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Socialism and Health the magazine of the Socialist Health Association

April 2011 On 4 April the Health Secretary, Andrew Lansley announced a ‘pause’ in the progress of the Health & Social Care Bill through Parliament. This Brief distils key points for those wishing to make good use of the ‘pause’ to seek radical improvements to the Bill. The need for radical change is predicated upon NHS failure – but evidence of success is being supressed. Satisfaction surveys which have provided a continuous performance check for decades have been irresponsibly abandoned: the 2008 survey showed a record 67% satisfaction (compared with a record low point of 37% in 1997), correlated with waiting times coming down from 18 months to 18 weeks over the same period. Tough targets have benefited patients, and while they have caused some clinicians to complain, they have also removed a perverse incentive to private practice. Commissioning by GP Consortia rather than PCTs has many drawbacks:

This issue: Summary

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State of the Health Bill

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The Right Kind of Competition Page 4 Assisted Dying

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NEC Report

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What to do about the Bill now

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Work and Benefits

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SHA campaigning events

and timetable of Page 8

Capacity: GPs may understand their own services, but not the huge range of specialisms, nor the operation of the system as a whole; Accountability: GPs themselves are concerned about how the apparent conflict of interest between decisions about care and their ‘bottom line’ as businesses will affect relationships with patients; Managing demand: GPs are incentivised to get care out of expensive acute care and into the community – but will the services be there to meet these needs? The NHS Commissioning Board (established in anticipation) will have to tackle these problems – but this is part of what the abolished PCTs did. Couldn’t they have done it? The fundamental basis of the NHS is being abolished. The duty on the Health Secretary to maintain a coordinated National Health Service is removed. Instead, regulation of the NHS will be carried out by Monitor, and will be economic: like other nationalised industry regulators Monitor will encourage competition and thus may actively prevent collaboration. Clinicians talking to each other about patterns of care, and Trusts agreeing on specialisations could be deemed anti-competitive. Services already close to the edge could close, with wide and damaging effects on service development and continuity of care. The Bill is about to go into the Lords, where there is widespread disquiet about the potential for destabilising the NHS. The ‘pause’ is an opportunity for action – so what can be done? Details of campaigning ideas are on the back page.

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 Please send contributions or ideas for articles

The state of the Health Bill—Irwin Brown As John Healey the Shadow Health Secretary has pointed out – the more that people examine what is in David Cameron and Andrew Lansley’s Bill the less they like it. Why Lansley studied the NHS for 6 years and still decided it was a good idea to turn it into a regulated utility like gas, water and electricity (don’t mention the railways) is unclear. He might have noticed, as Steven Dorrell readily spotted “that utilities’ products and services are really directly paid for solely by individual consumer payment, so the relationship between a utility and its customer is fundamentally different to the relationship between the NHS and its patients“. Quite. The Bill has finished its journey through scrutiny by a commons committee, and set new records for intransigence as every attempt by Labour to amend the Bill was voted down, thanks to the LibDem support act. Opponents are all "absolutely wrong". So, as Lansley’s Millwall Bill heads for the Lords and inevitable, but polite, ridicule, we might speculate on what could have been. We can start with what is actually a large measure of agreement, aside from a few extremists (like Lansley). We want a free at the point of need, universal NATIONAL service, paid for out of general taxation. We agree the NHS could do better at reducing health inequality (though mostly this is not the fault of the NHS); at reducing unnecessary variations; and in bringing integration of care along patient pathways and across organisational (and tribal) boundaries. Most think that the key priority for the NHS is to complete its QIPP programme which is about gaining the improvements in quality and productivity made possible by the greatly increased level of investment over the previous decade. We pretty much agree the NHS could be a lot more efficient (maybe 20% more) especially around things like procurement, IT, estates, and not starting daft major projects without a sound business case. Better use of information and dissemination of best clinical practice (with a touch of performance management) could eliminate some of the worst variations, improving quality and reducing unit cost. We can agree to

