"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Saturday, 31 July 2010

NHS Cuts

Where is this NHS ring fence, have you seen it anywhere? Don't try looking because it does not exist.

The Lancet reports that they were passed a document from Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust entitled, "Proposal for A/OA Organisational Change Paper." (A being adults, OA being older adults). The Lancet says:

"The current income budget of the [Adult and Older Adult] Directorate is approximately £42 m. The savings to be achieved are £5·3 million over the next 4 years.” In Appendix 3 and 4 of this proposal, staffing changes are set out in detail. For adult mental health services, three consultant psychiatrists out of 19 will lose their jobs. There will be 16 fewer care-coordinators and support workers, eight fewer allied health workers, and one less staff grade position, together with cuts in clinical psychologists. There will be an increase in a new category of support, time, and recovery worker, but their numbers and skills will not fully compensate for the loss of front-line health professionals, including the 15% cut in consultant psychiatrists. There are additional cuts in health professionals among staffing for older adults."

 So no front-line NHS cuts, eh?

NHS Privatisation: PCT properties

Primary Care Trusts currently commission work from hospitals, GPs and community services. The Coalition Agreement said that PCT boards would become elected, but the autocratic Andrew Lansley, behaving like a post-revolution Soviet Commissar, decided that this was not in his already prepared plan and he dismissed it out of hand. Lansley had already decided that as part of his NHS privatisation plans, PCTs would be abolished and that is what would happen.

So what is to happen to the property owned by PCTs? In 2008 an evaluation estimated that PCTs own as much as £36bn worth of property. That's community hospitals, clinics, walk-in centres and some GP surgeries, to you and me. But to s property developer they are a portfolio, and an opportunity to make profits. And to Lansley, PCT properties represent a quick source of cash equivalent to 180% of the cut efficiency savings that the NHS have to make by 2014.

Wouldn't you think that £36bn of property would be important enough to be addressed in the NHS White Paper? No, apparently not. There is not a mention, which means that Lansley plans something that we will not like.

Public Property UK list the options:

  • Local authorities could manage them. This is unlikely, because local authorities may not have the relevant experience.
  • The government could form regional organisations to hold the properties.
  • The government could look for investment partners. This would offer opportunities for sale and leasebacks.
Expect in the next year or so for there to be lots of property developers making fortunes from PCT properties being sold off at knock down prices.

What's happened to democracy?

We discovered a fortnight ago that Michael Gove would using parliamentary procedures normally reserved for emergency bills like terrorism bills, to push through his academies bill. Now i have just found out that Andrew Lansley's plans to privatise the NHS are being implemented without even a bill being passed.

A key part of Lansley's plans is to abolish PCTs and hand public money over to GPs to commission hospital work. GPs do not have the experience or skills, and many are wary of the diktat that they have to "align clinical decisions with the financial consequences". The NHS White Paper invites comments and the deadline is the 5th October, which is only a month before the Queen's Speech so it seems unlikely that any comments could influence the health bill planned for the autumn.

Now it comes to light that the NHS White Paper is not being treated as a discussion document at all. This is the health bill and Lansleyis treating it as if it has already been passed by Parliament. The following is reported by healthcarerepublic:

In a letter to managers and senior staff, NHS chief executive Sir David Nicholson says that all service changes should be signed off by consortia, or other GP representatives if consortia have not yet formed. PCTs will have to amend their proposals if it does not have the support of local GPs.

It is frightening that an extreme right-wing government that failed to get a majority at the 2010 election can change our national institutions without even passing a bill in Parliament.

UPDATE: 02/08/10

Pulse magazine reports that "A quarter of GPs have already entered talks with their PCT on increasing their commissioning responsibilities".

But not every GP is happy:

But Dr Keith Holtom, a GP in Oldbury, West Midlands said: 'Like many of my colleagues I took up medicine and became a GP because I want to treat patients; I have extensive training and expertise in this field.

'I do not however have extensive training in health service management and I most certainly do not relish the prospect of this as I believe that it will mean less time for face to face patient care - and I believe that in a cash strapped NHS the GP will be made a scapegoat as rationing inevitably kicks in.'

Thursday, 29 July 2010

Reactions to the NHS White Paper

This is an interesting article from the Northern Echo.

Professor David Hunter, who holds a chair in health policy and management at Durham University says:

"There will be no experiments, no pilots, just the whole NHS system put into freefall ... [it is] a scorched earth policy ... [the white paper gives the] impression that the plans are the result of some back-of-the-envelope thinking, you do get that impression because, at the moment, it doesn’t really add up"

He also fears that setting up 500 GP consortia: "with at least half a dozen people managing the back office functions in every group", will end up costing the NHS a lot of money.

"Will these managers go directly into the consortia from the PCT or SHA, or will they be paid off by the NHS, nip off to the private sector and then sell their skills back to the Health Service? ... There are a lot of big American and European companies who are sniffing around and are incredibly enthusiastic about what is happening."

Prof Hunter says that NHS managers are left feeling "like being on the bridge of the Titanic" and he believes many must be considering jumping ship before the PCTs and SHAs sink beneath them. He fears the new health team in Whitehall could be making a huge mistake.

"Everybody’s health is at stake and the whole basis of the NHS could be undermined ... we could end up with a shell organisation with the NHS brand and nothing behind it"

Professor Alan Maynard, who holds a chair in health economics at Nottingham University sums up the gung-ho approach adopted by Mr Lansley as like "jumping off a cliff" into the unknown, he warns that the high-speed reforms being pushed through without any attempt to evaluate their success involved "potential risks" for the NHS.

Private Sector Are Worried

The NHS White Paper says:

"[the new health bill will] abolish the arbitrary cap on the amount of income foundation trusts may earn from other sources" (4.22)

When an NHS trust becomes a Foundation Trust it is told how much private work it can perform. This is effectively the level of private work that it was doing as a NHS Trust and the cap basically says that the trust can do no more. For example, my local FT has the cap set to 1.3% of its income. This money mostly comes from things like pathology where the hospital are paid by GPs to do tests on a private basis. The hospital - to my knowledge - does not have private patients.

Lansley wants to privatise the entire NHS and throttle the money coming from the taxpayer, and as part of this plan he has to persuade private patients to use NHS hospitals. I find this disgusting for several reasons but mostly because I do not want a two tier system where a patient will jump the queue by paying.

The Health Service Journal report today that the private sector are not happy about this because clearly a private patient in an NHS hospital is one fewer patient in a private hospital. HSJ say that private hospitals may complain to the EU under European state aid law rules.

Lansley has tried very hard over the last couple of years to persuade the private sector that his plans will be good for them. For example, the White Paper even says that they will be allowed to use NHS facilities. So I wonder why the private sector are threatening an EU ruling? Perhaps it may be because they think that the UK public do not have the capacity to pay for more private healthcare and there is no scope for the market to expand? The private sector are only interested in performing NHS work - replacing NHS hospitals - and they are suddenly realising that politically Lansley cannot simply hand them the keys to NHS hospitals (much as he would like to) and they realise that the "sink or swim" attitude that lansley is applying to the NHS is being applied to them too.

Monday, 26 July 2010

GP Commissioning

The excellent Roy Lilley from nhsmanagers.net makes the following point in his email newsletter.

In 1998 the New Labour government created Primary Care Groups with the intention to: improve health and address health inequalities in their communities; develop primary and community services; advise on and commissioning, directly, services that met the needs of their patients; develop the highest quality provision and provide value for money within available resources.

These are all the aims of the current Conservative government which they hope to achieve through GP commissioning. But Lilley says that like PCGs GP Commissioning will fail. He says:

"They failed because there were too many of them, too small, too poorly run, cost a fortune in running costs and duplication and were beset with bickering GPs. ... On the face of it, they were a good idea, the PCGs reflected coterminous boundaries and natural communities but they duplicated functions and cost stupid amounts of money. As a result, the planned 'option' for PCGs to mature and work towards a more independent Primary Care Trust status was turned into a 'requirement'. All the 'Groups' were rammed into 'Trusts'.

