Socialism and Health the magazine of the Socialist Health Association January 2011 This issue: Editor‟s Opening Excitement is mounting as we all await the arrival of THE HEALTH BILL. It is said to be huge and unless there are extraordinary parliamentary machinations it could take many months to get past Commons and the Lords. How the cross benchers in the Lords, many very well informed on health matters, respond to the Bill is a matter of some interest.. In late December we had an update which showed how the thinking had changed after consideration of responses to the “consultation”. Another potentially key development has been the floating of an idea for there to be a guarantee of no redundancies for lower grade staff in return for a general agreement to suspend increments across the whole system. The various trade unions are considering this but with little evidence of wild enthusiasm. It appears to be a proposal that is unenforceable. Within the BMA there is early evidence of disquiet with the policy of “engagement” and signs of a hardening of the line. Much of what is proposed will depend on being able to persuade the vast majority of GPs to collaborate, with major changes in their contracts. Whilst a few dissidents could be accommodated it would be very dangerous to try and force through a change of contract without agreement, as the Tories did in the 90’s. Once the Bill is out the SHA will try to get out an analysis of at least the key bits. There will, of course, be many others responding. In the meantime we should all get on with campaigning, as best we can, as the more you look at it the more this looks like the beginning of the end of our NHS.
News & Comments
Shiny Thing Make It Better
Who Said That?
More News and Comments
Some New Year Promises
Sympathy For LaLa?
Troubles Ahead (Issues around competition)
Our Aims .. Universal Healthcare meeting patients' needs, free at the point of use, funded by taxation Democracy based on freedom of information, election not selection and local decision making Equality based on equal opportunity, affirmative action, and progressive taxation
Editor Irwin Brown Socialist Health Association 22 Blair Road Manchester M16 8NS 0161 286 1926 firstname.lastname@example.org Please send contributions or ideas for articles
News and Comments In his New Year message to doctors, BMA chairman Dr Hamish Meldrum warned: ‘Against a backdrop of an unprecedented financial challenge, with efficiency savings of at least £20bn being sought in England alone, the government is pushing ahead at break-neck speed, with an unnecessarily ambitious programme of reform.’ Dr Meldrum predicted the profession would rise to the challenge, and backed plans to boost clinical involvement in the design and delivery of healthcare along with plans to replace ‘crude targets’ with a greater focus on quality and outcomes. But he said: ‘We have real concerns about other aspects of the planned reforms. 'In particular, the lack of detail in many areas, the increasing emphasis on competition and the market, and the significant risks created by the process of rushed and unnecessarily risky transition, particularly at a time of such financial stringency.’ Meanwhile, BMA Scotland chairman Dr Brian Keighley urged the government not to cut medical posts. ‘It is disappointing that over the course of this year, cuts to the NHS workforce and attacks on doctors’ contracts have been identified by politicians as the way to navigate the NHS through these difficult financial times.’ More than 80 per cent of nurses believe their trust would fail to honour a proposed deal not to make compulsory redundancies over the next two years if they agreed to forgo a pay rise, according to an poll by Nursing Times. The government’s pay negotiator NHS Employers has proposed freezing increments for two years from April in exchange for a “no compulsory redundancy” agreement. All Agenda for Change staff would have their increments frozen, but only those in pay bands one to six earning up to £34,189 would benefit from the “no compulsory redundancy” agreement.
