NHS reforms pose worrying questions for Britain’s democratic process

At the end of April, amid growing condemnation of NHS reforms, the Government asked for a 'pause' in the Health and Social bill to allow it to perform a second consultation. As the third reading of the Health and Social bill starts today it would be fair to assume that a pause in the legislation has translated nto a pause in ground-level implementation. But that hasn’t been the case.

In early July, Lansley announced at the NHS Confederation conference in Manchester, that the 'pause' in the Bill was "over. It's now time to act” - which may explain the speed of reform over the summer.

After last year’s initial consultation process, when doctors said they would struggle to meet the 2013 deadline for all GP surgeries to be part of a local consortium to manage NHS budgets, Lansley declared in December 2010 he would “press ahead immediately with pathfinders of emerging GP consortia”. Ostensibly they would blaze a trail for the proposed reforms and help the Government discover any potential future pitfalls in the plan. However, since the Bill is yet to pass, these consortiums are operating “under existing legislation”. At best this seems undemocratic as, according to Lansley himself, 97% of the population is now covered by these consortia without any legislative change to account for this rapid transition.

This leaves the NHS reforms in a muddle as, in a speech at University College London Hospital in June, David Cameron scrapped the 2013 deadline for GPs to take on full commissioning responsibility. With PCTs already offloading staff (Freedom of information requests from 54 PCTs show that at least 2010 jobs have been shed through a combination of redundancies, unfilled posts and mutually agreed resignation) and some consortia further advanced then others, what will fill this authority vacuum?

A recent investigation by trade magazine Pulse found that only 84 PCT-led GP surgeries now exist in England and PCTs are re-tendering existing PCTMS contracts (for which they are directly responsible) under the belief that any such contracts still in existence by April 2013 will not be legal as PCTs will not exist. Of the four types of alternative contracts the PCTs could choose, 41 of these 84 practices have had, or are in the process of having, their contracts retendered under Alternative Provider Medical Services (APMS), which has been specifically designed to broaden the range of providers that GPs can commission from. In short it allows private companies to bid for GP contracts. Unison has said of APMS contracts: "Worryingly, APMS contracts allow for increased privatisation of primary care services and a profit-driven approach to health care provision".

Just as worryingly, some PCTs want to put out to tender entire care pathways, opening up its patient care provision to private companies. According to Pulse: "NHS East of England plans to auction off £300m of services to GPs, private companies or a combination of the two, in pathways including respiratory and musculoskeletal medicine." A further eight PCTs are expected to follow suit.

Yet the health bill’s most contentious aspect has been the desire to open up the NHS to “any willing provider”. Following strong criticism, the wording in the Bill is likely to be changed to “any qualified provider” meaning that all providers would have to meet a set of standards – yet as these are yet to be agreed upon, it seems the offloading of entire care pathways is moving faster than the legislation that allows it to.

Finally, the Department of Health has announced that Hinchingbrooke NHS hospital in Cambridgeshire has been given the go ahead to be run by a private company, called Circle Health, as long as the Treasury approves it’s “viability” . This contract has been given an initial green light despite the fact that the company in its recent flotation document warned that a profit might "become unachievable". Having watched the disastrous collapse of care homes operator Southern Cross, putting many patients at risk of becoming homeless, it seems extraordinary that the Government is considering allowing a company to take over a hospital when it has openly announced it may struggle to make and maintain a profit. This will call into question the long-term survival of Hinchingbrooke or the need for a Government bail-out should Circle Health fail to keep its investors happy.

When they return to debate the Health and Social Bill this week, I think many MPs will be shocked at the pace and extent of ground-level reforms. It seems almost inevitable now that GPs will take on some form of commissioning as PCTs have all but dismantled themselves, even though the Bill allowing this to happen has yet to be signed off. Meanwhile private companies are already sniffing out profits by taking on GP contracts, care pathways and even whole NHS hospitals. It poses worrying questions for Britain’s democratic process when the sitting Government pushes ahead with reforms while intense debate in the Commons has by no means reached its conclusion.

The Winterbourne abuse scandal provides a stark warning against NHS privatisation

This week's Panorama about systematic abuse of patients at Winterbourne View private care home was shocking and uncomfortable television. Yet behind the fear of the patients, routinely and daily abused by their carers, was a story to be told about how private companies operate in social care. And it is a story we must pay urgent attention to as our Government looks to open up mainstream NHS treatment to 'any willing provider' - exactly what has already happened in social care.