greater efficiency as long as it means more care for the same cost not the same amount of care for less cost. We might agree that the NHS has too many managers and not enough management expertise; but we sort of agree that some management and bureaucracy are a bad thing and we want far less (25% or even 33%) of the bad bits. That would imply having less things to manage. Most agree that care, including social care and public health, is not yet funded at a high enough level! We know care costs as a percentage of GDP will continue to rise as it does in every developed country. We know that to slow down the rate of increase we need to deal with the causes of ill health and increase our own responsibility for our health. We know involving patients in their own care, and involving communities in the care of their locality works. We know we need more care closer to home but we also know we do not yet have the capacity in primary care to do that – too much resource goes into secondary care. We are edging towards an agreement that we should have a wellbeing approach led by local authorities, with a local well being strategy based on needs assessment; but do not yet agree to actually giving local authorities the powers to deliver the strategy – we are not yet ready for democracy in the NHS.

We pretty much agree we should shift to greater emphasis on outcomes. Most agree we should have some (but less) targets and we should keep entitlements for things such as maximum waiting times. We pretty much agree that clinicians should have a greater role in decisions about how resources are allocated, what services are necessary, what priorities are set and which types of pathway are best to meet local circumstances. The heretics still say that decisions about how our money is spent should be made by people we elect and can hold accountable. And we agree that patients should have information and support to enable them to share in making decisions about their treatment options – if that is what they wish to do. We pretty much agree that, where this is possible, we should offer patients the choice of which NHS setting they attend to have their

appointment or treatment – but the NHS has to ensure that every setting meets the same high national standards. So where is the disagreement? Well, the coalition believes the NHS is second rate, and until fairly recently were routinely highly critical about the NHS in relation to other European countries. The evidence is that they are wrong and that the NHS is up there with the best, but can still be better. But fundamentally they believe that competition is the answer, although they are not specific about the question. Competition has worked in other sectors so it must work in health care, so we need to make it work and have a powerful regulator to enforce policy, domestic and European competition law. The Bill is structured to ensure that competition law will increasingly apply to all parts of the NHS. And that is it. The only difference is that they think using a regulated market will solve the problems. Everything else flows from that belief – starting with ending the duty of the Secretary of State to provide services and with the axing all the bodies which brought public accountability into the NHS – that is inconsistent with a market structure. They will start with a market structure where price competition is constrained, but leave open the possibility to extend it later, as envisaged by the already appointed chair of the regulator. There is no alternative – at least according to the Impact Assessment of the Bill, provided by the Department. The issues are ones of presentation not substance – critics are absolutely wrong even if they have just been appointed into key posts. Actually there is a perfectly sensible alternative, although it comes in various flavours. Its components are: don’t engage in a major costly and risky

reorganisation  don’t have a market regulator  don’t have anyone promoting competition  stop the haemorrhaging of good management,

value what you have  stop looking for ways to take staff out of the

NHS family

 allow the QIPP programme to do the things it

says it is going to do (even if it takes a bit longer and is a bit less successful than its targets)  keep the main elements of system

management and financial control  form PCTs into clusters (free of any provider

responsibilities) and make them subnational bodies with greater clinical involvement but with same public accountability  keep national, subnational and local population

based structures so that everyone is clear who is responsible for population health at each level with no “selection” of patients permitted.  allow local commissioning consortia to develop

as publicly accountable bodies and delegate responsibility to them as they earn it  allow local authorities to develop wellbeing

strategies as they decide best, give them the duties and responsibilities and leave them to deliver  continue with the programme for all NHS

providers to have some form of foundation trust model, but have a failure regime, which starts with support and assistance – keep some NHS trusts  don’t allow FTs to become focused on their

private patient income  allow competition where it is appropriate and

leave local commissioners to decide what is appropriate – do not “promote” competition  use the top down powers to stop the endless

flow of top down regulations, initiatives, guidance, fads, and new management consultancy ideas. There may be some other stuff around the margins like what is an Any Willing Competent and Comprehensive provider model? What is a level or fair playing field? What is a conflict of interest? When do we use tariff and when not? Just details. The Bill is based purely on ideology, it sets off an experiment which will do irreversible damage to our NHS. It has no electoral mandate and no support aside from a few business people who are also doctors. It is not based on evidence and has not been through any kind of proper assessment.