Trusts were given real budgets, real money and all of the responsibility. They were not ready, not trained and key players, such as GPs, were trying to do 'PCT stuff' whilst they were doing 'doctoring stuff'. As a result, standards and the brand quality were diluted but more importantly, they never really caught their breath. They were unprepared. The natural consequence happened; small, badly run organisations, merged to became bigger, badly run organisations. The rest, as they say, is history."
 In effect, Lilley says that the aspects that are meant to be the most attractive about GP Commissioning (teh "localism" of many small consortia run by GPs) will be the reason why they will fail. This "localism" is something that cannot be afforded at a time of reducing budgets and over time the GP consortia will merge into 150 consortia with very much the same aspects of today's PCT.

The problem, of course, is the matter of the £2bn to £3bn that it is estimated that this experiment will cost.

BMA urges guerilla tactics

This is from HealthInvestor.co.uk (whose subscription code is broken at the moment):

The chairman of the British Medical Association has written to GPs encouraging them to use their commissioning powers to freeze the independent sector out of the NHS. Laurence Buckman said the reforms set out by health secretary represented a “potentially huge opportunity for GPs”, but he also said the developments represented a “major threat both to the current form of general practice and even to the NHS as a public service”. To mitigate this, Buckman urged colleagues to refer patients to NHS providers, rather than private or voluntary sector operators, whenever possible. Hamish Meldrum, chairman of the BMA council, said this would effectively allow GPs to “bypass if not ignore” the government’s attempts to introduce competition into the health service.
This sounds like a plan :-)

Saturday, 24 July 2010

Social Enterprises

The NHS white paper says:

"Our ambition is to create the largest and most vibrant social enterprise sector in the world." (4.21)

Will it work? According to Becky Malby, Director of the Centre for Innovation in Health Management (CIHM) at Leeds University Business School the answer is no.

"Social enterprises work because they are nimble, socially orientated, and embedded in real need. Our NHS model starting point is completely different. These social enterprises will be the biggest of their kind in the world, and so will need breaking up into smaller services. ...Turning NHS staff into entrepreneurs overnight is highly unlikely particularly given the age profile of community nurses and doctors. If they were going to be entrepreneurs they would have taken that path long ago. It will be hard to break up NHS services turned social enterprises once they have made the move. At best this looks like a cost-shift making the NHS a private sector provider – or possibly a not-for- profit, but that’s not clear."

The last sentence says it all. Lansley is simply privatising NHS hospitals.

Paying for private healthcare

The NHS white paper repeats often that patients will be given the choice of "any willing provider", but I have not been able to find anywhere that says how these providers will be paid.

One of the aspects that is internationally acknowledged about the NHS is that it is extremely cost-effective. If you want a cheap, high quality system then the NHS has always been regarded as the best system. So how will private providers provide treatments as cheaply as the NHS?

The Coalition Agreement says:

"We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices."

The important point outlined here is that these private providers will only be paid at NHS rates. These rates are going to get tighter. The new national tariff (the rate for each procedure) will be the rate of the most efficient NHS provider rather than the average that is paid at the moment. Private healthcare cannot meet this rate. I have to point out that this phrase is from the Coalition Agreement, and the white paper does not repeat this phrase. Since the white paper has already broken one statement in the Coalition Agreement - by abolishing PCTs rather than making them elected - we must regard the statements in the agreement as being optional, but for the time being let us assume that the government will stick to this pledge.

I have blogged elsewhere that I think that the effect of paying at the rate of the most efficient NHS provider will be to close NHS hospitals since the government has said that they will not bail out hospitals. These new national tariffs will be extremely low rates.

The downside of the cost effectiveness of the NHS has always been long waiting lists: non urgent cases have always been subject to waiting times. The white paper says nothing about waiting lists and since Andrew Lansley says that the 18 week Referral to Treatment (RTT) target will no longer be used for performance rating hospitals, he is giving an indication that he expects waiting lists to rise. For your reference the median RTT waiting times in May 2010 was 8.4 weeks for admitted patients and 4.3 weeks for non-admitted patients. We will never see waiting lists as low as this again. While it is expensive to cut waiting lists, allowing waiting times to rise does not necessarily cut the cost of the treatment in the long term. So it is not likely that private healthcare can reduce their costs to NHS rates simply by increasing waiting lists.

The NHS white paper gives no clues about how private healthcare can provide treatment at the lowest NHS rates.

Then I discovered this transcript of the Health Select Committee on the 20 July 2010. The interesting point is this:

"Dorrell says govt is looking at future co-payment model, have to look at funds and also at achievable levels of private funding compatible with principles of equity."

There are three ways that co-pay could be used:

  1. You could be asked to pay a token contribution for appointments, say £10 to see your GP. The idea is that there is a financial incentive not to miss an appointment. There will be the usual safeguards for those on low incomes and children.
  2. You will be asked to make a contribution towards treatment. This is just an extension of the concept of prescription charges to treatment. There will be the usual safeguards for those on low incomes and children.
  3.  Private providers will be allowed to charge co-pay.
Think about it. You will be allowed to use any willing provider at the NHS rate but if the provider charges more than the NHS rate then you will top-up the fee with co-pay. Over time, NHS providers will become "social enterprises", that is, private companies, and will be allowed to charge their own co-pay. This will mean that the national tariff will not be the rate of the cheapest NHS provider, but merely the contribution to your treatment that the tax-payer is willing to pay.

This will be the end of the principle of "free at the point of delivery".

NHS White Paper Part 6

Conclusion: making it happen
This section ismainly a summary and a timetable of the legislation.

"Much work now needs to be undertaken over the next two to three years, both to manage the transition, as well as to flesh out the policy details." (6.2)

Remember that this has been described as the biggest re-organisation of the NHS in its 60 year history, and the white paper indicates that it will be rushed through in just two to three years. There will be no pause for democratic accountability to take effect, your only chance will be in May 2015 when you will finally have a say about what you think of the de-nationalisation of the NHS. By then there will be no publicly owned hospitals and most services will be performed by private companies with the NHS merely a brand name for the source of (some, but not all) of the money that pays for your healthcare.

"To support the ownership of the strategy within the NHS and to inform the implementation of this White Paper, the Department of Health will carry out a series of consultation activities with: patients, their representative groups and the public; NHS staff, their representative and professional bodies; local government; and the voluntary, social enterprise and independent sectors. This will run in parallel to the formal consultation on the proposals above." (6.5)

This is your invitation to indicate that you dislike some or all of this white paper. However, remember that the Department of Health has 31 spin doctors. This is more than any other department and more than the Prime Minister or the Cabinet Office. If you hear of an event local to you, ask all of your friends, neighbours and relatives to attend. Make sure that your opinion is heard and recorded.

"Reforming the foundation trust model, removing restrictions and enabling new governance arrangements, increasing transparency in their functions, repealing foundation trust deauthorisation and enabling the abolition of the NHS trust model;" (6.7)

The Foundation Trust model was intended to give local people control of the governance of hospitals. The idea was that if a hospital delivered bad services or changed services then the public would have a mechanism to hold the hospital management to account. This accountability is being removed. (Note that Mid Staffs Foundation Trust became a Foundation Trust after the period when the services deteriorated. The newly elected governors were informed during their first governors' meeting that the hospital was being investigated by the Healthcare Commission.)

Foundation Trust status was always intended to be an accolade of excellence. The idea that the trusts that could prove that they had excellence in management and governance would be allowed greater freedom to manage their budgets. But before they would get this autonomy they would have to prove that they had the skills.

Initially, trusts had to show that they had achieved high levels of financial probity before they could be authorised as a Foundation Trust, however, following Mid Staffs the regulator, Monitor, introduced more stringent conditions which included higher standards of clinical quality. The Labour government then introduced legislation that allowed Monitor to de-authorise existing Foundation Trusts if they fell below these financial and health quality standards. The fact that the white paper says that all hospitals will have to become Foundation Trusts by 2014 and that they will repeal the laws allowing Monitor to de-authorise Foundation Trusts shows that the government does not treat Foundation Trusts as models of excellence.

The current government are only interested in the fact that Foundation Trusts have autonomy from strategic health authorities. The government indicate that they do not care about the quality of the hospitals' financial or clinical services.