What truly shocked me about the Panorama programme, wasn't just the terrible individuals metting out suffering to vulnerable young adults, but the complete failure of the Care Quality Commission to identify the abuse. CQC is the Government regulator of social care providers, it is meant to ensure that private health providers that win Government contracts ensure that quality of service does not come a lowly second to a profit motive. Yet during three inspections of the unit the CQC did not uncover any inappropriate behaviour and, even more worryingly, it failed to act on three emails it received from a highly qualified nurse who used to work at Winterbourne which detailed the abuse at the unit. The question is: how many other units have passed a CQC inspection are also hiding dark secrets?

Whereas social care has already been opened up to private providers, the health service is still largely nationalised. Yet the Government's controversial Health and Social care bill wishes to allows 'any willing provider' such as private companies and charities to compete for health contracts. The Government will be reliant on the CQC and 'people power' to ensure these providers are of good quality.

Lansley in speaking with the Guardian in February believes that people will 'vote with their feet' and go elsewhere if the health service they receive is not good enough. I've doubted this is possible since I heard this claim - a person's ability to maintain family life and jobs relies very often on accessing local health care regardless of its quality. But the scandal of Winterbourne shows that very vulnerable people cannot exercise a choice at all. Which would leave them at the mercy of the CQC to ensure "quality and safety" from their health provider - if the CQC is already struggling to identify problem providers can it really be trusted to do so in the future with a vastly expanded portfolio of providers to oversee?

Moreover, while the Panorama programme caught the nation's attention over extreme abuse, it would be terrible if we saw a patient's basic safety as the only target to aim for. The documentary also showed that the patients, in the words of an expert, 'had nothing to do' day in and day out. Disgracefully the Government pays £3,500 a week for each patient to live there but other than basic carer supervision there appears no programme of activities or experiences that might enable a person to learn how to gain independence and move out of the institution. Where is the quality or value for money there? Winterbourne is meant to be a therapeutic environment yet one can only imagine that once Castlebeck, the company behind Winterbourne, creamed off its profits there was only enough money left for basic care.

The same day the Winterbourne scandal hit the nation's papers the alarm was also sounded on the financial fragility of Southern Cross, a provider of care homes for 31,000 elderly residents. City analysts believe that a series of poor decisions taken when it was owned by a private equity company have brought the care home to its knees, generating real fear amongst residents as to what will happen to them if the business folds.

There is no suggestion that care at Southern Cross is in anyway substandard but its financial concerns yet again leave highly vulnerable people exposed by the machinations of a private company in the pursuit of profit over consistent and reliable care.

I only hope that the public recognises that these simultaneous failures in social care are stark warnings of what could happen to our health care system if private companies are allowed to cherry pick services it wishes to offer, gleaning off profit at the very expense of the people it is meant to be providing a first-rate service to. At the very least, the CQC must not be given any more 'providers' to oversee until it has become apparent how widespread its failure runs, people are held to account, and meaningful reforms are implemented.

Time to rethink the approach to NHS reforms

The first debate of the NHS reforms took place on Monday, and the second reading of the bill was passed with 321 MPs voting for and 235 voting against. It followed six hours of debating.

But while MPs are battling each other in the House of Commons, they are also trying to win over the public to their plans. So wide-reaching are the reforms, it has taken a while for health journalists to fully realise the implications, let alone the general public who have very little understanding of the NHS machinations at work behind their GP surgery.

This week has been full of statistics and surveys aimed at influencing the direction of the debate. While the reforms are focused on giving power to the GPs over the way NHS money is spent, it is the MPs who will decide whether the reforms are happening. So GPs, powerless in the face of empowerment, are using the media to bang on the doors of the Commons. A snapshot survey of the Royal College of General Practitioners, found that of 1,800 responses, 70% disagreed or strongly disagreed that patient outcomes would improve by opening up the NHS to private companies. 50% also felt GP commissioning would not give more power to patients.

And the MPs themselves have resorted to throwing statistics at the press in the hope of making their opinion the dominant story in the papers. Shadow health secretary John Healey claimed that 3 out of every 4 GPs disagreed that NHS reforms would improve patient changes. (The excellent blog Factcheck questioned the veracity of this stat though).

The Tories have hit back at Labour claiming these reforms were begun in part by Blair's Government. I'm currently reading Andrew Rawnsley's brilliant book 'End of the Party' about the last two terms of the Labour Government. He continually highlights Blair's frustration at being unable to make great public service reforms. In a 2002 interview with Rawnsley, Blair said: "We will not maintain public services and the welfare state unless we radically recast them" (pg76). He wanted to introduce choice to the users of the NHS and diversity of providers, hoping the third sector and private companies would tender for contracts. His reforms were watered down due to party opposition, but it is clear that parts of New Labour were of the same mind as the Tories now are.

So the questions is, why can't we all have a sensible conversation about it?