“The Right Kind of Competition: what is it?” (Chris Ham)  commissioners should be able to both

The debate about markets has been “unhelpfully polarised…*they are+ neither wholly good or wholly bad”. Noted academic research identifying the “wrong kind of competition leads to cost shifting, fragmentation, inequity” “the aim should be to promote the right kind of competition while also encouraging collaboration and integration” Previous challenges for policy makers have involved market regulation and encouraging providers to exit the market (ie go bust), to encourage innovation from new entrants. “Choice and competition are most relevant to elective care, diagnostics and primary care….collaboration and integration are need for unplanned care , specialist care (eg stroke), and much of chronic care – all areas which form the NHS’ biggest challenge” He feels that integrated arrangements without competition, as in Scotland, Wales and N Ireland, lead to monopoly providers and less progress in improving efficient and responsiveness. He notes that their arrangements consist of organisational integration rather than clinical/pathway integration. He feels there are relevant examples from leading US integrated care organisations eg Kaiser Permanente, who are both insurers and providers. They are a Health Maintenance Organisation - who have a preventative role that can align primary and secondary care. Their hospitals are merely cost centres, whereas in the NHS hospitals are (esp as FTs) profit centres in terms of stand alone organisations. Their length of stay is one third of that in average NHS hospitals for common diagnoses. Key features of successful US integrated systems included integrated IT, constant benchmarking of clinical performance/outcomes, and “home as the hub of healthcare”. To achieve the right kind of “disruptive competition” (that brings in innovative new entrants) using integrated commissioning systems, there is a need:  to involve secondary care specialist

clinicians, besides GPs, in commissioning

“make and buy” services  integrated systems need to have

overlapping geographies (which could work in urban but nor rural areas) He noted some parts of the country have variable quality of GPs – eg London, where there is great strength in specialist centres (eg Academic Health Sciences centres) Questions: 

How to move beyond Payment by Results? PbR not well designed to deliver current NHS challenges eg chronic care. Need to develop capitated health budgets

How to accommodate any willing provider? Test on elective care only

Monitor: nothing in its remit about promoting collaboration where appropriate, only promoting competition.

Risks of market exit: “some populations will lose access to valued services” as a result

Some other quotes from the audience: 

“there should be some standardisation of what the NHS is” (from senior DH policy lead)

 “4% efficiency savings 4 years on the trot is

unprecedented for the NHS… there will be some severe shocks to the system as result”  “you cannot do competition without knowing

what things cost, and the NHS is not well developed in this regard”  “the political class have an appetite for market

entry (new providers) but not for market exit”  “innovation in healthcare is tough, and

depends on so-called soft stuff, like people, relationships and culture”  “the challenge for the NHS continues to be best

practice: to find it and replicate it. This will not happen under competition; people will keep the best ideas to themselves” Nye Harries’ Notes from the Civitas seminar on 8 March 2011 -

Campaign to help terminally ill adults in the UK to die at a time and place of their choosing greater choice at the end of life, ensuring that within reason the wishes of terminally ill, mentally competent adults are respected.