The decision to let NHS hospitals compete with each other on price from next year threatens to harm care and raise death rates, experts warn. The 2011 NHS operating framework confirms that, from April, hospitals will be allowed to charge rates lower than the national tariff, which sets the prices for thousands of NHS procedures and covers roughly half of hospital income. The move means hospitals will be able to compete for contracts from commissioners by cutting prices, not just by raising quality. But health economists and unions fear this will drive down standards and working conditions for hospital staff. Zack Cooper, a health economist from the Centre for Economic Performance at the London School of Economics, told HSJ: “Every shred of evidence suggests that price competition in healthcare makes things worse, not better. You save money, but as you’re lowering price you will lower quality.” Mr Cooper was one of the authors of a study, published in June, which found evidence that the intra-hospital competition introduced in the NHS in 2006 had made hospitals more efficient. He believes England has done a “fantastic job” creating a market in the NHS where “competition leads to higher quality”. But he warned that removing fixed prices from the equation will put this at risk. “The moral of the story is not ‘more competition: good; less competition: bad’,” he said. “It’s that you need to create sensible incentives and meaningful regulation in order to get competition that produces good quality.” The danger of price competition in healthcare, economists warn, is that commissioners find the “quality” of complex medical procedures much harder to measure than price. The risk is that this leads them to commission cheaper services, without realising until later that they are worse. Chief economist at the Nuffield Trust Anita Charlesworth says she has “grave concerns about the reintroduction of price competition” in the NHS. She warned: “There is a real risk that the harder-toobserve but fundamentally important aspects of quality, like mortality rates from acute myocardial infarction [heart attacks], will deteriorate.”
The following is an extract from the web site The Daily Mash. It is very funny but a bit offensive.
Shiny Thing Will Make It Better
The government is to press ahead with massive structural changes to the NHS because this time it is obviously going to work. Health secretary Andrew Lansley insisted all the previous massive reforms had missed out something really simple and that all he had to do was to make sure that did not happen again. And he stressed that this time it would definitely work because the government had asked a lot of doctors what they think. Mr Lansley said: "The key problem is the primary care trust system which has reduced hospitals to being nothing more than a lot of doctors and nurses in a big building treating people who aren't well. We need to erase that idea from our national consciousness and instead see hospitals as large buildings, staffed by distinct types of medical professional who are focused on making sick people feel better." He added: "It is time to put patients in charge of their own healthcare. While that may lead initially to some catastrophic misdiagnoses and thousands of easily preventable deaths, it is surely better than some top down, centralised bureaucracy where ordinary patients are constantly told what to do by qualified medical professionals who see them as nothing more than a human being that is displaying a set of symptoms of which they have a high degree of expert knowledge. Patients have welcomed the latest massive reform claiming it could not possibly fail and that they were all really looking forward to going to hospital now. One recently took part in a pilot scheme which he described as 'fresh and exciting' and 'easily the best NHS reform' he has ever seen. He added: "When I went in it for some tests it was just Peterborough City Hospital, but when I came out three hours later it was the Edith Cavell Wellness Delivery Interchange, Powered by Diet Fanta.
Who Said This? The market undermines the sharing of good practice within the NHS. One of the curses of the NHS has been the variability in standards. Turing the NHS into a series of competing units is likely to reinforce those divisions. The simplistic market led model of the NHS is riddled with problems which will become steadily more acute as the reform rolls out. I am a believer in evolution rather than revolution and this applies particularly to health services. A collective groan goes up (from health professionals and patients) at the thought of yet more upheaval and change in the NHS. The professionals are increasingly weary and the patients confused. Surveys show that patients do not want a choice of hospitals, some far away from home. The choice people want is of a good local responsive hospital – familiar and closer to home. Accountability and activity in the NHS should be radically decentralised so that local people know what is going on and can help shape the strategic direction. The pattern of health services should be determined locally and accountable locally. In addition to local accountability we need to see co-operation not competition operating within the health service. An approach based on co-operation and local accountability is far more likely to raise standards and morale than the ill-judged market-driven approach. There needs to be an end to the arbitrary and artificial distinctions between what counts as “health “and what counts as “social” care. The key to solving this problem is to merge the budgets between health and social care. (I could add more but you get the flavour.) This is not the response from Unison to the White Paper it is all taken from a 2006 paper - The Liberal Democrat Vision for the NHS - by Dr Steve Webb. Since Dr Steve is a ConDem minister maybe he could have a word with LaLa Lansley.
More News and Comments BMA Dr Hamish Meldrum, chairman of council at the BMA, said: ‘There is little evidence in this response that the government is genuinely prepared to engage with constructive criticism of its plans for the NHS.