If the parties are both thinking the same thing - that the NHS must change before it starts to fall-apart - then perhaps an honest conversation with the British public is required. In which the case for change is explained and a realistic time-frame is established for such measures. Perhaps the first step is to start on the path to GP commissioning, but in a more balanced, state-managed way rather then the piecemeal free-for-all that is currently being considered. Once commissioning is up and running then the next step might be to consider what benefit, if any, private companies can bring to the NHS.

In contrast, it is clear to me that the current state of affairs in which GPs are fighting to be heard and the public haven't even been asked their opinion will just result in chaos. The BMA today even said a strike over NHS reforms is a possibility.

As plans currently stand reforms could result in a wildly variant health-service - with some GPs succeeding with commissioning while others fail, and private companies taking advantage of the mess to take over services that undermine the viability of NHS hospitals.

The first step of reforms must be to accept that the NHS, which has been developing for 60 years, cannot be recast in just 60 months. And if reforms cannot be implemented before a general election, and a possible change-over of power, perhaps the fate of much-loved British institution is deserving of the parties to come together and work towards strong, effective and safe reforms for the NHS, which override party politics.

MPs that spend less time fighting each other could then spend more time listening to the opinion of those affected: medics, nurses and us, the service user.

Waiting-list Watch - part 1

In June 2010 health secretary Andrew Lansley scrapped NHS waiting list targets. He argued they created too much paper work and he wanted the NHS measured on "patient outcomes' instead of arbitrary targets. Unsurprisingly with the targets gone, waiting lists are now creeping up. Lansley is wrong to think patients will only judge the NHS on outcomes, they will judge it on the whole process from start to finish. How long you wait to see a doctor, receive a diagnosis and start treatment are intrinsic to what patients think about the NHS.

Trade magazine, Pulse, announced today that waiting lists have increased, on average, by a quarter already. 
For example:

• The proportion of admitted patients who did not receive treatment within 18 weeks has risen by a fifth – from 6.7% to 8% – with 23,826 missing out.
• The number of people waiting more than the previous target of six weeks for diagnostic tests rose by more than 90% compared with the same period last year.

In short, ill patients are being told to wait longer to receive treatment or to even know what is wrong with them.

All statistics are based on the Department of Health data. I'll continue to blog on waiting time targets, as it is my guess they will continue to rise and rise as the NHS struggles to make £20 billion of efficiency savings by 2014 with just a 0.1% annual increase to their budget in the same period.

Lansley may want to remember that NHS patients are also voters. His decision to scrap targets, which at the time received little coverage, may well come back to haunt him in four years time.

Just how secure is the ring-fence around NHS funding?

We've all been told since the election that
NHS funds are going to be protected and more often than not we breathe a sigh of relief and conversations move on to think about areas such as defence, policing and justice which are under scrutiny. But should we just accept what we are told about NHS funding?

Looking into the figures more, it looks like belt-tightening is going to hit the NHS significantly. The King's Fund, a think tank focusing on health, has written a great blog post about this very subject, I'm not going to replicate it but just draw out some of its most interesting points.

It argues that in the past the NHS budget has increased by 6 per cent on average, but going forward that looks more likely to be reduced to a 1 per cent increase. In addition, the baseline on which to measure an increase has been reduced. In the 2007 Comprehensive Spending Review, spending for 2010/2011 was projected to be £109.8 billion. By 2009 expected spending for this period was reduced to £105.8 billion. Its always easier to find an 'increase' in funding for 2012, if the last year's funding is £4 billion less than demanded. In short, with these increases, the NHS can only do all that it currently does if there is no extra demand on its services. And that seems highly unlikely.

Ignoring the fact that we are facing an increasingly old and obese population, the real concern for me is the reduction in social care spending. There are suggestions that £400 million of NHS funding could be transferred to social care spending, although we'll have to wait until tomorrow's Spending Review to see if that is confirmed. Not only would that mean that in reality the NHS will lose a chunk of its money, but in addition, the institute for Fiscal Studies expect local authorities to lose 33 per cent of funding by 2014/2015.  It's clear that if social funding is heavily reduced - meaning that elderly people and those with long-term health conditions have community care removed - the pressure on hospitals will be immense, as admissions creep up and patients stay in hospital for longer as care they would normally receive at home is removed.

This is really false economics. In July this year the Nuffield trust said unplanned emergency hospital admissions had increased by 12 per cent since 2004, at a cost of £330 million per year.  Speaking at the time, Nuffield Trust director Dr Jennifer Dixon said: "Reversing this unsustainable rise in emergency admissions must be the number one priority for the NHS - any reform to the health service that does not tackle this will fail." So you can see that a decline in local social care funding will have a direct impact on the NHS, which won't have its funding increased in line with the rising cost of the problem.

