Don’t want the Government to let the NHS die?

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Don’t want the Government to let the NHS die?  Here’s one crucial thing you can do right now – Caroline Molloy – first posted 13.11.15

The government is setting out what it will tell the NHS to do for the next five years (the ‘mandate’) – and there are lots of worrying signals. Here’s ourNHS/openDemocracy‘s response – you’ve until the 23rd November if you’d like to respond, too.

You probably won’t have noticed, but you’ve got just ten days to comment on the only bit of democracy left in the NHS. It’s the NHS mandate – ie, what the government tells the NHS to do for the next 5 years.

Pretty important, huh? 

As the introduction to the mandate consultation explains:

“The mandate to NHS England sets the Government’s objectives for NHS England, as well as its budget. In doing so, the mandate sets direction for the NHS, and helps ensure the NHS is accountable to Parliament and the public… This consultation document sets out, at a high level, how the Government proposes to set the mandate to NHS England for this Parliament.”

The mandate is what Jeremy Hunt talks about whenever he’s accused of no longer having any proper responsibility or political accountability for securing a comprehensive NHS service, since the 2012 Act.

At the end of October, the Department of Health quietly put the mandate aims and objectives out to consultation for 4 weeks, with a deadline of 23 November. Local HealthWatch organisations have stated that they only became aware of the consultation on 11 November, although since this article was first published, HealthWatch England (the national body that is supposed to give patients a voice in the NHS) have asked OurNHS to point out that they did take some steps to publicise it to those groups prior to that date (see editors note below). 

Do have a read through here, and think about submitting your own response

Here’s what OurNHS has just submitted. I’ve written a fair few consultation responses in my life, and this is probably the grumpiest I’ve ever done. So do feel free to use any of this – but you may wish to tone down the grumpiness and make your response more formal!

Bear in mind, ‘high level’, in this context, means the government’s document contains lots of vague, aspirational sounding stuff – so you have to read through it carefully for clues about what kind of policies it might open the door to…

OurNHS’s response to the NHS mandate consultation

  1. It is very worrying that the word ‘comprehensive‘ doesn’t appear in the document once, which seems a pretty major omission given this document is supposed to summarise what our NHS will do in future…
  2. It is worrying – particularly given the current fraught relationship between government and NHS staff, and the exodus of the skilled staffthat are the backbone of the NHS – that the document mentions ‘staff’ only once (in the context of a commitment to continue the flawed friends and family test) – and doesn’t mention doctors or nurses once.
  3. It is worrying that the document does not say anything that would rule out an increase in health co-payments (ie patient charges), given that voices within government such as health minister Lord Prior have been floating the consideration of such charges.It does state that the mandate will focus on “the changes needed to ensure that free healthcare is always there whenever people need it most.” But hang on – why do we need that last word, ‘most’? Are we creating a mandate for unelected people to decide when people need free healthcare ‘most’ – and when we may be charged for previously free healthcare?
  4. It is worrying the document does not say anything that would rule out large groups of people being prevented from accessing NHS serviceson account of (clinically unrelated) lifestyle choices/diseases, as Devon attempted to dolast year. Government ministers criticised Devon – Eric Pickles said the plan was “not the kind of Britain I recognise” – but if these are not to be crocodile tears, government needs to make sure no other cash-strapped local health bosses try the same plan. 
  5. It is worrying that the document commits the NHS to ‘maximise income’, without saying how, exactly. NHS hospitals are already increasing their private patients, meaning fewer beds and longer waits for people without means to pay. The mandate should not be encouraging this practice – the supposed safeguards we were promised in 2012 are clearly insufficient.
  6. As for setting the NHS an objective to ‘minimise costs’ – well, there isn’t an NHS hospital in the land that is not already desperately trying to do that! Indeed, as hospitals’ duties to provide mandatory services are whittled away, and again in the absence of an overarching duty to provide comprehensive health services across England, we are told by governors that many hospitals are discussing how they can shed unprofitable procedures and patients. This must be stopped – not encouraged.
  7. It is worrying that there is no commitment to sufficient funding through the fairest and most efficient system (which the evidence shows, is public funding through progressive taxation). 

