact that in urban areas the catchment of hospitals overlap, so in the overlapping areas (where patients have two or more hospitals that they can regard as "local") the poor finances of one hospital will have a lesser effect. Clearly, any analysis means taking into account several constituencies around the trust and making estimates to "weight" the effect of poor finances.
Even so, in June I created the following spreadsheet to try and analyse the political effect of hospital finances. This is an extract because I collated more information but I could not come up with a good conclusion from the data. If you take a figure of around 5% as a "marginal" then the figures (for the combined HSJ-22 and FT-17 list) show that three Labour marginals and five Conservative marginals are affected. If we assume the campaigning in these marginals will target the Coalition (and increase the Labour vote) then these hospital trusts will only affect five seats, and of these only two are where Labour came second (and could take the seat). I rejected this analysis because it is far too simplistic to assume that only one seat would be affected by the local trust's finances.
Over the last few months I have tried to get an idea of the catchment areas of trusts. It is not an easy thing to do. Some trusts list in their annual reports the populations they cover; some trusts list this in their descriptions on the NHS Choices and some list it in their descriptions on the Dr Foster Intelligence website. The problem is that not all trusts do this, so if you use data from these sources you have to do some guess work.
A better way to determine the catchment area is to look at the home addresses of the patients who use a hospital. Such information is collated by the Hospital Episode Statistics Online website. Home addresses are personal and it would not be ethical for this information to be made public. However, it is possible to convert a postcode into a local authority election ward and since each ward is about 10k - 15k such data will not have patient identification values but can still be used to determine catchment areas. Unfortunately HES Online do not provide this data by default, but can provide it on request (for a fee).
This is what the South West Public Health Observatory have done. They have analysed HES data which includes the home address of the patient and produced a series of maps with electoral wards colour coded according to the number of patients who use the hospital. Take for example North Bristol NHS Trust. This is on both the HSJ-22 and FT-17 lists. The SWPHO gives the following map for the catchment area (I have provided an extract to conserve space).
The darker the blue shading, the more patients use the trust (the circles also indicate the number of patients). If we ignore the cyan areas (since some patients choose to go to other hospitals in these areas) and concentrate on the three shades of blue, we can see that patients come from seven 2010 constituencies and partially from another constituency. These constituencies are:
Bristol East (Labour, majority: 8.3%, 3,722)
Bristol South (Labour, majority: 9.8%, 4,734)Bristol West (LD, majority: 20.5%, 11,366)
Thornbury and Yate (LD, majority: 14.8%, 7,116)
Bristol North West (Conservative, majority: 6.5%, 3,274)
Filton and Bradley Stoke (Conservative, majority: 14.3%, 6,914)
Kingswood (Conservative, majority: 5.1%, 2,445)
North Somerset - partially (Conservative, majority: 13.6%, 7,862)
If we use the simplistic analysis of looking at the constituency where the trust is located then only Bristol North West would be at risk. However, widening out the analysis to include neighbouring constituencies where many patients live, the figures show that if there is a backlash against the Coalition parties due to the situation at North Bristol NHS Trust then at least two Conservative seats (Bristol North West and Kingswood) would be affected.
Saddly, other Public Health Observatories have not carried out the same analysis (or if they have, they do not make it publicly available). So to do a complete analysis of the effects of the HSJ-22 and FT-17 work will need to be done using HES data to map the catchment areas of these trusts.
Catchment areas are important.
MHP is a consultancy agency that have recently got some publicity over an article they wrote about the political aspect of the financial situation of trusts using the new constituency boundaries. Unfortunately they have rather lazily taken the approach of looking at the constituencies where the trusts are locate (an approach which I rejected - see above). Their "analysis" that caused a bit of a stir amongst the health policy twitterati says
"New research reveals that 21 struggling NHS trusts will be located in marginal constituencies at the next election following a review of constituency boundaries. Of these, 12 are located in ‘super-marginals’ with a notional majority of less than 1,000 after proposed boundary changes come into effect."I think that this seriously under-estimates the effect of the finances of these trusts: using the constituency where the trust's registered address is located is a poor method.
So why haven't I done a more complete analysis? Money. Currently I am unemployed and I cannot afford to pay for the data. A tailor made dataset from HES Online that lists the patients using a hospital broken down into the wards where they live will cost between £348 and £773. I do not have that sort of money to spend. Also, the analysis will take time and if I get offered a job I will stop that work immediately. If someone is willing to pay me, say, a month's work (plus the expenses of getting the HES data) then I am willing and able to do the work.