"We are clear about the coherent strategy, and we will engage people in understanding this and its implications. We are consulting on how best to implement these changes. In particular, the Department would welcome comments on the implementation of the proposals requiring primary legislation, and will publish a response to the views raised on the White Paper and the associated papers, prior to the introduction of the Bill. Comments should be sent by 5th October 2010, to: [the Department of Health]"(6.8)

The contact details are:




White Paper team
Room 601
Department of Health
79 Whitehall
London SW1A 2NS

Please, also send a copy of your comments to your MP and (since local authorities will get substantial new responsibilities) to your local county, district and town councillors.

Sunday, 18 July 2010

NHS White Paper Part 5

Cutting bureaucracy and improving efficiency

All governments say they will cut bureaucracy and improve efficiency and all governments fail. The problem is that when the cuts are made the public (voters) complain that services are being implemented unfairly (for example "postcode lotteries") or unsafely, or are not being provided at all and then governments step in and apply regulation. You either have a regulated system with bureaucracy or a de-regulated free market. I wonder which the Conservatives will plumb for?

Cutting bureaucracy and improving efficiency

"The Government has guaranteed that health spending will increase in real terms in every year of this Parliament." (5.1)

The Conservatives promised this, but have already failed to deliver. The spending plans for 2010/11 set by New Labour froze the budget so that there would be no real term increase (indeed, it represented a cut at the rate of inflation). Lansley has rather conveniently forgotten to unfreeze this budget, so there has been no real term increase for the first year he is in charge of the NHS. What a major fail!

Cutting bureaucracy and administrative costs

"Over the next four years we will reduce the NHS's management costs by more than 45%." (5.2)

Is it wise to pick an arbitrary figure? The white paper does not say why a level of 45% was chosen nor how it would be achieved. The figure appears to be arbitrary, possibly it comes from a rather sloppy calculation of the proportion of management performed by SHAs and PCTs and assuming that if you abolish those organisations then you save the management costs (hint: no, someone else will have to be paid to do some or all of this management).

"PCTs – with administrative costs of over a billion pounds a year – and practice-based commissioners, will together be replaced by GP consortia. The Department will radically reduce its own NHS functions. Strategic health authorities will be abolished." (5.4)

There are no estimates of how much the GP commissioning consortia will cost. Since there will be three or four times more such consortia than PCTs it is reasonable to estimate that the total number of commissioners will increase and this could cost the NHS more.

"The Government will cut the bureaucracy involved in medical research. We have asked the Academy of Medical Sciences to conduct an independent review of the regulation and governance of medical research. In the light of this review we will consider the legislation affecting medical research, and the bureaucracy that flows from it, and bring forward plans for radical simplification." (5.8)

This is potentially explosive. The current regulation structure has been built up over many years and this has been a very careful piecemeal process. Different people have different views about what you can or cannot do. A "big bang" in de-regulation will upset someone and the problem is who. For example, will animal testing be de-regulated and will researchers be allowed to do whatever they like?

"We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions." (5.10)

This is huge.

Increasing NHS productivity and quality

This can be summed up as: more for less. Every government pledges this, every government fails. Will this government succeed (answer: no, but they are shifting the blame onto someone else so it does not matter to them).

"Patients will be more involved in making decisions about their own health and care, improving outcomes and reducing costs." (5.12)

I interpret this as "patients will shoulder more responsibility". It will be your fault if you register with a GP practice that generates a deficit and so they cannot afford your care. It will be your fault if you choose to be treated by your local hospital and you get an infection.

"Patient choice will reward the most efficient, high quality services, reducing expenditure on less efficient care." (5.12)

"Prices will be calculated on the basis of the most efficient, high quality services rather than average cost." (5.12)

So every provider will be paid at the same rate as the most efficient provider. So what will be the "reward" for the most efficient provider? Since only the most efficient provider will have their costs met (and just met, there will be no incentive to being the best provider) it means that all but the best provider will generate deficits. These two statements simply say that the most efficient providers will survive and everyone else will close. That is frightening.

"Prices will be calculated on the basis of the most efficient, high quality services" is the same as the lowest price tendering in cleaning services that plagued the NHS in the 80s and lead to the dirty conditions that caused hospital infections like MRSA. This is seriously bad news.

"GP consortia will align clinical decisions in general practice with the financial consequences of those decisions." (5.12)

In other words the cost of treatment will guide the GP rather than clinical need.

"Local authorities' new functions will help unlock efficiencies across the NHS, social care and public health through stronger joint working." (5.12)

My local authority is about to close the local fire station to save money. Is it wise to put the responsibility for peoples' health in their hands too? I think not.

"Existing providers will be set free and will be in charge of their own destiny, without central or regional management or support. [...] Hidden bail-outs will end." (5.12)

Sink or swim. NHS hospitals will close.

Enhanced financial controls

Now here is an interesting statement:

"NHS services will continue to be funded by the taxpayer." (5.14)

The problem is that by 2014 there will be no NHS services because all former-NHS hospitals will be "social enterprises", and as (5.12) says they "will be set free and will be in charge of their own destiny". Further, "competition" and "any willing provider" will mean that other services will not be provided by NHS providers, they will be provided by private sector providers. So the only part of the NHS that will remain is the NHS Commissioning Board. It is reassuring for them that they will continue to be funded by the taxpayer.

"[GP commissioning consortia] will be accountable to the NHS Commissioning Board for managing public funds." (5.14)

So the GP commissioning consortia will not be accountable to the public? Whose money is it that they are spending? They had better be careful with it because:

"the Government will not bail out commissioners who fail" (5.14)

... so bad luck if you are a patient of such a consortium. This means in effect that your GP practice can go bankrupt and the government will do nothing about it. Nice, eh?

"Commissioners will be free to buy services from any willing provider; and providers will compete to provide services. Providers who wish to provide NHS-funded services must be licensed by Monitor, who will assess financial viability." (5.14)

See what I mean about services not being NHS? Also, what is this competing, some kind of doctor cage fight?

"Monitor will be able to allow transparent subsidies where these are objectively justified, and agreed by commissioners." (5.14)

This is very interesting because it is an admission that they will be able to apply subsidies. But for whom? Is this the private providers' subsidy that will have to exist for private providers to provide services at the NHS rate?

Making savings during the transition

It won't happen. The Nuffield Trust calculates that under GP commissioning every year there will be £1.7bn in deficits. No one knows who will provide this money, but paragraph 5.14 gives a chilling response.

The BMJ say that based on data from the National Audit Office of other government re-organisations, the cost of this re-organisation of the NHS will be between £2bn and £3bn. This is in addition to the £1.7bn a year of GP consortia deficits. However, the right-wing think tank Civitas are even more pessimistic:

"If the kind of performance drop seen with the merging of PCTs in 2006 – a comparatively minor change – is repeated with current government plans, the NHS will have a major problem. The bulk of proposed NHS efficiency savings rely on efficiencies driven by commissioning, yet the evidence presented suggests that these would not be made."

That's right, they reckon that the three year cost could be as high as £20bn. They continue:

"Ruling out the fiscally implausible possibility that large extra spending on the NHS would follow, this would mean only one thing for patients: a return to explicit rationing, either by increased waiting times or by reductions in services."

This is not good news. Further, Zack Cooper and John Van Reenen on the Public Finance website talking about the GP Fundholding experiment in the 1990s, say:

"In the long term, GP funding led to higher managerial and transaction costs. That's precisely because GPs had to spend vastly more of their time negotiating with hospitals, while hospitals had to spend more time and money negotiating with them.  In what also should be a very worrying factoid for David Cameron, GP fundholding led to a substantial drop in patient satisfaction.  One explanation for this unhappiness is that GPs were spending more time working as managers and less time dealing with patients."

In other words, make sure that doctors make clinical decisions and managers make managerial decisions, then the patients can hate the managers, not the doctors.

"We will implement the reforms in this White Paper as rapidly as is possible. But the NHS cannot wait for them all to be in place to begin to deliver improvements in quality and productivity. Patients are rightly demanding the former, and the national economic position requires the latter." (5.15)

The indications are that they will rush these changes through Parliament curtailing our democratic rights by preventing our representatives to scrutinise and amend these plans. The Conservative government are already doing this with the education bill. The Conservative government have to move fast because they know they have no mandate for such huge changes and the public will oppose them. They also know that their junior partners, the Liberal Democrats, are nervous because any unpopular policies are having a disproportionate effect on their support. These NHS plans could wipe out the Liberal Democrat party at the next local election.

