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

Thursday, 21 October 2010

Will GP Consortia fail?

They had better not!

Actually the answer is more likely that they will not be allowed to, because we value our helth so much in the UK that we could not leave it to the free market.

HealthcareRepublic has some interesting comments from a US academic and expert on commissioning in the US:
"Professor Lawrence Casalino (Weill Cornell Medical College, New York) cited the experience of Independent Practice Associations - the US equivalent of GP consortia - as evidence of this. He said there is ‘no question’ that the vast majority of IPAs ‘failed badly’ by going bankrupt or by not improving patient care. ‘Of the 2000 IPAs that were set up, less than 200 groups were successful,’ he said. "
A rate of nine out of ten IPAs failing is terrible. The final remark from Prof Casaline is interesting:
‘Don’t skimp on management funds,’ he said. ‘These organisations will not work without good leadership and management.’ 
Since Lansley is expecting to save £850m a year from commissioning on a budget that is already too small it looks like GP Commissioning Consortia will fail. Except that they won't be allowed to. I wonder how Lansley will prevent them from failing? I wonder if he knows how?

Social Enterprises

The term "social enterprise" sounds benign because it has the word "social" in it. But it is the "enterprise" that we have to be wary of. Social enterprises are businesses. They are not-for-profit (meaning that any surpluses should be re-invested in their business) but they still behave as businesses. They can pay their directors astronomical salaries and their workers a pittance and they can pull out of a service sector if they choose. They are businesses and independent of government. As a taxpayer and citizen, you have no say about how they are run or what they do.

For example Health Investor reports: 
Social enterprise group Housing21 is set to sell its care package provider The Complete Group to private equity firm Sovereign Capital, HealthInvestor can reveal. Sources close to the deal have confirmed that Sovereign is now in exclusivity with Housing21, who acquired The Complete Group’s parent company Claimar Care last year. However, Housing21 has since begun looking to divest itself of The Complete Group as it did not fit with its business strategy.
Here you have a social enterprise (presumably claiming to have some high-minded ideals, they all do) buying a social care business from another company. Presumably the employees and the customers felt re-assured that such high minded people were now providing the service. But a social enterprise is a business, they can buy and sell businesses. This is what Housing21 have done with The Complete Group. Their customers and employees have now been shunted from the high-minded idealists over to the most profit hungry of businessmen, a private equity firm.

Why do I say this? Well it is the Conservative plan for the NHS. Lansley wants hospitals to become social enterprises. When this happens don't be surprised if they sell off parts of their business that they feel do not "fit in with its business strategy". You'll get a company that you've never heard of, and most likely do not want, taking over those "services".

Honestly, it is best not to get in this position by keeping our hospitals public.

Wednesday, 20 October 2010


I thought this was a spending review, the government providing the figures for the headline cuts provided in the so-called "emergency budget". In fact it was far more than that: it was a policy document indicating a shift towards a country with no public provision of services.

Download the Spending Review document and have a look at page 35 sections 1.86 to 1.90 in a section called "Sharing responsibility". This is nothing about deficit reduction, it is pure ideology, it is what Thatcher could never do.
1.86 A fairer and more responsible society requires greater freedom so all can play their part. The Spending Review builds on measures to provide new opportunities, new rights and new resources to enable all parts of society to play a larger role in providing services and strengthening community life.
There is the fairer word again. They have dropped progressive because it did not work, I guess they will drop the fairer word soon. I wonder how long it will be before we hear Thatcher's favourite word medicine?

1.87 The Government believes that while it should continue to fund important services, it does not have to be the default provider. This stifles competition and innovation and crowds out civil society. 
The important point here is the phrase does not have to be the default provider. In the NHS a hospital is often the monopolistic provider, it is the default provider. So how does the Big Society handle that? Read on.