NHS Confederation The NHS Confederation warned the government must be ‘realistic’ about the dangers of transition. Nigel Edwards, chief executive of the NHS Confederation, said: ‘The scale of the challenge facing the NHS is immense. NHS organisations are grappling with three major issues, all at the same time: unprecedented efficiency savings, major management cuts and radical structural reforms.
‘Most of the major concerns that doctors and many others have raised about the White Paper seem, for the most part, to have been disregarded. The response completely fails to acknowledge that proposals to increase competition in the NHS will make it harder for staff to work more cooperatively. While we still believe that clinician-led commissioning can improve patient care, this document does not provide assurance that it will be implemented effectively.
'There is a real squeeze on hospital budgets that will seriously effect their income. NHS leaders up and down the country are really worried about the prospects for the next two to three years.
He concluded: 'The government also seems to have ignored the warnings of the BMA and many others about the pace and scale of these reforms.’
He added: ‘No one should be in any doubt that these reforms are both radical and high risk.’
'While we support the objectives of these reforms, we have to get there first. The absolute priority is to be realistic about the dangers of transition and take firm action to avert them so the reforms have a chance of success.’
Royal College of Physicians RCGP Dr Clare Gerada, chairwoman of the RCGP, said the college was pleased the government had engaged with clinicians over the plans, and that GPs remained centre stage. She said: 'However we still have a number of questions. These include the pace of change and how this sits alongside having to make unprecedented savings; how to balance patient choice with health inequalities (those with the greatest health needs are often those with the least ability to exercise choice); and how the policy of ‘any willing provider’ may impede the development of effective coordinated services as well as drive up the cost. 'Our starting point is what delivers the best outcomes for our patients. We firmly believe putting GPs at the centre of commissioning is the right way forward and we will continue to engage with the department to shape the policy so it is safe for patients, safe for GPs and safe for the NHS.'
Patrick Cadigan, registrar of the Royal College of Physicians, welcomed the inclusion of arrangements to include health professionals in consortia. ‘More broadly, the government is right to adopt a more phased approach to its reforms. Whichever way you look at it these are an ambitious set of proposals that happen to coincide with the biggest efficiency drive in the service’s history.
Greater Choice and Control The public consultation on reorganising England‟s health service is a sham. The latest part of health secretary Andrew Lansley‟s consultation, which closes on February 14, was dismissed by the Socialist Health Association as duplicitous. The public consultation document, Liberating the NHS: Greater choice and control, is about extending private sector provision of NHSfunded services. Lansley‟s idea is that free market competition will drive up standards and drive down prices. Yet the words „private‟, “market” or “commercial” do not appear once in the 58-page document. Instead, commercial services are referred to as „any willing provider‟. When they are described, it is as „independent providers‟. These are weasel words. This is not bureaucrats forgetting to use plain English. It‟s an attempt to stop people saying what they think about NHS privatisation. Companies owned by shareholders and hedge funds are not independent. They are accountable to their owners who want to see profits. The Conservative-led coalition government want to increase the use of the private sector in health care. But the well-respected British Attitudes Survey recently found that the public are suspicious of private organisations running or providing public services. Less than a third of those surveyed favoured private companies providing NHS hospital services. Mr Lansley is well aware of the results of the survey. He just wants to get
round them. It is sad when a public consultation document that claims to be „about giving people the information they need to exercise control‟ is doing precisely the opposite, for fear of the public saying what the Conservative-led government already knows they think. A lot of people think that services owned by shareholders and hedge funds won‟t have their long-term interests at heart. They will try to introduce top-up charges. These reforms undermine the comprehensive service which the NHS provides. To make more money, the private sector‟s long-term plan will be to increase charges to those who can pay. That is the logic of a market in health care. We support choice for patients over treatment options and amongst existing (mostly NHS) providers. We do not support the use of choice to artificially create a market. Most patients want more choice about how they are treated. Very few want a choice about where they are treated, and most money is spent on patients who are too ill to exercise choice at all. The examples of choice in the document are of choices which are already available to patients. The plan to fragment services so that every aspect of the patient pathway is exposed to competition is not apparent to the reader.