Dear SHA Member, I am writing to seek your support. I have recently been involved in setting up a group of healthcare professionals whose aim is to change the law to allow doctors to assist mentally competent adults with terminal illness to die when and where they wish within well defined safeguards. At present such action would be illegal. I hope I can persuade those of you who are, or were, healthcare professionals, to join (sign up to) the group. The group, ‘Healthcare Professionals for Assisted Dying’ (HPAD), was launched at the King's Fund in October l2010. It is chaired by a GP, Dr Ann McPherson, who herself is terminally ill. I am deputy chair of the group and member of its steering committee. The group, which is a wing of ‘Dignity in Dying’, has three objectives. These are: 

First, to change medical culture. Society should recognise that dying is inevitable and is part of life. For those with terminal conditions, the dying process is not a failure of the healthcare team or the patient – but it does become a failure if the patient suffers an undignified death. Moreover since dying in these circumstances is not a failure, help in dying should be thought of as assisting dying and not assisting suicide.

Second, to change the law. Healthcare professionals can indirectly hasten death through the withdrawal/withholding of treatment or through the principle of ‘double effect’, but direct and deliberate assistance to die (that is prescribing life ending me di ca ti on), a t the patient’s request, is illegal. The law must change to provide safeguarded

Third, to change clinical practice. Assisted dying should be just one of many options at the end of life. It should complement end-of-life care, as it does in other countries that have legalised and regulated assisted dying. Those wanting an assisted death should be supported by their healthcare professionals to die when and where they choose, within safeguards.

There will be a lot of opposition to change and I expect the campaign will take many years. In my view change will ultimately come, but I would prefer this to be sooner rather than later. If you are interested to know more about the group, and indeed joining it, you can do so by contacting http:// . In this sort of campaign, the more members we have, the more influential will be our voice. I do hope this is a cause with which you can identify. Joe Collier (MA MD FRCP). Deputy Chair of HPAD; Member of SHA; Emeritus Professor in Medicines Policy

Labour Party NEC Report At our Socialist Societies consultation meeting the night before the NEC, representatives of Societies expressed their concern that a strong and clear Labour narrative on the cuts and our alternative is needed. They asked me to raise it and it became the major discussion at the NEC. However first we picked up on a number of business items. The ongoing reviews - some of which are getting a bit entangled - are a major opportunity to reform our processes and get ready for being a 21st century political party. The Socialist Societies have now made a collective submission to the Partnership into Power review (looking which is looking at our policy-making structure). The Policy Review (led by the Shadow Cabinet, a 2 year process to review our policies) is generating many submissions based on the document launched in Gillingham). A first report will go to the National Policy Forum on 25 June. Whilst 80 constituency-based events have happened already, the thematic groups have not yet reached out. The Socialist Societies have provided a list of contacts but I am chasing these as the links do not appear to have been made yet. There is also some concern about the involvement of LibDems on the fringes of the review although others argued that this reaching out is strategic. Potentially the biggest review is the Party Reform. As we all keep pointing out, our systems and structures were devised at the beginning of the 20th century; when most communication was face-to-face, when people joined political parties and made a lifelong affiliation, when access to information was scarce and verbal. In the 21st century people do most of their communication online and they lend their support for various issues but are less likely to join political parties. A discussion document for this Reform has now been launched with deadline for submissions of 24 June, so that they NEC can look at it in July with a view to taking proposals to Conference. There are relevant sections on affiliates and how the relationship with socialist societies can be strengthened. The issue of multiple votes in leadership elections is raised and my suggestion that the MPs' multiple votes should be the main focus appears to have be accepted. However I argued that the process is too rushed and little time for the ambitious discussions that we were going to have. Ellie Reeves argued that the PiP review has been going on for some time and this had informed the Refounding Labour document. A Code of Conduct for mayoral and AV referenda was