To address this and create new opportunities for non-state providers, the Spending Review announces that:
Here create new opportunities for non-state providers suggests that there will be new providers in addition to the state providers (umm, the NHS). The problem with this (and in general with the concept of competition in services) is that there must be an over all (ie existing + new providers) excess of capacity. This is supposed to happen at a time when money is so tight that PCTs are now delaying all but the most urgent treatments until next April. There is no spare cash in the health budget so why will  an unproven, new provider take the risk?
  • the Government will pay and tender for more services by results, rather than be the default provider of services. The use of simple tariffs and more innovative payment mechanisms will be explored in new areas, including community health services, processing services, prisons and probation and children’s centres. This builds on measures already announced to implement payment by results in welfare to work, mental health and offender rehabilitation services; and
First note that the NHS is not mentioned in the list of services. It is on their list, but the government knows that politically it would be dynamite to mention the NHS in a paragraph that is blatantly about privatisation. The paragraph starts by saying that they would prefer anything but the public service (the NHS). There is none of the careful language in other policy documents that have said that they will use "any willing provider" but only if they can provide at the quality and cost of the NHS. No, this says blatantly that the intention is not to use the existing public service (NHS).

  • the Government will look at setting proportions of appropriate services across the public sector that should be delivered by independent providers, such as the voluntary and community sectors and social and private enterprises. This approach will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services, and early interventions for the neediest families.
This is a rather bizarre statement. Andy Cowper at Health Policy Insight describes it as "the government is still in the business of setting tractor-production quotas". The stateemnt reinforces what I said above. It is nothing to do with using the best provider, nor the most cost-effective provider, it is blatantly saying that the government will determine an arbitrary proportion that must be provided by non-state providers. At the beginning of the year I suggested that Lansley intended to produce an equivalent of the 1990 Broadcasting Act. This act of parliament mandates that 25% of TV and radio production broadcast by the BBC has to be from non-BBC suppliers. This government is clearly thinking of doing the same thing in other public services like the NHS.
1.88 These announcements to increase opportunities for all independent providers build on the Government’s existing commitments to extend specific rights to communities, citizens and employees to run and own services. These include:
  • giving communities due notice and the right to buy or run public assets and services that might otherwise close or face significant reductions;
So in effect this is saying that if a school or hospital is due to close then "communities" can have notice to get together to run the service themselves. This does raise the question of why anyone would want to run a services without the vast underwriting of the government that a public services has. I can imagine such rights being taken up for a small village school, but not for a multi-million pound enterprise like an acute hospital. But the wording seems odd to me: the right to buy or run. Why are these exclusive? If you have bought such assets then why would you not want to run the service?

Anyway, call me a cynical bastard, but looking at the woeful NHS budget for next year and the severe pressure that the health service will be under (compounded by Lansley's ludicrous re-organisation) I can imagine that plenty of hospitals will go into debt over the next couple of years and face significant reductions.

  • developing a new right for public sector workers to form employee-owned cooperatives and mutuals to take over the services they deliver which is being taken forward across departments; and
  • giving parents, teachers or community groups the right to bid to start new schools.
So here is the derogation of responsibility that is ingrained in this government. This is saying that the state should not provide services, should not provide healthcare; that the NHS should not be publicly owned. Forget the nice sounding words cooperatives, mutuals and public sector workers, this is about privatisation. The director on a hospital board is a public service worker, but unlike a porter, or a nurse, or a pathology lab assistant, the director has the ability to find the private funding to buy the public asset that was mentioned above.

1.89 As well as new opportunities and rights, the Government will assist new providers by improving access to the resources they need. The Spending Review announces that:
The problem is that under the new regime service provider must provide more for less. The private sector know this and know that they cannot provide healthcare at the cost-effective rate that the NHS does. There has to be sweeteners, and this is what section 1.89 is all about.