"The Department will require SHAs and PCTs to have an increased focus on maintaining financial control during the transition period" (5.18)

SHAs and PCTs will soon stop functioning because if it becomes apparent that Lansley's plans have any chance of being implemented these organisations will haemorrhage staff. The same can be said about managers elsewhere in the NHS. The very people who will be needed to implement the efficiencies will not be there. It's a bit of a daft thing to do, isn't it, to tell managers that 45% of them will be sacked?


This section has wild claims about how much money they will save. £20bn in "efficiency savings" was difficult enough under the previous government's plans, but at the same time as this re-organisation it seems impossible for these savings to be made. Arbitrary values do not help (30% cut in administration costs, 45% cuts in management costs) and they do not say how much GP commissioning will cost.

There are huge problems for providers because the funding formula for the work they do is designed so that every provider, except the most efficient, will not be able to do the work for the price and therefore, all but a handful of hospitals will go into deficit. This will be back to the 80s level of "lowest tender" that resulted in dirty, unhygienic hospitals, but in the 80s "lowest tender" only applied to cleaning. In the 2010s the plan is to apply "lowest tender" principles to clinical care. Hospitals will go into deficit and there will be no bailouts: it will be sink or swim for both GPs and hospitals. Worst of all, GPs will be told that the cost of treatment will have to lead their judgement rather than clinical decisions.

Be very afraid.

Saturday, 17 July 2010

NHS White Paper Part 4

Autonomy, accountability and democratic legitimacy

This is where the white paper starts to get really worrying. The title should be "De-nationalisation of the NHS". The fact that they even think that they need to reinforce some new idea about the "democratic legitimacy" of the NHS shows what little regard this new ultra right-wing Conservative government have for the NHS. On the subject of legitimacy, what mandate has Lansley got to do this? None. His party could not squeeze a majority at the last election.

Autonomy, accountability and democratic legitimacy

The whole idea of these plans is to shrink the state, and since the NHS is the largest employer in the UK and hence is the state, it goes without saying that Lansley wants to shrink the NHS.

"The Government's reforms will liberate professionals and providers from top-down control. This is the only way to secure the quality, innovation and productivity needed to improve outcomes. We will give responsibility for commissioning and budgets to groups of GP practices; and providers will be freed from government control to shape their services around the needs and choices of patients." (4.1)

There are those silly words again "liberation", "freed". The paranoia of Lansley must be clinical. Here's a clue to you, Secretary of State, the NHS is not an oppressor, quite the opposite, it is the embodiment of the cotton wool of the state caring for its citizens. Lansley wants to "liberate" us from this. He is truly evil.

GP commissioning consortia

What is commissioning? Well someone has to plan for the treatments that will be performed in the near future. So a commissioner determines how many operations will be needed next year based on last year's figures, and then looks in the locality for providers (hospitals) that can do those operations. For a larger locality (say a rural shire) this may mean several different providers. The commissioner then agrees contracts with those providers and this means that they can plan for the staff, facilities and consumables for the coming year. If the commissioner is lucky, the budget for next year will be enough to pay the providers.

At the moment commissioning is carried out by Primary Care Trusts (PCTs) which are local organisations each covering roughly 400,000 people. The PCTs know the local hospitals, know the health problems of the area and have the skills to plan for that population. The large number of people they cater for simplifies commissioning for hospitals because a hospital will usually get the majority of their patients from the area covered by a single PCT. (Tertiary hospitals – for example those who perform organ transplants – will typically treat patients from a much larger area.)

So let's look at the future for commissioning.

"In order to shift decision-making as close as possible to individual patients, the Department will devolve power and responsibility for commissioning services to local consortia of GP practices." (4.2)

GP practices typically cover 15,000 or 20,000 people and most experts say that it is impractical for commissioning to be carried out for such a small population. Lansley recognises this and he expects GP practices to work together as "consortia". Lansley has not yet decided how many consortia there will be. Experts say that they should cover at least 100,000 people so that may mean 600 consortia (quadrupling the number of commissioners?). However, Lansley has suggested that the figure will be lower, and some people have suggested 300, which is twice as many commissioning bodies as there are PCTs at the moment. The more consortia there are the more local their decisions are, but the more costly they will be because they will be duplicating work carried out by neighbouring consortia. Further, the more commissioning consortia there are it means that hospitals will find it more difficult to plan since they will have to handle more commissions. This increases administration for hospitals who are under pressure to cut administration by 30%. Is it possible? Probably not.

However, as you'll see (4.6) it is expected that most GPs will purchase commissioning from private companies. This is privatisation of commissioning, and private providers are likely to be more sympathetic to commissioning private hospitals.

So the bottom line is that GPs will be responsible both for clinical decisions and financial decisions. This is stated blatantly in the white paper:

"It will bring together responsibility for clinical decisions and for the financial consequences of these decisions." (4.4)

GPs should only make clinical decisions. When your GP tells you the treatment that you will receive you want to be assured that it is the best treatment from a clinical point of view and that finance should not be taken into account. This is the case at the moment. PCTs make the financial decision, GPs make the clinical decisions. If the PCT refuses to pay for your treatment then your GP is your friend, your advocate; your GP will represent you and will persuade the PCT to fund your treatment. When the financial and clinical roles are combined who will be your advocate? This is a nasty and dangerous policy.

I have written before about GP commissioning. In the 1990s it was introduced by the Major government when it was called GP fundholding. GP fundholding was optional and not all GPs decided to participate. The white paper gives its opinion about this:

"Fundholding led to a two-tier NHS;" (4.5)

Yes, the patients of GP fundholders had a poorer service!

By 1997 half of English practices were fundholding and so this meant that a comparison could be made between the two systems. The results showed that GPs who were fundholding referred 7% fewer patients to specialists. Think about this. If you are a patient of a fundholding GP there is a 7% less chance of you getting the specialist care you need. On the other hand, a hospital will get 7% fewer patients from fundholding GPs. If all GPs are fundholding, then this represents a real cut in the number of patients going to hospital and hence a cut in hospital funding. Remember that phrase "I will cut the deficit, not the NHS"? Are you starting to understand what a barefaced lie it was?

"We envisage putting GP commissioning on a statutory basis," (4.6)

"a reserve power for the NHS Commissioning Board to be able to assign practices to consortia if necessary" (4.6)

"On a statutory basis" means that there is no option: whether a GP likes it or not, they have to do it, and the NHS Commissioning Board will enforce this action.

"[GPs] will not be directly responsible for commissioning services that GPs themselves provide" (4.6)

This is, of course, the chicken-and-egg question. All GPs treat patients and refer those patients they cannot treat to hospitals. So who will decide how much work a GP practice will perform and how much they will be paid? Wait and see.

At the moment PCTs commission healthcare from GPs and hospitals. They also commission work from pharmacies, dentists and opticians. So who will do this work when the PCTs are abolished (see 4.16)?

"[GPs] will not commission the other family health services of dentistry, community pharmacy and primary ophthalmic services. These will be the responsibility of the NHS Commissioning Board, as will national and regional specialised services, although consortia will have influence and involvement." (4.6)

This is a huge level of centralisation. At the moment these services are commissioned locally by PCTs and hence there is local accountability. The new super-quango, the NHS Commissioning Board, will take over these powers. But they are not limited to commissioning these services:

"The NHS Commissioning Board will calculate practice-level budgets and allocate these directly to consortia. The consortia will hold contracts with providers and may choose to adopt a lead commissioner model, for example in relation to large teaching hospitals." (4.6)

"GP consortia will include an accountable officer, and the NHS Commissioning Board will be responsible for holding consortia to account for stewardship of NHS resources and for the outcomes they achieve as commissioners." (4.6)

So this is who will commission GPs. The hugely powerful super-quango, the NHS Commissioning Board, will commission GPs and determine the additional funds that the GPs are responsible for through their commissioning consortia. But unlike PCTs (who do this work at the moment) there is no public accountability. So if your GP refuses to prescribe you a drug there is nothing that you can do about it. With PCTs there is an appeals board.

"Monitor and the NHS Commissioning Board will ensure that commissioning decisions are fair and transparent, and will promote competition." (4.6)

Note that word competition. We will return to that later on.