Of course, we recognise that this gaping hole is inherent in the ‘mandate’ system set out in the 2012 Act, with its greatly narrowed political accountability. We want to put on record how unsatisfactory it is, to be ‘consulted’ on a document that is separated from the political and financial settlement in this way, and which blithely states we have to wait for the Spending Review to see if any of the commitments are actually deliverable. 

  1. We also feel concerned about the heavy emphasis on self-care/self-management of patients own care. Given the lack of commitment to proper funding and a comprehensive system, we fear this opens the door to excusing reductions in the amount of care patients are entitled to receive on the NHS.
  2. We also feel particularly concerned about the related heavy emphasis on so called ‘person-centred’ care without any proper explanation of what this nice sounding buzzword means, beyond patients being “empowered” to “make meaningful choices”. We fear that – given Simon Stevens commitment to rolling out personal health budgets to millions– ‘person-centred’ may be interpreted as treating patients as consumers, shopping around with their personal health budgets. Such a system we see as little different to the Thatcherite voucher schemes of old, and similarly likely to lead to cost caps for patients and devastated budgets/planning for NHS providers. There is a paucity of independent evidence for the benefits of personal health budgets, per se – and some evidence that they are dangerous even at an individual, short-term sweetened level.
  3. It is also worrying that the proposed mandate green-lights the continued merging of NHS and local authority spend. The impacts of expenditure through this route to date have not been sufficiently assessed, and the Public Accounts Committee foundmuch money had been wasted. We also have serious concerns about the pace of, and lack of accountability of, the delivery of some of this merging of expenditure, through devolution, vanguards, ‘success regimes’, and personal budget roll-out. The mandate is worryingly silent on the implications of all of these – despite the fact the Kings Fund has just raised serious concerns that the NHS cannot cope with devolutionon top of its other challenges.
  4. It is very worrying that there is a green light given to a vague commitment to ‘harness digital and online technology‘. This is misleadingly implied to be mostly about patient access to records online. In fact there is a mushrooming of initiatives (and expenditure) where not just admin, but patient careis increasingly delivered through digital means. Once again, there is a paucity of evidence for the benefits of much of this ‘digital health’ and a surplus of magical thinking about its benefits.

For example, NHS England’s recent submission to the Department of Health for the spending review (as reported in Digital Health) was full of claims that remote monitoring equipment “has the potential” to reduce length of stay, and that in primary care tele/web consultation “may lead to substantial benefits” (my emphasis). The summary of the Department of Health’s submission (in a heavily McKinsey influenced presentation) also states that “While it is envisaged that data transparency may (my emphasis) have benefits for patient care direct evidence for economic impact has not been found.” And in primary prevention it admits that there is “relative scarcity of longitudinal studies linking digital programmes to encourage healthy living to long term impact”. In integrated care and screening it admitted the evidence for telehealth was “mixed”. 

  1. Indeed it is very worrying indeed that the word ‘evidence’ doesn’t appear in this document about what should drive the NHS – not once.

The Kings Fund have raised similar concerns, particularly in relation to mental health, where they said this week that ‘trusts have embarked on large-scale transformation programmes aimed at shifting demand away from acute services towards recovery-based care and self-management. This has seen a move away from evidence-based services in favour of care pathways and models of care for which the evidence is often limited. There has also been little formal evaluation of the impact of these changes.’ The Kings Fund characterised this as a ‘leap in the dark’ approach with highly deleterious consequences for the quality of patient care.

We need a mandate that stops the toys for boys / creative destruction / disruptors and heretics / leap in the dark approach, and returns to a proper, evidence-based approach to health care improvements. 