  • the Government will direct around £470 million over the Spending Review period to support capacity building in the voluntary and community sector, including an endowment fund to assist local voluntary and community organisations. As part of this, the Government will provide funds to pilot the National Citizen Service and establish a Transition Fund of £100 million to provide short term support for voluntary sector organisations providing public services. The Big Society Bank will bring in private sector funding in addition to receiving all funding available to England from dormant accounts;
This specifically mentions bringing in private funding to provide public services. The other figures are really small change. For example, my local hospital is a medium sized district hospital with 340 beds and has a turnover of £130m a year. It is valued at £75m. You don't get many such hospitals from the figures being mentioned for the capital of the Big Society Bank. Thus the money has to come from the private sector.
  • to bring external investment and expertise into the public sector and share the responsibility and risks of reform, the Government will work with the financial sector, the voluntary sector and community groups to develop innovative equity investment opportunities in public services; and
This plethora of jargon is privatisation, pure and simple.
  • cultural institutions such as museums will be allowed to use money raised independently more flexibly and establish trust arrangements that enable them to generate more funding from private sources. In addition, the Government will undertake a review of ways to increase philanthropic giving, and will announce further details later this year.
The government thinks we are American and that a wealthy philanthropist will be willing to throw money at our museums. Fat chance. 
    1.90 To maintain the momentum for reform, and consult further with public sector staff, citizens and communities on how to deliver better services, the Government will publish a reform White Paper early in the New Year. This will set out further detail on the policies announced above.
    So clearly the message is "the white paper on the privatisation of the state will be published next year". It is in my diary.

    Monday, 18 October 2010

    24 Hour Urgent Care

    Lansley's obsession with "choice" seems likely to be pushing primary care towards a more expensive system. The new policy is that anyone will be able to register with any GP practice regardless of where the patient or the practice is. There have even been suggestions that this will be beneficial to the dimwitted homeopathy fanatics who will seek out and register with a sympathetic GP; since there are few such GPs and the dimwits are spread over the country, this will result in a lot of distilled water being posted across the country. (My tip: buy a bottle from Halfords.)

    Of course there are serious reasons behind this choice. If you commute a long distance and have a long term condition then it may make more sense to register with a GP near your work so that you only need to take an hour or so off work to see your GP rather than the entire afternoon (remember: Lansley has told GPs that they no longer need to have extended hours, so you are unlikely to be able to get an appointment in the evening or ion a Saturday).

    The problem is that what happens if you are ill when you are at home? The government suggests setting up a separate 24 hour urgent care system integrated with the out of hours service.
    The Government stated: ‘If you choose a GP practice further from where you live, it is important you also have access to urgent medical care near home. We propose to develop a 24/7 urgent care service in every area of England, incorporating GP out-of-hours and in-hours urgent care where necessary for people who aren’t registered with a local GP.’
    But the BMA says that this policy "risked a potentially dangerous fragmentation of care, and could prove unaffordable at a time of biting cuts" More interestingly are these comments from Paul Conroy:
    There are two hidden agendas here that GPs need to be alive to: 1) GPs will have to commission out of hours and therefore, they will also have to commission the 'in hours urgent care' as well. This will hit our pockets, not the central purse. 2) The long term objective is to re-shape primary care to a provider approach, where family practice disappears completely, in favour of big corporations who dispense care like a medical supermarket.

    Sack for doing a job badly that you did not agree to do

    Imagine this. You choose a career and you are good at it. Then with no discussion with you, nor even agreement with you, you are told that your job has changed and you will be forced to do something you do not know how to do and have never chosen to do. And then you are told that if you fail at the new role you will be sacked and be prevent from doing the job that you can do? Unfair? Welcome to the world of Commissar Lansley.

    GPs go through a lot of training, not only medical school, but also post-graduate GP training. Lansley wants to turn them into commissioners, which is a skill all of its own. Sure Lansley says that GPs should "lead" the process rather than do it themselves, but ultimately the responsibility for the commissioning will lie in the GPs and if, through their inexperience, the commissioning fails, the government wants them to suffer the "ultimate sanction" and be sacked.

    Public Finance reports:
    'The government must negotiate with the British Medical Association to impose the ultimate sanction on GPs who repeatedly fail to live within their means and fail to control their commissioning budget: they must lose the right to continue to work for the NHS,' says Danny Ruta, joint director of public health at Lewisham PCT and the London Borough of Lewisham.

    Isit fair to sack someone for not being able to do something that they did not even say that they could do? This is why the NHS Alliance are asking for there to be a two tracked approach.