"GP consortia will have the freedom to decide what commissioning activities they undertake for themselves and for what activities [...] they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies." (4.6)

This makes the private sector service companies salivate. Roy Lilley from nhsmanagers.net says:

"Commissioning will be managed and influenced by the private sector. The provider side of the NHS will be moved into the private, social enterprise, sector and the NHS will no longer provide services, employ staff or have a responsibility for pensions. The NHS becomes a 'brand' that is franchised to any suitable willing provider; services commissioned, monitored and quality checked by regulators."

Frightening, huh?

"GP consortia will have a duty of public and patient involvement, and will need to engage patients and the public in their neighbourhoods in the commissioning process. Through its local infrastructure, HealthWatch will provide evidence about local communities and their needs and aspirations." (4.6)

So commissioning is statutory but patient involvement in commissioning is merely "a duty"? Where is the accountability?

An autonomous NHS Commissioning Board

We have heard a lot about this "NHS Commissioning Board" so who are they and what will they do? I will go into a lot more detail in another blog post, but first let's have a look at what the white paper has to say.

"through commissioning guidelines, [the NHS Commissioning Board] will help standardise what is known good practice" (4.10)

"[NHS Commissioning Board] will hold GP consortia to account for their performance and quality" (4.11)

This means that the NHS Commissioning Board will tell GPs what to do: a huge centralisation of power. The Conservatives pledge to make decisions local is rapidly draining away. Their plan is to put far more power into an unaccountable quango.

"[NHS Commissioning Board will host] some clinical commissioning networks, for example for rarer cancers and transplant services, to pool specialist expertise" (4.11)

"[NHS Commissioning Board will commission] GP, dentistry, community pharmacy and primary ophthalmic services; national specialised services and regional specialised services set out in the Specialised Services National Definitions Set; and maternity services." (4.11)

This is a centralising power grab from local commissioners. If you are not happy with the maternity services in your area then you will not have the right to complain to a local body, instead, it will be a national, and unaccountable quango. You will have little chance of changing their decisions.

"[NHS Commissioning Board will be responsible for] allocating NHS revenue resources to GP consortia on the basis of seeking to secure equivalent access to NHS services relative to the burden of disease and disability;" (4.11)

The NHS Commissioning Board will hold the purse strings. You will not be allowed to vote them out. There is no accountability.

A new relationship between the NHS and the Government

Let's get this right. The Conservative government believe in a small state and the NHS represents "big state" so by default the Conservative government hates the NHS. Labour governments typically love the state, and love the NHS, so the new relationship is a shift from love to hate. Easy, right?

"the Secretary of State will hold the Board to account on delivering improvements in choice and patient involvement, and in maintaining financial control" (4.14)

This indicates that the NHS Commissioning Board will get their orders from Lansley. The statement indicates how he will wield this power. Through this "choice" agenda, Lansley will impose his privatisation plans.

"The legislative and policy framework. Responsibility for Department of State functions will remain with the Secretary of State. This includes determining the comprehensive service which the NHS provides" (4.14)

"The mandate [of the NHS Commissioning Board from the Secretary of State] is likely to be over a three year period, updated annually. The mandate will set out the totality of what the Government expects from the NHS Commissioning Board on behalf of the taxpayer for that period." (4.15)

So Lansley is allowed to decide which services that the NHS will provide (and pay for)? With this power how Lansley will be able to introduce co-pay and health insurance, which are the second term plans of the Conservatives (and Nick Clegg).

Freeing existing NHS providers

More nonsense phrasing in this nonsense white paper: NHS providers are not shackled, so they cannot be "freed".

"Our ambition is to create the largest and most vibrant social enterprise sector in the world." (4.21)

This is a hugely ambitious and risky plan. Social enterprises are private companies. Yes, you read that right, the government want to privatise NHS hospitals.

Roy Lilley (nhsmanagers.net) says:

"Social enterprises are not part of the NHS. Neither are they part of the public sector. They are businesses. They have a social purpose, but they are a business. They are only 'different' because they generate 'profits' that must be recycled into the business and not taken out as dividends or profits."

So when the white paper says

"As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises [...] Foundation trusts will not be privatised." (4.21)

Lansley is clearly lying.

"Patients will be able to choose care from the provider they think to be the best." (4.21)

This is the Patients' Passport that David Cameron devised for the 2005 election and the public rejected. The man just could not take rejection, could he? The problem is that every patient that goes to a private provider is one less that will go to the local NHS hospitals and hence this is a cut in the hospital's funding. Patients must be made aware of this savage equation.

"As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients." (4.21)

These are effectively management-buy-outs and they are not necessary because Foundation Trusts already have the power "to use their front-line experience to structure services around what works best for patients". This is not about patient care it is about privatisation.

"we envisage that some foundation trusts will be led only by employees; others will have wider memberships" (4.21)

Foundation Trust memberships are patients and the public and are the mechanism whereby the trusts are kept to account. However, this statement only mentions Foundation Trusts not social enterprises. The white paper does not say what, if any, governance arrangements will be required of social enterprises. The most likely arrangement is as little as possible.

However, even though Foundation Trusts will only survive another three years, their governance model of Foundation Trusts will be changed for the last few years of existence:

"we intend to consult on [...] whether we should enable foundation trusts to tailor their governance arrangements to their local needs," (4.22)

At the moment, if your local hospital is a Foundation Trust then you will have an opportunity to vote for, or stand as a governor. This opportunity will be changed as it is "tailored".

"We will complete the separation of commissioning from provision by April 2011 and move as soon as possible to an "any willing provider" approach for community services, reducing barriers to entry by new suppliers." (4.24)

"Any willing provider" means that the service will be contracted to a private provider. This statement means that the provision of community services – district nurses – is being privatised.

Economic regulation and quality inspection to enable provider freedom

Gosh, that weasel word, "freedom", again. Those poor hospitals should complain to the UN.

"Our aim is to free up provision of healthcare, so that in most sectors of care, any willing provider can provide services, giving patients greater choice and ensuring effective competition stimulates innovation and improvements, and increases productivity within a social market." (4.26)

What more can I say? This is privatisation.

"[The role of Monitor] Promoting competition, to ensure that competition works effectively in the interests of patients and taxpayers. Like other sectoral regulators, such as OFCOM and OFGEM, Monitor will have concurrent powers with the Office of Fair Trading to apply competition law to prevent anti-competitive behaviour;" (4.27)

Monitor currently regulates Foundation Trusts and ensures that they maintain quality levels in finance and healthcare provision. Now they will be in charge of creating a free market of healthcare and they (and the OFT) will apply competition law to healthcare provision. This is worrying. Polly Toynbee says:

"Monitor is to become a competition regulator, whose first duty is to enforce a free market. Opening everything to the market means all NHS contracts fall for the first time under EU competition law, so tenders must be advertised internationally. GPs favouring local providers can be challenged in court if their consortium rejects a cheaper offer from a loss-leading large company: cue extreme disruption for local hospitals losing out to private bidders."

This means that unelected EU commissioners will decide who runs your local hospital. Did you vote for that?

Monitor's scope and powers

This section covers Monitor's powers and I will list the significant changes.

"Monitor should have proactive, "ex ante" powers to protect essential services and help open the NHS social market up to competition" (4.28)

This means that the unaccountable quango, Monitor, will make decisions about the providers in your area. If they decide that too much work is carried out by your excellent NHS hospital, they will have the power to remove services and hand them to private providers. Monitor will become another arm of the Lansley privatisation machine.

"[Monitor will be able to] require monopoly providers to grant access to their facilities to third parties;" (4.28)

The is Lansley's pledge (given at their smug manifesto launch at Battersea Power Station) to "invite-in the private sector". In effect, it means that if a private company likes the look of your NHS hospital's facilities, Monitor will demand that they be allowed to use them. Private providers can come in to NHS hospitals and use NHS facilities. Nasty, eh?

So with this power to close down NHS services to provide "competition" and to force NHS hospitals to allow private providers use their hard earned facilities, Monitor is clearly the friend of the private sector. And it gets worse:

"Monitor's powers to regulate prices and license providers will only cover publicly-funded health services." (4.29)

This means that there is one law for the NHS another for private providers.