agreed: candidates must be very careful to avoid incurring expenditure by expressing views on these. Statements of fact about a candidate's position on the AV referendum are acceptable but should not make arguments for one side. The party has instructed that no party funds can be used for referenda campaigning. The Barnsley Central result was welcomed and Jonathan Ashworth (who has done the NEC liaison from the Leader's Office for a long time) was congratulated on his selection by local members to fight Leicester South. We discussed all the elections happening on 5 May which will be very important for us, including the overall share of the vote, to show Labour building momentum. Ed was congratulated for deciding to speak to Saturday's March for the Alternative. After the May elections we will start the process for recruiting a replacement for Ray Collins as General Secretary. Ray gave the financial report and said that the policies that the NEC adopted to reduce debts but preserve our activities was the most significant decision. We will be debt-free by the next election. Various NEC members called for a clear line on the cuts which can be hammered home, both for members but also for shadow cabinet media appearances. Our message is not coming through clearly yet and people need to hear a clear argument for what Labour would have done differently. The Leader pointed to the bankers’ bonus tax which the Tories refused to renew and their political decision to reduce the deficit over 2 years when they acknowledge they could have done it over 4 years. I asked Ed M to meet with the Socialist Societies soon, which he readily agreed to do. The Equalities committee review was reported to the NEC. While the vice-chairs are encouraged to get their relevant groups to make submissions to the Party Reform, I still want the Equalities committee to make a joint submission. At the end, Ed Balls joined to give a report on economics policy. In response to the call for a clear line he said there should be three parts: it was a global recession, not a UK one; the Tories cuts are too far and too fast and they will not work as they are destroying growth. The media comparison of Labour's £12bn cuts vs Tory £14bn cuts is false as was based on very different projections made at different times. As always, Socialist Society members are welcome to email me to learn more and tell me your views. Simon Wright NEC Member: Socialist Societies 07976 907291

The NHS Health Bill: what to do before its final reading?

Working is good for mental health and wellbeing – at what cost and to whom?

Abstentions indicate a feeling, or a doubt, among those present, much as silence in a discussion. Of the 650 MPs, just 556 at the second reading of the NHS Bill on 31 January used their votes. 104 did not. Parliament does not record which MPs abstain or even how many MPs are present at a division. Andrew George, Lib Dem MP for West Cornwall, promised a constituency meeting on 28 January that he would abstain from the vote at the end of the second reading and BBC News and the Guardian on 1st February reported “Andrew George deliberately abstained.”

Part of the welfare reform agenda is to put more people on means-tested Job Seekers Allowance (JSA) and Income Support and take them off Incapacity benefits and other contribution based benefits. There will be a face to face medical assessment for all claimants. Those who pass this assessment will be entitled to ESA and those that don’t pass will be eligible for Job Seekers Allowance.

On 28th February The Times published an article by Lib Dem Shirley Williams in which she wrote she had a “moral duty” to challenge the Bill. Andrew George (a member of the Commons Health Select Committee) endorsed Shirley's comments." On his website he had taken up the concerns of local nursing staff who face downgrading : “Nurses are complaining that, in spite of 20 to 30 years of loyal service, the so called 'Skill Mix Review' has been forced on them at very short notice with the intention of downgrading at least half of the nurses under the review. Nurses who currently work together as a team are now having to compete against each other. …Nurses have only to the end of this week to express their views. Nurses are the backbone of our hospitals. To threaten them with such significant levels of wage cut at a time when they can still see bankers awarding themselves billions in bonuses…It is understandable that nurses should be asking: If we are 'all in this together' then why are they picking on nurses rather than bankers?". The 4 March result in Barnsley and the 15 March BMA vote in London show the position summed up in the Commons debate on 17 March by John Pugh MP Chair of the Lib Dem Health and Care Policy Group: “the Health and Social Care Bill is in trouble. There is hostility to it from the professions, anxiety about it among the public, concern in the Cabinet and an unease that can be felt spreading in all sections and all parties in this House and the other place”. Now is the time to lobby Lib Dem councillors, party members, friends and MPs and those Tories with unsafe seats. Roger Gartland