    Wednesday, 13 October 2010

    Council chiefs want a veto

    Pulse reports that the Local Government association want the final say on commissioning performed by GP consortia. It seems unlikely that Lansley is likely to do this, but it is interesting to see that various groups really do not understand what "liberation" is supposed to mean.

    Guys, it is quite simple: Lansley wants to remove all public accountability for the NHS so when the shit hits the fan he can say that no Conservative had anything to do with it. That means Conservative councillors too, you know.

    Lansley really had better let his Tory chums in local authorities know more details about his master plan.

    Friday, 8 October 2010

    GPs should not own their premises

    GPs are small businesses and they contract to the NHS. Most members of the public think that GPs are the NHS but the relationship is more complicated than that.

    Anyway Pulse today reported a rather interesting article that essentially says that if GPs owned their own premises it would "frustrate’ the Government’s reforms". This is the point of view of an organisation called the Local Improvement Finance Trust Council (LIFT Co). LIFT Co while sounding slightly community based, are actually an organisation that represents the privatisers waiting to benefit from the break up of the NHS. Pulse report that LIFT says:
    'Should providers own and manage the primary and community care estate, the Government’s reforms will be frustrated,' the council said. 'Any willing provider necessitates changing providers when standards fall.'
    Some PCTs own GP practices and LIFT are suggesting that their members should manage these premises through 'expert asset managers'.

    This is a deliberate threat to GPs. It will be interesting to see how Lansley will manage this. LIFT have a point, if Lansley is serious about "any willing provider" then he will insist that poorly performing GPs are replaced. Replacing a GP practice with another becomes far more complicated if the premises are owned by the practice, and the public will suffer if they have to go to different premises to see their doctor. But the implication of this idea is very serious. GPs who (mostly) have operated from their own premises will find that some quasi private organisation will take it over. GPs will no longer have ownership fo their premises and a distant landlord is unlikely to be as responsive to the surgery needs as an owner-occupier.

    Wednesday, 6 October 2010

    The Power of Targets

    Today the Department of Health showed that there is an increase in the number of people that have to wait more than 6 weeks for a diagnostic test. There are two statistics, one is eye popping, the other is bland. It is the bland one that is the more important. First the eye popping one:
    The number of patients, for whom English commissioners are responsible, waiting over 6 weeks for any one of the 15 key diagnostics tests at the end of August 2010 was 5,900, an increase of 2,100 (56.7%) from July 2010, and 1,900 (46.7%) from August 2009.
    Wow 57% increase in the number of people waiting more than 6 weeks compared to July, or 47% increase on the same month last year. That is a huge rise! The problem is that the numbers are small compared to the total number of people actually having diagnostic tests (I estimate that the total is about 1.5 million). Yes, the rise is eye popping and it can be pinned on Lansley's diktat that targets have been abolished, but is this significant? Not yet, let's see how these figures go over the next few months.

    The other statistic is more important because it gives the overall figures for waiting times:
    Of the patients waiting at the end of August 2010, 98.9% had been waiting under 6 weeks, down 0.4% from July 2010 and 0.2% from August 2009.
    The important point here is that we want no one to have to wait more than 6 weeks, so we want to make sure that 100% of people wait 6 weeks or less. 98.9% is good, but clearly 99.3% is better (the July figure). This shows that more people are waiting for their tests than in July this year or in August last year.

    Now have a look at this graphic from @Davewwest from HSJ:

    The waiting times under the Tories is the blue part at the right hand side. This does show a dip, but there really isn't enough information to say whether this is a trend or just a blip. Notice that there is a blip at January 2010, no doubt a Tory looking at the figures in January would say that fewer people were waiting less than 6 weeks and therefore things were getting worse under Labour. Clearly this is not the case because the figures went up again the following month: January was a blip.

    However, the most important thing about this graph is that in January 2006 only 45% of people had their tests done within 6 weeks, but there was a relentless increase until March 2008 when it was around 98%. Of course the last few are always the most hardest to improve and yet we have still seen a trend upwards (albeit slower) until November 2009.