Training and education

At the moment the state pays a large amount towards the training of clinicians. Sure, tuition fees claw a small proportion back but largely we regard the training of clinicians to be a social responsibility because we all benefit. (In my opinion, the move to tuition fees was an abomination, the state should pay for all training and simple income tax should claw back the advantages that people get from this state sponsored training.)

"In future, the Department will have a progressively reducing role in overseeing education and training. [...] Healthcare employers and their staff will agree plans and funding for workforce development and training; their decisions will determine education commissioning plans. [...] All providers of healthcare services will pay to meet the costs of education and training." (4.33)

This means that NHS hospitals will be responsible for funding training. This is a huge new expense for NHS hospitals, so will the government provide more money? (Hint: no.)

NHS pay

I am not sure why they have this section because all hospitals will be social enterprises and hence responsible for their own employment policies. In this section paragraph 4.35 complains that currently ministers have too much control over pay and paragraph 4.36 says that "pay decisions should be led by healthcare employers rather than imposed by the Government". However, as is typical with this nasty government, they say one thing and do another because at the moment they have imposed a pay freeze on the entire NHS.

NHS pensions

This section says nowt.

It is important to remember that hospitals are supposed to become "social enterprises" and this means that each hospital will have the responsibility of providing pensions rather than the NHS. Employees will no longer be allowed to accrue contributions to their NHS pensions – ie from the point that a hospital is privatised as a "social enterprise" employees will not be allowed to make more contributions to their NHS pensions and will have to take out a private pension.


NHS hospitals will be privatised as "social enterprises". They will be commissioned by GP consortia, and the most likely model will be the consortia buying commissioning from private services companies, so this is privatisation of commissioning. There will be an "any willing provider" policy which means private companies will be asked to do NHS work and healthcare will be subject to competition law, from the UK and the EU, which may result in the EU competition commissioner specifying that an NHS provider cannot provide services. Monitor will enforce this competition and will also force NHS hospitals to allow private provider use their facilities. There will be a massive centralisation of power in the new super-quango called the NHS Commissioning Board who will commission GPs and determine how commissioning consortia will commission hospitals, and the Board will have the responsibility of commissioning dentists, opticians, pharmacies and maternity services. And Lansley will get to tell them how to do this.

Wake me up please, this must be a nightmare.

Friday, 16 July 2010

NHS White Paper Part 3

Improving healthcare outcomes
Before I start I should point you to the three blog posts I wrote about the Conservative policy documents on outcomes.

Health Outcomes: Part 1
Health Outcomes: Part 2
Health outcomes: Part 3

Reading through this section in the white paper I was struck by how different it was to the other sections. For a start there is less of the rabid, right-wing free market approach, it talks about an integrated services as opposed to the fragmented "health market" that the other sections promote (and by necessity mean competition rather than integration). I was also rather struck by the fact that the section has a lot of emphasis on targets standards. If I didn't know that this was from Lansley's Department of Health as part of a Cameron government I would think that it was from Alan Milburn's Department of Health as part of a Blair government. There is a striking contradiction between Cameron and Lansley's tedious mantra about abolishing "top-down targets" and the hugely bureaucratic tick-box culture that "standards" will produce. But I will let you make up your mind as you read the section.

Improving health outcomes

Anyone in healthcare who does not want to improve health outcomes should be taken out and tarred and feathered. I can happily say that because there is no one in the NHS that does not want to improve health outcomes. (The same cannot be said about private healthcare – their only goal is increasing profits. So I would be happy to provide the barrel of tar and the pillow of feathers for anyone willing to start the job on the chief executive of their local private hospital.) So let's have a look at some of the more interesting parts of this section.

"the Government will now establish improvement in quality and healthcare outcomes as the primary purpose of all NHS-funded care ... this primary purpose will be enshrined in statute, the NHS Constitution, and model contracts for services" (3.1)

I have no complaint here. All healthcare providers must put quality first. I am a little worried that the law will only cover "NHS-funded care". I take a relaxed attitude to people choosing to buy private treatment, on the proviso that the provision of this healthcare does not adversely affect the provision of NHS healthcare. If such people want to spend their money on private health, then they should be allowed to spend it how they wish. So why exclude them from a law guaranteeing quality care? Does Lansley want private hospitals to provide poor quality care? Clearly he thinks that the only way to ensure quality in the NHS is to legislate, so by excluding private hospitals he is saying that he is happy for them to provide poor care. People buying private healthcare are citizens too and they should also be protected by the law. Or am I missing something here?

"In future, performance will be driven by patient choice and commissioning; as a result, there will be no excuse or hiding place for deteriorating standards and our proposals will drive improving standards." (3.2)

This is extremely worrying. Other commentators have said how these plans will turn public healthcare into a system similar to electricity provision, that is, the consumer (patient) has to constantly check and double check that their provider is providing the highest quality service because no one else will. This is not how things should be. Patients are often in discomfort or pain and simply want to be treated. They are not in a frame of mind to check quality metrics. That role should be taken by regulators. Healthcare providers should be constantly monitored and if there is the slightest deviation from best quality the provider should be told to improve.

Research has shown that patient choice has limited effect in improving quality. The Kings Fund say:

"Data from choices made in hypothetical and real situations showed that patients valued aspects of quality when choosing a hospital. However in practice, most patients chose to be treated by their local provider and few consulted published performance information on quality to help them choose, instead relying on past experience and their GP's advice. While the threat of patients choosing a different hospital led some providers to focus more on reputation, there was little evidence of direct competition for patients' custom and choice has not so far acted as a lever to improve quality."

Since 2006 NHS patients in England have had a choice of four or five providers for their treatment. Since four years of evidence shows that choice does not improve quality, why is the government so keen? Ideology?

The NHS outcomes framework

This is where the paper starts to sound very Blairite.

"The Secretary of State, through the Public Health Service, will set local authorities national objectives for improving population health outcomes. It will be for local authorities to determine how best to secure those objectives, including by commissioning services from providers of NHS care." (3.5)

This section refers to public health and social care. It is interesting that there are national targets objectives which "will provide for clear and unambiguous accountability". However, like all other cases when Conservatives talk about accountability they fail to mention how the accountability is implemented. You do not get accountability simply by mentioning it, you get it by identifying transgressions and penalties.

"A new NHS Outcomes Framework will provide direction for the NHS. It will include a focused set of national outcome goals determined by the Secretary of State, against which the NHS Commissioning Board will be held to account, alongside overall improvements in the NHS. In turn, the NHS Outcomes Framework will be translated into a commissioning outcomes framework for GP consortia, to create powerful incentives for effective commissioning." (3.6, 3.7)

You can just feel the bureaucracy oozing out of these words: lots of frameworks, lots of quangos to implement them.

"It is essential for patient outcomes that health and social care services are better integrated at all levels of the system. We will be consulting widely on options to ensure health and social care works seamlessly together to enable this." (3.11)

This is talking about an integrated system. By definition a system where there are many providers is fragmented, so where will this seamless integration come from? Are these just platitudes or is there a civil servant trying to getting something workable out of Lansley's ideological diktats?

Developing and implementing quality standards

The section gets even more bureaucratic.

"Progress on outcomes will be supported by quality standards. These will be developed for the NHS Commissioning Board by NICE, who will develop authoritative standards setting out each part of the patient pathway, and indicators for each step. NICE will rapidly expand its existing work programme to create a comprehensive library of standards for all the main pathways of care. ... Within the next five years, NICE expects to produce 150 standards." (3.12)

NICE will develop 150 targets quality standards which will cover every patient pathway (ie all stages of treatment). As you'll see these quality standards are supposed to be performance markers. One hundred and fifty is a lot of standards. This is about three times more than all the current targets and ten times more than the targets that are currently used for performance benchmarking of hospitals (the targets that really count, and the ones that the Conservatives hate). We were promised a "post-bureaucratic age", so where did that go?