Lastly, we have an allergic reaction to phrases like this:

“We propose to set an objective for NHS England to support the transformation of out-of-hospital care using whole system approaches to ensure people get the right care in the right place at the right time.”

Banalities do not improve un-evidenced policies.

In summary, our view is that the mandate’s aims and objectives need to be driven by the NHS values the public understand (and hold dear).

These are not buzzwords like ‘transformation’, but values that actually mean something to patients – a service that is comprehensive, universal, staffed with sufficient skilled and properly rewarded staff, run ethically, and underpinned by proper evidence. 

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Editors note: HealthWatch England have asked us to clarify that they “contacted local HealthWatch groups to let them know that the consultation was coming” on 14 October, adding “though we had not ourselves been informed of a specific date at that time”. OurNHS understands this took the form of a brief mention in a newsletter. HealthWatch England also advise that “when the consultation was launched on 29 October we retweeted it and this was retweeted by a number of local HealthWatch” and that they also sent a tweet and a message on their internal “Yammer” network “to provide some advice on how local HealthWatch could promote this Department of Health consultation”.

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Jeremy Hunt’s Plan for the NHS

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It may not look like it, but Jeremy Hunt DOES have a plan for the NHS – Caroline Molloy  First posted 23 October 2015 on openDemocracy/OurNHS

The Tories would have us believe that they are backing away from NHS privatisation.  In fact, they’re stealthily laying the groundwork for maximum profit opportunities – and comprehensive healthcare may be their first casualty.

Don’t worry about the fact that 82% of GPs are planning to leave or cut their hours in the next five years. Don’t worry that junior doctors aren’t any happier. And don’t worry that every week reveals another NHS hospital deeply in the red – even ones we thought were ok.

Don’t worry about any of that, because Jeremy Hunt has a plan.

It’s the NHS’s own plan, he repeats in every media interview. It’s the plan it would be a ‘disaster’ to deviate from, he told us before the election.

But what is this plan?

We’ll get to that in a minute.

First, let’s look at what we’re being told it’s not.

It’s not like that toxic Andrew Lansley stuff, the pro-competition 2012 Act, the “reorganisation so big you can see it from outer space”. No, that was Cameron and Osborne’s “worst mistake”, they’ve let it be known. It wasn’t really their fault, of course – they didn’t have “a clue” what the then Health Secretary was up to.

They were so cross with him, they made him a Lord. And he was such a fool, he’s just landed a job at private equity firm, Bain, advising on healthcare privatisation.

But let’s not worry about that. Lansley’s Act is “being ignored” anyway, the pro-market Health Services Journal tells us. Forget competition, forget the idea of external takeovers and internal dog-eat-dog competition between standalone trusts and powerful CCGs – under current Health Secretary Jeremy Hunt and NHS boss Simon Stevens’ plan, it’s all about collaboration now. Even KPMG (who’ve just poached another former Health Secretary, Steven Dorrellsay so.

So what is this plan? And, er, collaboration with whom?

Has Stevens – long-time Blair advisor and former United Health Vice President– really sent the private sector packing? And – after a few brand-damaging failures – have private health firms really scuttled away defeated from the £120bn “unopened oyster” of the NHS budget, deciding the NHS would be ‘shown some mercy’ after all?

It would be nice to think so. The more naïve sections of the liberal media have certainly bought that idea. When Simon Stevens launched his “Five Year Plan” last year, Andrew Rawnsley in the Observer said he had “only one fundamental objection” to the “generally excellent” plan – that it had the wrong picture on the cover. Polly Toynbee in the Guardian told us it was great because “the word competition doesn’t appear once in his 37 page document”. Shadow Health Secretary Andy Burnham appeared to sort of welcome the Stevens plan, then to sort of welcome it not quite so much.

Aside from this site, one of the few mainstream commentators to nail what the Stevens’ plan was really about was Fraser Nelson, in the Telegraph. “Like the best revolutions, it came carefully disguised,” Nelson observes. Yes, “the c-word didn’t appear once” but (like Nelson himself) Stevens still “firmly believes” in the competition/choice agenda – he’s just experienced enough to know that “the secret of successful radical reform is not to announce it with any fanfare.”

