Norwich South

I think Norwich South shows what went wrong with Labour over their three terms of office. This first graph is the majority that Labour had from 1997 in a seat that has been a Labour seat for a decade before:

A huge 14,000 majority in 1997 has shrunk so much that the Labour candidate lost at the 2010 election by 310 votes. Why was this the case? Well, let's ignore for a moment the candidate who achieved the 14k majority and lost it last year, and instead look at how people have voted in that constituency. In this graph I have plotted the votes for the three main parties, and the Greens:

The Labour vote plummets: halving over the 13 years. The Conservative vote dips and rises slightly over that period. The main beneficiaries of the lost Labour vote have been the Lib Dems and the Greens, and in particular the latter: the Green vote has increased by a factor of ten. The interesting point is that the polls for the three parties are converging over that decade.

Now look at the British Attitudes Survey from 2009

This shows a similar convergence between Labour and the Conservatives. (The Lib Dem bounce in the year before the 2010 is not recorded here.) There is a rise in those people who regard themselves as having no political affiliation, or don't know, and  'other' also increases. In Norwich South the Greens have benefited from the rise in 'other' and possibly from those people with no affiliation choosing the Greens as a protest vote.

Of course, it could be the Labour candidate who inherited a constituency with 6k majority at a time when there was a national mood for a Labour landslide and then, after gaining a 14k majority in 1997, allowed it to slide by his behaviour in Parliament both as a minister and as a backbencher with a grudge. The losing Labour candidate was, of course, Charles Clarke.

Secretary of State Responsibility

The Department of Health has produced a document called the Memorandum for the House of Lords Delegated Powers and Regulatory Reform Committee. At 322 pages, it is rather long, but it is worth skimming through to see how the department thinks it can persuade the Lords.

In this blog I want to address the duty of the Secretary of State for Health.There is a lot of controversy about this at the moment and it is rumoured that the Liberal Democrats will capitulate and will not take part in voting in the House of Lords if the government can come up with words that reassure them about the role of the SoS. If this is the case then it is disgusting that Lib Dems have agreed to a shady backroom deal and shirk their Parliamentary duty, but to be frank, it would not surprise me.


The memorandum starts with the following paragraph:

10. The Bill maintains the overarching duty of the Secretary of State, which dates from the original NHS Act of 1946, to promote “a comprehensive health service designed to secure improvement in the physical and mental health of the people of England, and in the prevention, diagnosis and treatment of illness.” It distinguishes for the first time between healthcare and public health, laying the way for the new Public Health England. It also sets clear constraints on the Secretary of State’s ability to intervene in the NHS.

This is bizarre, first it says that the SoS duty conferred by the 1946 Act will be maintained, but then says that the SoS's ability to intervene is constrained. So which is it, the SoS maintains his historic duty or is constrained? You cannot have both.

The next paragraph makes it clear that the SoS will lose powers:

11. The Bill sets out a framework for the NHS in which functions are conferred directly on the organisations responsible for exercising them and the Secretary of State retains only those controls necessary to discharge core functions. This contrasts with the current model, in which the majority of duties, powers and functions are conferred on the Secretary of State and then delegated to NHS bodies.

This tells us that the current situation is that the SoS has "duties, powers and functions" conferred upon him but the Bill will strip him of these and will only get "those controls necessary to discharge core functions". This is exactly what we are complaining about. The original NHS Act put a duty on the SoS and we expect the minister to be responsible. The Bill removes that responsibility. It is clear that the SoS cannot run the entire health service himself and so has to delegate that responsibility to other organisations. But the important point is that at the moment the buck stops at the SoS. We hold him to account, and this means that he has an incentive to improve the service. The Bill removes that incentive.

The document is full of contradictions, it tells you what will happen and then tells you that the result will be something other than what the policy will do. For example:

15. The Bill also places a new duty on the Secretary of State to act with a view to promoting the autonomy of arm’s length bodies, commissioners and providers to exercise their functions as they see fit, so far as is consistent with the interests of the health service. This duty would require the Secretary of State, when considering whether to place requirements on the NHS, to make a judgement as to whether these were in the interests of the health service. If challenged, the Secretary of State would have to be able to justify why these requirements were necessary. It does not undermine his duty to promote a comprehensive health service. The Secretary of State will remain ultimately accountable for the NHS.

First this says that the SoS has a "duty" to lessen his responsibility as much as possible, then it says that this does not reduce his duty. If you restrict the duty of the SoS then the SoS's duty has been restricted! (Incidentally, "providers" are hospitals, community health services and primary care like GPs. This is saying that the SoS has no control whatsoever over what they will do.)