I am surprised that MHP didn't do this work correctly, since their analysis shows that they really do not understand catchment areas of hospitals.
Saturday, 1 October 2011
Charidee
What are charities, the "voluntary sector", the "third sector"?
My definition of a charity is an organisation that has a social purpose not already provided by the state. Charities campaign and they provide support. These two aspects of charities are vital. And it is vital that they do these independent of the government. (Hence why the term Non Government Organisation is used for many charities.)
But should a charity provide services?
Support and campaigning are services, but should they provide services that are already (or should be) provided by the state? In my opinion, they should not. If charities provide services how can they continue to provide support for service users? How can they campaign on behalf of service users? They cannot, because they will be campaigning against themselves and supporting service users against themselves. There is a huge conflict of interest that no one seems to have noticed. Once a charity provides a service, it cannot support the people using that service. The only solution is for someone else to create a charity to support service users who are using a service provided by another charity. Madness!
Sadly, some charities seem to have decided that they are more than they should be. At the Labour party conference this week I attended a fringe meeting hosted by two charities, Rethink and Age UK. These charities described the Health and Social Care Bill as an "opportunity". They do not see the Bill as a danger, a Bill that will fragment the NHS. In fact, I got the impression that they regarded the NHS as the "problem", and themselves as the only "solution".
There is very little difference between such charities and the private sector. Indeed, such charities are run as if they are businesses, with high paid executives, plush offices and extensive marketing departments. The only difference between such charities and private sector companies are that the profits in the former are recycled back into the organisation and in the latter profits are distributed to the shareholders as dividends.
There is very little that is "voluntary" about the "voluntary sector". In most charities, the majority (and probably all) of the staff are employed. In some cases I would prefer a private sector company to provide a public service because at least with a private company there is accountability to the shareholders. With a charity the accountability is to the trustees, but who are they? Often no one knows who the trustees are, or how they get to be appointed.
(Not all charities are bad. Some are excellent and campaign for, and provide support for very vulnerable people. Often they do so with very little administrative costs. However, this is not typical of the "third sector", it is filling with organisations that are simply businesses with little or no accountability.)
So when someone talks to you about charities providing public services, unblinker yourself and see them for what they are: non-public, non-accountable private organisations.
My definition of a charity is an organisation that has a social purpose not already provided by the state. Charities campaign and they provide support. These two aspects of charities are vital. And it is vital that they do these independent of the government. (Hence why the term Non Government Organisation is used for many charities.)
But should a charity provide services?
Support and campaigning are services, but should they provide services that are already (or should be) provided by the state? In my opinion, they should not. If charities provide services how can they continue to provide support for service users? How can they campaign on behalf of service users? They cannot, because they will be campaigning against themselves and supporting service users against themselves. There is a huge conflict of interest that no one seems to have noticed. Once a charity provides a service, it cannot support the people using that service. The only solution is for someone else to create a charity to support service users who are using a service provided by another charity. Madness!
Sadly, some charities seem to have decided that they are more than they should be. At the Labour party conference this week I attended a fringe meeting hosted by two charities, Rethink and Age UK. These charities described the Health and Social Care Bill as an "opportunity". They do not see the Bill as a danger, a Bill that will fragment the NHS. In fact, I got the impression that they regarded the NHS as the "problem", and themselves as the only "solution".
There is very little difference between such charities and the private sector. Indeed, such charities are run as if they are businesses, with high paid executives, plush offices and extensive marketing departments. The only difference between such charities and private sector companies are that the profits in the former are recycled back into the organisation and in the latter profits are distributed to the shareholders as dividends.
There is very little that is "voluntary" about the "voluntary sector". In most charities, the majority (and probably all) of the staff are employed. In some cases I would prefer a private sector company to provide a public service because at least with a private company there is accountability to the shareholders. With a charity the accountability is to the trustees, but who are they? Often no one knows who the trustees are, or how they get to be appointed.
(Not all charities are bad. Some are excellent and campaign for, and provide support for very vulnerable people. Often they do so with very little administrative costs. However, this is not typical of the "third sector", it is filling with organisations that are simply businesses with little or no accountability.)
So when someone talks to you about charities providing public services, unblinker yourself and see them for what they are: non-public, non-accountable private organisations.
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