Sympathy for LaLa? Are we getting to the point where we have to show some kind of sympathy for poor LaLa Lansley? He had 6 years planning his programme, and expended endless charm on all parts of the NHS but especially the GPs, and they are now turning against him. Even the GPs, about to be bribed to lead change yet again, are starting to rebel, even as they sign up for trials and pilots. The BMA has shifted visibly towards resistance through constructive engagement! The negotiations on changes to the GP contract are going to be about as productive as those around the BA cabin crews. My money would be on the BMA though. He must be in some kind of trouble having already broken two of the promises made in the Coalition Agreement. He also showed an almost contemptuous attitude to the agreement to the effect that he had never read the document and the bit about the NHS was slid by him. The announcement that participation by local authorities in wellbeing boards is voluntary undermines the only remaining vestige of any trace of Lib Dem policy. With the scrapping of restrictions on a two tier workforce we have everything in place for the full scale privatisation of the NHS, to a bunch of quangos and John Lewis’s – not exactly Lib Dem policy. His flagship bill is much delayed, apparently because of the volume of responses to the consultation. Now he must have been shocked by the responses since just about every one questioned the approach. Even supporters are pointing out putting a reorganisation of an unprecedented scale on top of expenditure reductions also on an unprecedented scale is risky! There is a very wide consensus that the scale of change is way beyond the capability of the NHS to manage. Making efficiency gains on a scale never achieved before accompanied by a huge reduction in management capacity (announced so the managers could all see the axe falling) was perhaps unwise? His dreams are in the hands of a Chief Executive who does not appear to share them. Repeatedly the man in charge of delivering the biggest and most complex programme in history anywhere has given the impression he does not think it can be done – and probably that it should not even be tried, there are better ways, and anyway his job won’t be there is a couple of years! And LaLa should be worried about those being brought in to drive his changes. Some of the “top” man-
agers providing leadership left endangered posts and, without the unpleasantness of applying for a job, have wafted into the safety of the DH! These are people who have supported every other initiative to date, including those now rubbished to justify the latest redisorganisation. Surely if you are SoS and want change then you go to the people who argued against the previous changes not those who were evangelists for the systems that you say have failed. The studied brutality by understatement directed at his reform programme by the Health Committee was sad to behold. Things were so bad that when the Report was released a Lib Dem was deployed to go on the Today programme; a sure sign of desperation. Whilst admitting that the NHS had never achieved a 4% productivity gain in any year, let along 4 years on the trot, the Lansley supporting Lib Dem came up with “no one says its impossible”, it was just “extremely challenging”. Are we sure he has got the right ministerial team to support him? The challenging nature of the Committee Report was not surprising given the lacklustre performances of Lansley and his colleagues in front of them. Everyone thinks he is sincere and that he thinks he knows what is needed but as the committee has pointed out there are no actual plans to deliver what he wants. Leaving it to locals to come up with the answers is not a credible position when £80bn of public expenditure is involved. The Treasury appear to incline to a similar view. Anyway I think he has a lot to put up with and he should get our sympathy. Anyone being overshadowed by Oliver Letwin deserves that at least. PS Since writing this piece LaLa has appointed Sir David Nicholson to be designated chief executive of the National Commissioning Board—poacher, gamekeeper and vermin? Irwin Brown
Troubles Already? New lot not competition?