This statement on autonomy is like handing him a cage of sparrows and saying "it is your duty to look after these sparrows, but you cannot keep them in the cage". If the SoS opens the cage the sparrows will fly free, so he cannot be responsible for what they do. How can a SoS be responsible for organisations that are autonomous? Autonomy means that the SoS no longer controls them. This statement is clearly saying that the SoS cannot be responsible for the NHS, yet the last sentence tells us that he is!

To labour the point further, the memorandum says:

16. The overall framework proposed in the Bill is designed to give the NHS greater freedoms, improve transparency and help prevent political micro-management. The powers of the Secretary of State would be constrained and made more transparent. At the same time, political accountability to Parliament would be strengthened. For example, the Bill places a new duty upon the Secretary of State to keep health service functions under review and to report annually on the performance of the comprehensive health service.

Yet again: "the powers of the SoS will be constrained". But look at the last sentence: the new "duty" of the SoS is merely to report annually. Currently the SoS has to answer health services questions once a month and MPs can ask the Prime Minister a question about the NHS at PMQs which is held weekly. Instead of weekly or monthly accountability, we will have annual accountability. Is this really an improvement?

The SoS will no longer be able to tell NHS providers to improve. For example, in 2007 the government decided that MRSA infections had to be tackled and the government ordered a "deep clean" of NHS hospitals. In August 2010 Andrew Lansley pledged to end mixed sex accommodation by the end of the year (in fact, he has failed, as he admitted at the Tory party conference where he said that mixed sex accommodation has been "curbed by 90%", whatever that means). Under the new system the SoS will not be able to order "deep cleans" or to rid the service of mixed sex accommodation, because paragraph 12 says that the SoS "will be removed from operational management". Instead, the SoS will merely request that something should be done through something called "standing rules":

19. In line with the policy intention to give more autonomy to the NHS, the Secretary of State would not have a general power of direction over the Board or clinical commissioning groups. Instead, the Secretary of State would have a new power to make regulations ("standing rules") which set out the system rules with which the Board and clinical commissioning groups would need to comply in certain areas. These areas are specified on the face of the Bill, and the detail would be set out in regulations.

So when the SoS wants something to be done, he has to create a standing rule and pass this to the NHS Commissioning Board and/or the Clinical Commissioning Groups and ask them do to something about the issue. Of course, NCB and CCG do not provide healthcare, they commission it (the clue is in their names) and this means that if any operational changes need to be made the commissioners have to then ask the providers to make the changes. This is a labyrinthine process and is likely to paralyse the system. Further, the NCB will only be accountable once a year, (as will the SoS) so there will be no regular public accountability. Basically, nothing will be done and the SoS will tell us that it is not his fault that nothing is being done.

Can you seriously imagine someone like Lord Sugar wanting to change his business and being satisfied with writing a request for the change to be made and hoping that something will be done? Of course not. Lord Sugar will want to bang heads together, bark orders and if things don't get done, fire staff! That is what it means to be responsible. Yet the SoS, who we are told has ultimate responsibility for the NHS, will not be able to demand changes are made, and will not be able to sack those who fail to deliver.

The SoS currently has a power to create a Special Health Authority and delegate powers to that organisation to provide a service to all of England. The SoS has responsibility for the service and ultimately can intervene if the SpHA has problems. For example, the National Blood Authority is a special health authority and in fact, the National Commissioning Board itself is currently a Special Health Authority (its status will change once the Bill is passed). Currently SpHAs are created under the powers of the SoS, but the Bill restrict this power in the future:

23. The Secretary of State would continue to have a power to establish new Special Health Authorities by order, but this would be subject to limitations. In order to establish a new Special Health Authority, the establishment order would have to specify the period for which the body is to be established, which could be no more than three years. At the end of that period, the body would be automatically abolished and its staff, property and liabilities transferred in accordance with the establishment order. If deemed necessary, the lifespan of a Special Health Authority could be extended by order subject to the affirmative resolution procedure, or the functions, staff and property of the Special Health Authority could be transferred to a new body established as a non-departmental public body through primary legislation.

The "affirmative resolution procedure" mentioned here refers to a process where both Houses of Parliament have to agree to the motion.

This paragraph shows that the powers of the SoS are being seriously restricted, and even those things that the SoS is allowed to do, there is an automatic sunset clause. This is a legislative straitjacket, showing that the SoS will be largely impotent when it comes to running the health service in the future.