And some of the fall-out is already being seen. NHS Warwickshire has delayed IVF treatment until next April to ensure it doesn't overspend its budget. It has also postponed hip, knee and shoulder replacements and cataract operations. It is unacceptable that some Trusts see the best way to balance books as limiting what treatment is available year-round. It basically means that there are good times of the year to fall ill and bad times - and I would hate to be the surgeon trying to work out how best to get through a six month back-log of operations. How convenient that Health secretary Andrew Lansley abolished NHS waiting lists earlier this year.

I appreciate that there is not an endless pot of Government money and that spending reductions have to be found somewhere - but it seems pure political game play to ring-fence the very emotive issue of the NHS, and yet allow such significant cuts to areas that will directly increase the demands on the NHS along with how efficiently its money is spent. Like those people who live in the NHS Warwickshire catchment area, just pray you don't get the wrong type of illness at the wrong time of year, otherwise you could experience first-hand how weakly constructed the Government's NHS ring-fence really is.

NHS funding overhaul will create conflict of interest between public health and private enterprise

Ok so it's taken me a couple of days to respond to Monday's news that the NHS is in for a dramatic shake-up (blame it on the weather, the heatwave wiped me out completely - it's weird to think of myself in the 'vulnerable' group when it comes to things like that).
 
But anyway while we were all busy eating lollies and loving the recent weather, the Government was preparing to launch a white paper called 'Liberating the NHS' that plans to radically alter the way the NHS is funded. It wants to give £80 BILLION directly to GPs to decide how best to spend it on patients, scrapping Patient Care Trusts (PCT) along with it.


I'm not a big fan of PCTs, they have a habit of implementing localised policy that goes against the decisions of NICE, the body governing what drugs and treatment should be available to patients nationwide. Last November I was told by my PCT that I was no longer allowed to be given a nebulised antibiotic called Colomycin as according to old medical guidelines it should only be given in a hospital environment. Except I, along with countless other people with lung conditions, have been taking it at home for two decades. So clearly this sudden decision was one based on saving money.

My GP called the PCT to protest: "Sharon needs easy access to her medicines to be able to concentrate on resting and staying well, not worrying about receiving the drugs she needs". Despite this call, the PCT still said no. (I still get this drug, via hospital, so the NHS has saved no money, the patient has merely been inconvenienced.)

So given that scenario the new plans in principle are an interesting idea. GPs know their patients well and can best decide what treatment they need. However the truth of the matter is that the NHS is still cash-strapped and always will be so my concern is that GPs will instead be faced with a conflict of interest - a patient needs a drug he knows he cannot afford to prescribe. What happens in that scenario? He keeps quiet and offers a cheaper alternative that he knows is less likely to do the job?

The new plans also include a patient being able to choose where to visit a GP, meaning they no longer need to live in their GP's catchment area. But in practice will this be allowed to work in reverse? Perhaps GPs will balance the books by limiting the number of 'expensive' patients they look after, and it's exactly these patients who will be too ill or too busy with time-intensive medical regimes to be able to travel far. It's long been documented how people struggle to find an NHS dentist, will the same soon be said of GPs?

The Government has said hospitals will be encouraged to move outside the NHS to become a "vibrant" industry of social enterprises. Effectively meaning they will need to 'pitch' for money from GPs and that their cap on how much private work they can do will be removed.

The idea is that hospitals will have to become very good at care to ensure they survive, as otherwise GPs won't refer their patients there. But instead they could feasibly cut their prices to lure in patients - meaning those hospitals that achieve less good results could ensure survival by offering services to GPs at prices that reflect this lower quality, in a similar way that lower-rated Universities can offer cheaper tuition fees to attract less well-off students. In addition, waiting lists for NHS patients could soar as hospitals prioritise private patients, who will be unlimited in number. Notably, the health secretary Andrew Lansley already abolished hospital waiting lists.

And there will be no "bail-outs" if a hospital overspends and goes bust. This is completely unacceptable. Social services are provided in a local area to provide access to the care that local people need. If a hospital is failing it should be helped to improve not just be allowed to fail and close down with no thought for the needs of the local community.

And what about patients like me? I never see my GP except for prescription renewals and a common cold. Instead I visit my hospital doctors at least once a month, they decide on my care plan and drug regime and tell the GP what I need. I have no idea how this scenario will be dealt with when GPs are meant to commission hospitals, not the other way round. But it adds to the overall concern towards the Government's plan: it's untested, unpiloted and is meant to be implemented in just 24 months time.

This blog raises a lot of questions I don't know the answer to, but I'm not sure if the Government does either.