Working and indeed any type of purposeful activity is good for our mental health and well being. But if increased poverty is the result of these benefit changes the negative impact of both less income and more pressure to enter the workforce, could have devastating effects on recovery and maintaining quality of life for those living with enduring mental illness Disability Living Allowance (DLA) will be renamed the Personal Independence Payment. There will be 2 components (daily living and mobility) with 2 rates for each, a 6 month qualifying period (rather than 3 months) and an end to indefinite awards. Eligibility for the daily living component will be based on the difficulties experienced with the following activities: Planning and buying food; Preparing and cooking food; Feeding and drinking; Managing medication and monitoring health conditions; Managing prescribed treatment other than medication; Washing and grooming; Toileting and managing incontinence; Dressing and undressing; Communicating with others. And for mobility component: Planning and following a journey; Moving around. It is difficult to understand exactly how the assessed activities can make sense for those living with enduring mental illness. For those whose lives are affected by mental ill health, some will be restricted by the above activities. More often, quality of life is reduced by severe anxiety which prevents activities such as social engagement, using public transport, leaving home on a regular basis and sleep problems. Depression can cause similar difficulties as well as social isolation and withdrawal from activities of daily living. Someone may well fail on the ESA work capacity assessment and yet have significant factors preventing them to be successfully employed.

Carolyn Emanuel

Socialist Health Association Campaigning We must focus on a few key issues: the issues of accountability and competition have already attracted attention. We should aim to increase Parliamentary awareness of the extent of public and professional concern. Lobbying Lords and MPs of all parties: Disquiet includes leading figures within the Coalition (eg Norman Tebbit, David Owen and Stephen Dorrell). We should support meetings between Lords and patient and clinician groups to extend this. The Health Select Committee has produced a report with many measures which could be supported. In practical terms: 1.We need to mobilise support for our team in the Lords from July until about January. They need people who can draft amendments and write speeches, or at least summarise an argument. This could be done remotely and need not involve huge numbers, but it might give opportunities for people knowledgeable about specialist areas to contribute. 2. Political pressure on the Lords - supporting our friends and embarrassing our enemies. Not easy to do. Could involve stunts, celebrities, local meetings in the home areas of Lords. Also more thoughtful articles, arguments and perhaps events in the Lords.

strategy. This would mean shifting a lot of people in the Party and unions out of their comfort zone. Activity in traditional campaigning areas the centres of cities where people largely vote Labour - is of very limited value. We should be working in Leamington, not in Lewisham. We must also try to raise awareness of political issues to reinforce all this. So I would like to organise a meeting about regulated markets, and get someone from Monitor to speak - as well as people from gas or rail regulation. A meeting for councillors about health and well being boards would be good. And we should be focussing more on public health - issues around housing, debt, social security.

Expected Timetable 31st May Deadline for public responses to NHS Future Forum 26th June NHS Future Forum reports this week . Government produces response. Shortly after that, probably, 3rd reading of the Bill in the Commons 5th July NHS 63rd anniversary opportunity for stunts



Bill starts in the Lords

3. Pressure on coalition MPs: Meetings or stunts in their constituencies - especially in the 150 constituencies which are most marginal. The plan would be to invite (or get someone else to invite) the local MP to come and explain their government's plan for the NHS to the local population, especially patients and clinicians.

28th July

Lords recess

Our role is to try to mobilise people, especially clinicians and patient groups, around this

Sometime in January(?) the Lords concludes and the Bill goes back to the Commons.

17th Sept Lib Dem conference in Birmingham 25th Sept Labour Party conference Liverpool 5th October Lords resumes.

2012 10th Jan

Parliament returns

Rathfelder —Director Membership of the SocialistMartin Health Association Free entrance to local branch and central council meetings; reduced fees for our conferences; SHA Journal Socialism & Health and frequent email bulletins about developments in health politics; voting rights as a member of a Socialist Society affiliated to the Labour Party; opportunities to contribute to the development of health policies. Membership costs £10 for individuals with low income, £25 for Individuals , £25 for Local Organisations To join post or email your details to : Socialist Health Association 22 Blair Road, East Chorlton, Manchester, M16 8NS.


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