Oh dear, it gets worse:

"Each standard is a set of 5-10 specific, concise quality statements and associated measures. These measures act as markers of high quality, cost-effective patient care. They are about excellence, derived from the best available evidence and are produced collaboratively with the NHS and social care professionals, along with their partners, service users and carers." (3.13)

That's right, for each of the 150 targets quality standards there will be 5-10 tick box quality statements. Therefore, there will be 750-1500 of these mini-targets (or targettinies as Roy Lilley from nhsmanagers.net calls them). Wow, what a lot of bureaucracy! I am sure that the NHS will have to employ thousands more administrators to make sure that all of that box ticking is done, right? Wrong! Lansley expects there to be a 30% saving in administration costs and 45% savings in management costs. Since salaries are the biggest cost then we can interpret this as a 30% cut in administrators and 45% cut in managers. All of this additional bureaucracy must be done with 30% fewer admin staff and 45% fewer managers. Is that possible?

However, a target is only a target if there is a performance sting in the tail. In the current target system hospitals are performance tested against a couple of handfuls of key targets. If the hospital is not performance tested against a target then it becomes an aspiration of the management rather than a necessity. The 18-week referral to treatment target is part of the NHS constitution (therefore it is a right) but since Lansley has said that hospitals will not be performance tested against this target it means that hospitals will be less focussed to make sure the target is met.

So what about Lansley's new targets quality standards?

"Commissioners will draw from the NICE library of standards as they commission care. GP consortia and providers will agree local priorities for implementation each year, taking account of the NHS Outcomes Framework. NICE quality standards will be reflected in commissioning contracts and financial incentives. Together with essential regulatory standards, these will provide the national consistency that patients expect from their National Health Service." (3.15)

Yup, that's right, hospitals will be performance tested against the new targets quality standards. Rather than a couple of handfuls of targets there will be 150 of them.

Incentives for quality improvement

Erm, perhaps the incentive is to make people feel better and live longer? What other incentives does a healthcare professional need?

"In future, the structure of payment systems will be the responsibility of the NHS Commissioning Board, and the economic regulator will be responsible for pricing. ... Payments and the 'currencies' they are based on will be structured in the way that is most relevant to the service being provided, and will be conditional on achieving quality goals." (3.17)

The curious part of this statement is the word 'currencies'. Will there be different 'currencies' for different providers? Is this how Lansley will provide a hidden subsidy so that private providers can "match" the NHS on cost? I wonder if Lansley will intend to pay providers the same national tariff, but that the figure will be in pounds sterling (£) for NHS providers and Lansley pounds (L) for private providers where the exchange rate is L1 = £2. This will mean that the national tariff for cataract surgery will be £750 or L750, and will nicely allow private providers to "compete" with the NHS. Stranger things have happened.

The statement also says that quality targets goals will have to be achieved before there will be payment, so yet again, these "goals" are not much different from the targets they are replacing.

"The Department will also refine the basis of current tariffs. We will rapidly accelerate the development of best-practice tariffs, introducing an increasing number each year, so that providers are paid according to the costs of excellent care, rather than average price." (3.19)

I have written about the national tariff before. The original intention was for the national tariff to be the average cost of a procedure for all English NHS hospitals. A hospital is paid this average, regardless of their actual costs, and if the hospital manages to do the work cheaper than the average then they will generate a surplus that can be invested in other services (or pay for services that generate a deficit). The idea is to provide an incentive for hospitals to improve efficiency.

Since hospitals are paid per procedure, it means that the more procedures they perform the more money they will be paid, and if a hospital has a service that makes a surplus on the national tariff then there is an incentive to treat more patients. The main problem with this system is that the money to pay for treatments is limited by how much money the local Primary Care Trust (PCT) is allocated. This leads to a bizarre situation where hospitals over-perform. Yes, they are criticised for being too efficient and doing too much work! The white paper gives no solution to this problem because there will still be a limit on the money available to pay for treatments, the only difference is that the money will be held by GP commissioning consortia rather than PCTs.

In the final Operating Framework produced by the New Labour government they included a directive that some tariffs will be based on best practice rather than the average across England. This limited number of best practice tariffs put a lot of strain on NHS hospital managers since they did not have to be as good as their peers, they had to be as good as the very best. The pre-austerity Labour government also froze the tariffs so that hospitals will be paid the same money this year as last year for the same treatment regardless of inflation. The Conservative government have not unfrozen the tariff, therefore Cameron has broken his election pledge to provide "real term" increases in NHS funding.

In the white paper the Conservative government says that they will extend the idea of best-practice tariffs by producing "an increasing number each year". This means that there is a danger of hospitals going into deficit since only the very best hospitals are as efficient as the very best, and not everyone can be the very best. This stretch target will be the most difficult to achieve. (And remember section 1.22 which says that there will be no bail-outs?)


This section heralds a new target culture. Rather than a couple of handfuls of performance targets there will now be 150 "quality standards" and each one will have 5-10 tick-box "quality statements". The administration of a thousand such statements will be a nightmare with fewer staff. Furthermore, hospitals will be put under financial pressure by only being paid the costs of the very cheapest while under the threat of bankruptcy because the government refuses to "bail-out" hospitals.

Thursday, 15 July 2010

NHS White Paper Part 2

2. Putting patients and the public first

Well, if anyone in healthcare does not do this already then they should find another job. The vast majority of people in the NHS and this accusatory title is an insult to some extremely dedicated people. So let's have a look how the government intends to "put patients and the public first".

Shared decision-making: nothing about me without me

This section is full of platitudes and light on details. However, there are a couple of statements that are interesting.

"We want the principle of "shared decision-making" to become the norm: no decision about me without me." (2.3)

Of course this should always be the case, and in my experience, it has always been the case. However, we do have to question how this will work in practice. What happens for people who are unable to understand the choices? What happens for people who are easily confused or are hard of hearing? Advocacy is very important here. Does the "shared decision-making" make the patient responsible in part for their treatment? We need to know whether this statement is intended to empower patients, or whether it is intended to put more responsibility on them.

"The new NHS Commissioning Board will champion patient and carer involvement" (2.4)

The NHS Commissioning Board is a new quango and it is unclear at the moment what they will do. I will write a separate blog post on it, but for now consider it to be the quango in charge of privatising the NHS.

The idea of "patient and carer involvement" must be scrutinised carefully. Other Conservative documents on public health stress how they think that it is our fault that we are patients. At the moment the NHS is neutral about whose fault caused the condition, they treat health issues and as part of this clinicians may make recommendations for the patient to lead a healthier life. There are worrying statements from the more right-wing health pressure groups about things like charging patients if they need treatment for injuries sustained when drunk, or charging for treatment for health issues caused by a poor diet.

The government must pledge that the NHS will preserve the neutral attitude when it comes to free at the point of delivery, and will not break that principle by making patients responsible for their condition.

An NHS information revolution

Information is important. It is important for individuals and, in aggregate, it is important for epidemiologists. It is interesting that at a time when the government is talking about getting rid of the most systematic mechanism to gather information (the census) the Department of Health is talking about gathering more information. Gathering and making available information inevitably requires IT projects, yet the government has pledged to cancel the existing IT projects in the NHS. Information held on IT systems must be secure and must only be made available to authorised users, yet the government is cancelling the country-wide personal authentication system planned by the previous government (ID cards, note that I am not an advocate of compulsory ID cards, just pointing out one possible use for them). This government is full of contradictions.

"Our aim is to give people access to comprehensive, trustworthy and easy to understand information from a range of sources on conditions, treatments, lifestyle choices and how to look after their own and their family's health." (2.6)

We already have this information through the NHS Choices website, but more reliable information is always welcome. The previous government had an ambitious plan to provide more information through websites run by Strategic Health Authorities, but the government has now decided to abolish SHAs. It is unclear whether the SHA website plans will be cancelled or whether the government will reuse them.

"Information generated by patients themselves will be critical to this process, and will include much wider use of effective tools like Patient-Reported Outcome Measures (PROMS), patient experience data, and real-time feedback." (2.7)

It is important that patients' views are taken into account, and usually the best way to do this is through advocacy groups. Patient feedback is also important, but it must not be a box-ticking exercise. Patients recovering from treatment are often unwilling or unable to respond, so surveys after the patient has recovered are also important.

"As in many other services, this feedback from patients, carers and families, and staff will help to inform other people with similar conditions to make the right choice of hospital or clinical department and will encourage providers to be more responsive." (2.8)

"Information will improve accountability: in future, it will be far easier for the public to see where unacceptable services are being provided and to exert local pressure for them to be improved." (2.9)

This is where it gets a bit sinister. The government intends to create a "healthcare market" where problems in the service provided by a hospital are handled by market forces. That is, if a hospital is failing then patients will not choose the hospital and the hospital will be forced to improve their care. The problem with this is that the hospital has to be failing before action is taken, and this means that patients will suffer.