The government is trying very hard to convince people that the Secretary of State for Health will still be responsible for the health service. However, the House of Lords memorandum shows that this is not the case. Many of the SoS powers are being transferred to the NHS Commissioning Board, other powers (currently delegated - but not transferred - to Strategic Health Authorities and Primary Care Trusts) will be transferred to Clinical Commissioning Groups. This is very important, the SoS will transfer these powers, not delegate them, so he will not be, and never more will be, responsible for these powers.

After the Bill is passed the SoS will never again be responsible for the majority of the provision of the NHS.

Integration

Integration is the buzzword of the time. We are told that the Health Bill will promote the concept and a scan of the explanatory notes show that integration is covered in four clauses: 20, 23, 59 and 62. The first two alters the National Health Service Act 2006 the other two are clauses of the Health and Social Care Bill.

Clause 20 and 23 are almost the same, the former refers to the responsibilities of the NHS Commissioning Board, the latter refers to the responsibilities of the Clinical Commissioning Groups. Both of these say that the NCB/CCG must have a view to secure health services "in an integrated way" when "it considers" that this would improve quality or reduce inequalities. Similarly it says that the NCB/CCG must have a view to secure the provision of health services is "integrated with the provision of health related services or social care services" when "it considers" that this would improve quality or reduce inequalities. Further, clause 20 says that the NCB must encourage CCGs to work with local authorities to integrate health services and integrate health and social care services.

Clause 59 makes similar statements about Monitor, saying that it "must exercise its functions with a view to enabling health care services provided for the purposes of the NHS to be provided in an integrated way". Similarly Monitor must enable the provision of healthcare services to be integrated with social care services. Clause 62 says that Monitor must "have regard to" ensuring that different providers co-operate with each other.

All of this sounds fine, except that it does not say what "integration" is. The term is not defined in the Bill, nor is it defined in the explanatory notes. It simply says that services must be integrated if it is considered that this will mean a better quality for services or if it will reduce inequalities. The "it considers" phrase is interesting because it does not mandate such actions. It does not say what this consideration is, nor what redress there is if others have a different opinion. The Bill does not define what "quality" is when it comes to integration.

Presumably this means that integration (whatever that is) can be ignored if the NCB/CCG considers (whatever that means) that quality (whatever that is) won't be improved or if inequalities won't be reduced. None of this seems to promise anything at all.

The Bill explicitly maintains the separation of the duty to provide social care (a local authority duty) and health services (and NHS duty, that will be in the gift of CCGs). The Bill explicitly imposes a duty of competition and "choice" (see clause 71) which will fragment the service. The Bill explicitly sets up a price list system called the "the national tariff" yet nowhere within this pricing system does it mention the integration of services, or ensuring that the national tariff does not prevent the integration of health services or the integration of health and social care services.

Why is this important? Well competition is the antithesis of integration, competition means that providers must compete to provide services and therefore are always working to replace, rather than work with, other providers. Different providers can co-operate (clause 62 says that they must) but if there is a single provider for all services it is far easier for the services to be provided in an integrated way. For example, a single provider will have a single mechanism for patient notes; a single provider can provide a single system for patient complaints and the resolution of those complaints; and a single provider ensures that there is just one budget. Multiple providers allows for a considerable amount of buck-passing, with providers saying that it is "not their responsibility" or that their budget "does not cover that". There is nothing in the Bill saying that there is a duty to reduce (or eliminate) this buck-passing.

The Bill says that the NCB, Monitor and CCGs all have a duty to secure provision of integrated services, but Monitor has a responsibility to prevent "anti-competitive behaviour" so that would mean that CCGs would have to find a middle ground between integration of services (to keep NCB happy) and competition (to keep Monitor happy).

In HSJ Prof Bob Hudson says: 

"In the meantime, established joint arrangements between the NHS and social care are collapsing. The implosion of PCTs has destroyed the high trust networks that have been developed with some far-sighted councils; some CCGs are already demanding to have ‘their’ community nurses returned from integrated teams; councils are withdrawing social workers from integrated mental health teams; and disputes about responsibility for funding continuing health care are escalating. Far from moving forwards, the collaboration clock is actually being turned backwards."

This is concerning and does not bode well for the prospects of a comprehensive integrated service in the future.

Basically, the Bill plays lip service to integration but does not say what it is and makes little attempt to ensure that it happens.

PMI eyes PPUs

The Health Bill will abolish the private patient income cap (PPI) that was imposed by the 2006 NHS act. This cap says that Foundation Trust hospitals cannot earn more from private patient income than the proportion that was earned in 2003. Overall, Foundation Trusts' income generate 1.1% from private patients and services to private patients, but some specialist hospitals have large incomes from private sources (the Royal Marsden has the PPI cap set at 30.7%, Royal Brompton and Harefield the cap is 14.4% and Moorfields Eye Hospital the cap is 13.7%). Most of these hospitals have a private patient unit (PPU), quite simply because private patients pay not to rub shoulders with us, the hoi polloi.