    This graph amply shows the huge power of targets. If anyone says that targets do not work, show them this graph. My prediction is that now that Lansley has abolished targets the trend will be down, in fact I think that it will be down to 90% within a year. That will be the time that we can tell the Tories that targets really do work.

    Tuesday, 5 October 2010

    RCN Reaction to the White Paper

    Roy Lilley explains very well the RCN response to the NHS White paper:
    The reforms pose a significant risk to the NHS. Carter says; 'The NHS is not broken' and concludes this is a fix that is destabilising, untested and likely to lead to unacceptable variations in care. The RCN speak of a 'highly ambitious timescale'. Very gentlemanly. I think they really mean 'stupid head-long rush'.
    The BMA, RCN, Unison, Unite and the RCGP are all against the White Paper, surely this is the end of this policy to break apart this cherished national service? No. There are still some people in favour. The National Association of Primary Care have been cheerleaders for Lansley right from the beginning. In fact they even use the same "vested interests" argument that Cameron uses. They appear out of kilter with the rest of the healthcare professionals, and marginalised. However, Lansley has already (and deceitfully) claimed that he had been met with ‘more enthusiasm than expected’ from GPs which clearly means those few GPs who are members of NAPC. You can bet that Lansley and Cameron will try to claim that the NAPC "represent" GP views rather than the BMA or RCGP.

    Monday, 4 October 2010

    Hinchingbrooke: Labour's shame

    It is quite clear that Hinchingbrooke is a model for the future: public assets being taken over by private companies. The whole tale is a sorry story and the public in that part of Cambridgeshire have been thoroughly let down. They have been let down by Labour and the Tories. 

    Basically Hinchingbrooke is a failing hospital. It has huge debts (£40m, with a turnover of just £92m). No doubt there are many reasons for this: management, changing demographics, and most likely chronic underfunding. The Department of Health under Labour should have had the balls to sort out this hospital> They should have changed the management and re-finance the debt. Instead the Department of Health saw this as a trail blazer for what the Blairites (and now the Cameroons) want: to end the public responsibility for the provision of healthcare. They decided that in a "health market" providers fail and are taken over by other providers, so this is what they wanted to trial with Hinchingbrooke: see how a failing hospital could be taken over. The East of England strategic health authority (SHA) effectively put the management of the hospital out to tender. Local NHS Foundation Trusts were allowed to bid, as were private companies.

    Earlier this year the only FT bidder (Cambridge University Hospitals Foundation Trust) pulled out of the bidding, clearly realising that it was too much of a risk. Last year Hinchingbrooke made a surplus so there is a possibility that good management could eventually pay off its debts. However, rather than simply changing the management the Labour government decided to bring in the private sector. There are now just two bidders, Serco and Circle and the decision about the 7 to 10 year contract will be made in November.

    Andrew Lansley and David Cameron have often said how they prefer employee-led co-operatives as the embodiment of their Big Society idea. Indeed Lansley said at the launch of the Conservative manifesto that "if co-ops of doctors think that they can run a hospital better, then we will invite them in". Such a "co-op" is Circle, which is said to be "employee-owned" and having a "John Lewis style" profit share (this must be true because I heard it on BBC Radio 4). However, Circle is not owned entirely by its employees: 50.1% is owned by city investors (the chief executive, Ali Parsa, is a former Credit Suisse, Merrill Lynch and Goldman Sachs banker). The other 49.9% of shares are owned by the employees who can afford to provide the capital (ie, only the highly paid consultants, so it is not a "John Lewis Partnership" model at all).

    This is clearly the model for the future: as NHS hospitals fail the private sector will be brought in to take them over. And this will happen throughout the NHS in England. Mark Britnell, who was a former NHS chief executive and now works for KPMG, told Health Investor that,  
    "more than 20 organisations could follow Hinchingbrooke’s lead in the next 12 months. Our own analysis suggests there are perhaps 20 or 30 organisations that will be in a level of distress not dissimilar to Hinchingbrooke over the next year or so."
    Watch Hinchingbrooke very carefully, and also pay careful attention to how Lansley announces who will take it over. This will happen increasingly over the coming years.