The proper way is for the information to be used by regulators to take prompt action to make hospitals improve their care, and in this way the improvements are likely to be made quicker than waiting for a hospital to fail and for patients to leave.

"More information about commissioning of healthcare will also improve public accountability. Wherever possible, we will ensure that information about services is published on a commissioner basis. We will also publish assessments of how well commissioners are performing, so that they are held to account for their use of public money." (2.10)

Information about commissioning will be vitally important. It must be an open process and challengeable. The likelihood is that most GPs will not commission care themselves; instead, they are more likely to buy-in the commissioning services from a private company like Tribal, Serco or BUPA. In this situation the public will need to know why a GP commissions a private hospital over an NHS hospital, or a distant hospital over a local hospital. This level of transparency will put a break on the privatisation of NHS services and consequently the government will be unwilling to allow it to occur.

"We will enable patients to have control of their health records. This will start with access to the records held by their GP and over time this will extend to health records held by all providers." (2.11)

It seems very odd that the white paper mentions this since you already have this right. NHS Choices says this:

"Under the Data Protection Act 1998, you have a legal right to access your health records. If you want to see your health records, you can ask at your GP surgery, and arrange a time to come in and read them. You don't have to give a reason for wanting to see your records. ... Your request to see your [hospital] records will be forwarded to the health records manager. The manager will decide whether your request will be approved. Your request will usually only be refused if your records manager, GP, or other health professional believes that information in the records is likely to cause you, or another person, serious harm."

In effect, the Data Protection Act 1998 says that you can have access to all your health records whether they are held by a GP, hospital, optician or dentist. I have no idea why the white paper mentions this unless there are ulterior motives.

"Our aim is that people should be able to share their records with third parties, such as support groups for patients, who can help patients understand their records and manage their condition better. We will make it simple for a patient to download their record and pass it, in a standard format, to any organisation of their choice." (2.12)

Will doctors agree to this, what about patient confidentiality? Will patients be made fully aware about the dangers of losing that confidentiality?

So who are these "third parties"? Do they include, perhaps, life insurance companies? Imagine this scenario, you apply for life insurance and the company says that you could get a discount if you are in good health and so could you give them access to your health records to prove it? If you refuse access then it would appear that you have something to hide, so most people will be persuaded to share their health records with the insurance company. What happens when the company sees your records and they decide to reject your application (bear in mind that most companies ask you if you have had any applications rejected, so just one rejection may make you uninsurable)? What about if they accept your application, store the details and then at a later stage reject a claim because of a condition that you had treated years before? This plan is fraught with problems, so it needs a lot of scrutiny.

"The NHS Commissioning Board will determine these standards but they will include, for example, record keeping, data sharing capabilities, efficiency of data transfer and data security." (2.16)

So the NHS Commissioning Board gets involved again. They are clearly people to be wary of.

Increased choice and control

Yes, we want both, but the problem is are we capable of choosing and if we get control will we do the right thing? If we get choice and control, doesn't that mean that we are now culpable? Apparently we will be:

"We are also clear that increasing patient choice is not a one-way street. In return for greater choice and control, patients should accept responsibility for the choices they make, concordance with treatment programmes and the implications for their lifestyle." (2.18)

This implies that if you make a choice and that is the wrong choice then it will be your fault. Although this may seem fair, we have to determine when it is you who is making the decisions or whether the clinician is doing this for you and making it appear that you made the decision: simply handing the responsibility and culpability over to you.

"Increase the current offer of choice of any provider significantly ... choice of any willing provider ... " (2.20)

"We expect choice of treatment and provider to become the reality for patients in the vast majority of NHS-funded services by no later than 2013/14." (2.23)

This is the government's drive to bring in the private sector. If there is more private sector provision then there will be less NHS provider provision and the consequence of this will be closure of NHS hospitals or "merges" with private sector hospitals. I will have more to say about this in a later blog post because there are some truly horrific things in store for your local NHS hospital. (Sorry, did I say your hospital? It won't be yours any more, the government intends to hand it to someone else.)

"Introduce choice of named consultant-led team for elective care by April 2011 where clinically appropriate." (2.20)

Is this practical, what happens if you choose a popular consultant? This will lead to the case where some consultants will have more patients than they can treat? The term "named consultant-led team" simply means that the "named consultant" has his/her name above the door and you'll most likely be treated by one of their "team", so the policy may be meaningless.

How will these "named consultant" make a name? Does this mean that we will have doctors advertising their wares? More concerning, is this policy the fore-runner of consultants creating their own provider companies? Again, we need more information and we need to know the real reason for the policy.

"Give every patient a clear right to choose to register with any GP practice they want with an open list, without being restricted by where they live." (2.20)

Is this practical? I will cover GP commissioning in another blog post but for now: The idea is that GPs will hold the entire health budget for the patients they treat. GPs will form "consortia" with other GP practices so that they cover roughly 100,000 people and then the consortia will determine which providers (hospitals) will treat the patients, and what treatments will be available.

So, if one GP practice offers an expensive cancer drug to their patients because they have a budget surplus and they can afford to provide the drug, won't this lead to cancer patients from other areas registering so that they too can get the drug? Won't this lead to healthcare tourism within the country?

As GPs budgets change and commissioning decisions change, won't we find that patients will change GPs frequently? Perhaps we will see a market like we have with electricity suppliers where you have to reassess your supplier every few months to make sure that you are getting the best deal. Won't this happen to GPs, and if so, won't it kill the idea of having a "family doctor"?

I am all for the choice of GPs, but I am not in favour of the postcode lottery that GP commissioning will cause.

"As part of personalised care planning, the Department will encourage further pilots to come forward and explore the potential for introducing a right to a personal health budget in discrete areas such as NHS continuing care." (2.22)

Lord Darzi suggested this policy. I am not so sure it is a good idea. My concerns are that the patient is expected to make decisions and be responsible about those decisions. I am also wary about patients being told that they are an effective drain on society because of the cost of their care: I have never been in favour of patients seeing the bill for their care (some right-wing suggests that this should happen: the patient sees the bill, then the NHS pays). Personal budgets will tell a patient with a chronic condition how expensive they are.

"In future, the NHS Commissioning Board will have a key role in promoting and extending choice and control. It will be responsible for developing and agreeing with the Secretary of State guarantees for patients about the choices they can make, in order to provide clarity for patients and providers alike, ensuring the advice of Monitor is sought on any implications for competition." (2.23)

So who is it that will be making commissioning choices about care, "GP commissioning consortia" or the NHS Commissioning Board? My guess is that the unaccountable quango, the NHS Commissioning Board, will have the final decision and their policy will be to favour private healthcare. The NHS Commissioning Board is the NHS privatisation board.

The white paper makes few guarantees about your local NHS hospital. The term "any willing provider" means that private hospitals will more often than not be chosen by commissioners. The only guaranteed service from your hospital will be A&E:

"[The government will] Create a presumption that all patients will have choice and control over their care and treatment, and choice of any willing provider wherever relevant (it will not be appropriate for all services – for example, emergency ambulance admissions to A&E)" (2.20)


The government seems very keen on blaming you for your medical condition and making you responsible for it. You will also be responsible for deciding whether your local hospital is up to scratch. It all looks like the government expects you to do a lot of things, and you have to get well too! The government really hate NHS hospitals: I mean they seriously hate them. I will explain in more detail why and what this will mean in a later blog. It has to be said that what they really love is private healthcare. So I need to address the issue of private care.

Private hospitals are private companies and the Companies Act 2006 outlines the responsibilities of directors of private companies and states that:

"the duty of directors is to act in a way which they consider most likely to promote the success of the company for the benefit of its shareholders as a whole and that, in doing so, they will need to have regard where appropriate to long term factors, the interests of other stakeholders and the community, and the company's reputation"

This means that the "customer" or "services user" is not put first, the shareholder is always put first. Go back to the title of this section in the white paper: putting patients and the public first. Since by law private companies cannot put the customer first it means that private companies should not be used to provide healthcare.