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.

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.