Private providers of NHS services have lodged a formal complaint with the health department over plans that will see almost £10bn of care handed over to other parts of the health service or to social enterprise without being put out to tender. Under the previous Labour government, private providers were told there were “real opportunities” for them to bid to take over the community hospitals, district nursing and home and GP therapy services that are run by primary care trusts. By April, these “provider arms” of PCTs will be separated from the PCTs’ commissioning arms. However, under the Conservative-led coalition – and despite its public commitment to competition and choice in health – the health department has disclosed that only 4 per cent of the provider arms are to be put out to tender to the private and voluntary sectors. Some 86 per cent are being passed over to other parts of the NHS to run, or are being turned into a form of NHS foundation trust. The remaining 10 per cent, providing £900m worth of services, are being handed over to staff to run as social enterprises, without any formal competition, in what critics see as “sweetheart” deals. David Worskett, director of the NHS Partners Network that represents private providers of NHS care, said: “We have been told for some years now that there would be significant opportunities for the private and voluntary sectors to bid for this work. “Just before the election we were reassured by health department officials that perhaps 20 per cent of this business would be put out to tender. Now it appears that only 4 per cent will be going to market,” he said. “How can the health department possibly be sure that the arrangements being put in place will offer best value to the NHS at a time when it is completely vital for the service that this happens?” There were “fantastic opportunities” for the private and voluntary sectors to provide more NHS
care, a senior health department official publicly said as recently as September. The partners’ network, Mr Worskett said, had lodged a formal objection with the health department, asking it to refer the issue to the Co-operation and Competition Panel, which has the power to investigate market abuse in the NHS when asked by the health department. The department said it had “no plans” to refer on a complaint that in effect challenges its own behaviour. Susan Anderson, head of public services at the CBI employers’ organisation, said the coalition should be more radical. “Simply re-badging services is not the answer.” The best provider should be found to run them, she said. Simon Burns, the health minister, said the arrangements would put “frontline staff in the driving seat to improve quality and integrate services to ensure the most effective outcomes for patients”. Unison, the health union, said it was “delighted” that “despite a massive push from the government” only 10 per cent of provider arms at most would become social enterprises, where staff quit the NHS to sell their services back. The health department confirmed contracts for social enterprises were likely to be for three to five years. Mr Worskett said such providers would become entrenched, meaning “the scope to test the value of these services will be denied for the better part of a decade”.
We will ensure a stronger voice for patients through locally elected individuals on the boards of PCTs. Coalition Agreement
North East London NHS Foundation Trust
Foundation Trust Membership Foundation Trusts are, at least in principle, owned by their members. The members elect the Governors, and the Governors appoint and dismiss the Board of the Trust. You can become a member of your local trust and support socialist candidates. As the NHS comes under pressure this may become an important battleground. You can also join all these trusts which have a membership category for "The rest of England" (and sometimes Wales), so anyone with an address in England can join. It doesn't cost anything. The number of people who vote in these elections is quite small, so if we can find candidates who are prepared to stand we might well get them elected. Aintree University Hospitals
Papworth Hospital NHS Foundation Trust Rotherham NHS Foundation Trust Royal Bolton Hospital NHS Foundation Trust Royal Brompton & Harefield NHS Foundation Trust Royal National Hospital for Diseases NHS Foundation Trust
Royal Orthopaedic Hospital NHS Foundation Trust Salford Royal NHS Foundation Trust Somerset Partnership NHS Foundation Trust South London and Maudsley NHS Foundation Trust South Staffordshire and Shropshire Healthcare NHS Foundation Trust South Tees Hospitals NHS Foundation Trust
Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust
Surrey and Borders Foundation Trust
Basingstoke and North Hampshire
Tameside Hospital NHS Foundation Trust
Birmingham and Solihull Mental Health
Taunton and Somerset NHS Foundation Trust
Tavistock and Portman NHS Foundation Trust
Cambridge University Hospitals Cambridgeshire and Peterborough
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Walton Centre NHS Foundation Trust
Christie NHS Foundation Trust
Wrightington, Wigan Foundation Trust
Clatterbridge Centre for Oncology Dorset HealthCare University NHS Foundation Trust East Kent Hospitals University Liverpool Heart and Chest Hospital Liverpool Women's NHS Foundation Trust Medway NHS Foundation Trust Newcastle upon Foundation Trust