In the last year or so, several trusts have said that they want to increase their private patient income on a rather naive assumption that thousands of patients are desperate to spend their money with them. Private health in this country is in the doldrums and has hardly recovered from the recession, so it is naive to think that a NHS hospital's PPU will be a money spinner. PPUs are likely to be a drain of money since there is no guarantee that they will get enough private patients to pay for the investment they have had to make to shield the private patients from the NHS public. However, Foundation Trusts have recently been hit with a 1.5% cut in tariff (the payment for most elective procedures) and need another source of income, and private patients appears to be an easy ssolution.

A report by ippr in 2008 suggests that spending on private medical insurance (PMI) remained static over the previous decade at 2.81% of the entire UK economy. They suggest that in 2005, 6,536,000 people were covered by PMI (10.9% of the population) and that 51% of the insurance was paid by employers. Additionally, they suggest that in 2005 19% of the payment for private healthcare in hospitals was self-pay. More up-to-date figures from OFT suggest that by 2009 self-pay had fallen to 15% whereas income for private hospitals from NHS patients was 23% and from PMI was 61%.

The ippr report says:

"If waiting times are high and/or perceived treatment quality of the public system is low, [PMI] is perceived to be necessary for timely, high-quality medical treatment. As such, demand for [PMI] will be driven by middle and higher income groups. If waiting times are low and perceived quality is high in the public system, demand for [PMI] shifts towards non-clinical features such as 'convenience' of access to treatment, and 'hotel-like features' of medical facilities; as a consequence, [PMI] tends to concentrate among higher income groups only."

which is common sense. It is reasonable to assume that in a time of austerity, when there is a free-at-the-point-of-use service available to all (hence basic coverage without the "non-clinical features" mentioned above), self-pay for private treatment would be considered to be an unnecessary luxury and private hospital income from self-pay would fall. PMI is less sensitive to an economic downturn (since the contributions are smaller), but clearly as incomes shrink it too would be considered an unnecessary luxury both by individuals and employers and so the proportion of people covered by PMI should fall.

Considering that the UK economy is in such a poor state, all of this suggests that private hospitals are in a bad position. Indeed, the Nabarro Healthcare Industry Barometer 2011 (pdf) survey says that 60% of respondents think that their income will not return to "pre-credit crunch levels" until after 2014 (this was up from the figure of 55% in their 2010 survey). Interestingly, the Nabarro survey says that 35% of respondents thought that "budgetary pressure in the NHS led to increased demand for private care provision". Further, the government policy of Any Qualified Provider, which means that patients can choose care in a private hospital, is one way that private hospitals can make up for any falls in self-pay or PMI patients, so it will be interesting to see how the 23% figure given above will change when AQP is introduced.

Private medical insurance clearly need to do something to increase their subscribers and one way to do this is to lower the cost of the product. A few days ago I got the following junk mail from Aviva:

This is the usual nonsense: "you deserve private medical treatment" when in fact everyone deserve a comprehensive health service. However, I have highlighted an interesting paragraph:

"By choosing the Trust Care hospital list, you can reduce your monthly premiums by 25% by simply using private facilities within NHS Trust hospitals."

This ignores the fact that by choosing the NHS you can reduce your monthly premiums by 100%! The letter raises some questions. Why is it that insurance for NHS PPUs is 25% cheaper than private hospitals, what is it that makes them cheaper? If PMI is recommending NHS PPUs does this mean that in the past when they have emphasised that private hospitals are clean and have expert care - and by implication that the NHS does not - that they were actually, wrong? Will we see PMI actually promoting NHS PPUs in the future?

PPUs have got the private hospitals spooked. The Nabarro survey says that 37% of respondents either agree or strongly agree that removing the PPI cap is a "threat to the independent healthcare sector". Since Aviva is now pushing PPUs as cheaper alternatives to private hospitals this backs up the pessimism about PPUs in the Nabarro survey.

There's more of us than there are of you

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?

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:

"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?

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:

1. 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;
2. will produce a postcode lottery on a scale that England has never before experienced and as a consequence, health inequalities will increase;
3. will mean that rationing will be rife and people will find that they have no recourse;
4. together with the financial squeeze and the wasteful bureaucracy created by the Bill will result in a financial crisis

The time to get ill in England was a decade ago, from now on, you'll find yourself more and more on your own.

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.