Nelson nails it when he says: “Stevens’ Grand Plan is to have no more Grand Plans but, instead, lots of smaller plans.”

So what are these smaller plans – and what do they mean for the future of the NHS?

Whilst even Jeremy Hunt and his regulator Monitor have tacitly admitted that standalone, competing Foundation Trusts aren’t working, Hunt and Stevens see more privatisation, not less, as the answer.

‘Collaboration’ turns out to mean hospital mergers into ‘chains’ – a theme developed in the Stevens report. The man tasked to develop the ‘chains’ plan, Sir David Dalton, has suggested it could lead to more private takeovers. Junior health minister Lord Prior wants private takeovers of hospital chains, too – and he also thinks they should close lots of beds.

As Circle have found in the UK with their disastrous Hinchingbrooke foray, at the moment it’s hard to make a profit from competing to provide full service local hospitals.

As United Health, Kaiser and others have found in the U.S. – profit opportunities are much bigger if you integrate both the purchasing and provisionof healthcare under private control or influence, enabling you to ration or deny more expensive healthcare interventions. And it’s much easier to do that if you use your control or influence to reorganise provision away from full service local hospitals, towards a chain of disparate community-based clinics and far-flung specialist centres. Of course you have to claim all the while that this is all about integration, prevention, empowerment, localism, personalisation, specialisation, reducing ‘variation’, and ‘care closer to home’.

Stevens is pushing this approach through a range of supposedly ‘integrated’ new ‘smaller plans’. Like the new multi-billion pound lead provider framework to ‘help’ with purchasing healthcare (which United Health subsidiary Optum has won a sizeable chunk of). And a ‘prime provider’ framework to ‘integrate’ purchasing and providing (which both Circle and Virgin have won contracts worth billions for already). Not to mention the the array of ‘local’ NHS ‘Vanguard’ projects, which Stevens explicitly suggests could be modelled on US firm Kaiser Permanante’s ‘Accountable Care Organisations’ or similar Spanish companies. The tech-heavy projects are full of private sector opportunities and partnerships – particularly outside of unprofitable acute care. Meanwhile, tariff cuts leave the sword of Damocles dangling over many local full service hospitals.

Profit opportunities also expand if firms set their own easily-gamed ‘outcome based’ success measurements. Out go what Stevens calls ‘mechanistic’measurements (like the requirement to have enough nurses, properly trained healthcare workers, and hospital beds).

Since the general election, Stevens and Hunt have been busy tearing up such requirements.

And in come easily gamed ‘outcome’ measures – exactly what we see in the new style contracts.

Profit opportunities also expand if co-payments (ie, patient charges) are permitted. The right are getting more confident in calling for such chargesLord Prior has tried to launch an inquiry to consider it – and the government has still not clearly disavowed such an inquiry. The growing number of exponents of charges and co-payments are usually keen to stress it would only be for freshly defined ‘non-core’ services which, if you look closely, turn out to mean things like a bed to recover in after your op (£75 a night please!).

And there are many other attempts underway to undermine the comprehensive, universal, publicly funded core values of the NHS, by bringing the ‘undeserving’ narrative from benefits, into the NHS. An early sign is the attempt to refuse people care if they smoke or are obese, for example (cavalier to the fact that it is poorer people who will be disproportionately hit by such clinically uninformed decisions). Whilst Devon’s attempt to do this failed, experts saw it as a sign of things to come.

Stevens has just given all of this a big boost by pushing integrated health and social care budgets (and indeed integrated benefits budgets in some devolved areas, like Cornwall). All of this may be nice in theory, perhaps, but it’s pretty terrifying in a climate of ‘austerity’, where social care users already can, and have to, top-up or co-pay for services (and benefits are already heavily conditional).

And integrated personal budgets – which Stevens has been pushing since day one in the job – are now being rolled out to millions. No-one has yet managed to explain how these are any different from the old Thatcherite voucher plan (which would basically finish the job of destroying the NHS).

Lastly, as a big bonus, once firms nabbing all these contracts have their hands on the patient data needed to commission healthcare (or obtained by delivering it ‘digitally’), they can also make a packet selling our information to data, insurance and pharmaceutical companies – or worse.

Of course this entire bureaucratic market nightmare costs a fortune to administer, though the scale of the fortune is a closely guarded secret. The Health Select Committee pointed all this out in 2010 (referring to earlier data – and we’ve had two or three more tranches of ‘marketisation’ since then).

So if that’s the Stevens plan, what’s our plan B to get out of this mess?

First, the NHS urgently needs a cash injection to get it through this current manufactured crisis (with the DoH handing billions back to the Treasury in ‘underspends‘ in recent years – ‘doh!’ indeed!).

Healthcare needs are not a bottomless pit, as the neoliberal ideologues claim – but the demands of health, insurance, pharmaceutical, data, consultancy and tech companies for profit streams, may well be.

Ultimately, all this destruction is possible, not because of Stevens himself, but because the Coalition government finally removed the duty to secure comprehensive healthcare which was offered to the nation in 1948 and persisted, just about, til 2012. We need to restore that duty.

And we need to recognise that hospitals have been brought low by a combination of PFI debt and the dog eat dog, beggar my neighbour nightmare of even the ‘internal’ market, let alone the external one. We need to get rid of that market – as Scotland has done.

The NHS Bill – sponsored by Caroline Lucas, signed by Jeremy Corbyn when he was a backbencher, and due for its second reading in March 2016 – is a serious attempt to do both.

The market, internal or external, disguised as ‘collaboration’ or not, is not an effective way to allocate healthcare – we’ve known that since the pioneering work of Nobel prize winner Kenneth Arrow in the 1960s. It forces hospitals to hammer down staff costs and offload unprofitable patients, and creates impossible choices between the bottom line and patient safety.

It’s only ideology and vested interests that would seek to persuade us that the answer is more of the same.

And if anyone – Tory, Labour, or ‘non-political’ – says they support the NHS, we need to ask – do you mean an NHS that is comprehensive, universal, publicly funded, high quality, timely and ethical?

If not, they are not defending the NHS as the public understand and love it. And that’s what we need to fight for.

 

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Winter is coming. How bad is the scale of the NHS financial crisis?

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The NHS winter is coming – what’s the one thing all progressive politicians must do to save it?  by Caroline Molloy – Firsted posted 9th October 2015 at OurNHS

 

All week we’ve been waiting for the figures that would show just how bad the scale of the NHS financial crisis was.

The regulator, Monitor, had been ‘leaned on’ to delay publication til after the Tory Party Conference.

And no wonder.  The figures that were finally released today were bad.  Really bad.  NHS Trusts and Foundation Trusts have gone nearly a billion pounds in the red in just three months.  And patients are suffering as waiting lists are soaring.

Monitor said in today’s report that Foundation Trusts ‘could not go on like this’.

Health campaigners have reacted with anger – and a very clear message about the necessary way forward, urging politicians from across the spectrum who truly care about the NHS, to back the NHS Bill.  The Bill was developed with a team of campaigners led by Professor Allyson Pollock, and presented in parliament by Caroline Lucas MP in June – with backing from Jeremy Corbyn, John McDonnell and other Labour MPs, as well as the SNP, Plaid Cymru, and Lib Dem MP John Pugh.

The NHS Bill sweeps away the complex and expensive system of ‘autonomous’ Trusts forced into a game of ‘beggar my neighbour’, competing against each other for commissions, patients and dwindling funds.

“At what stage will those who advocated ‘standalone’ Foundation Hospitals, which have dominated health policy for 13 years, admit they were wrong?” asked Lord David Owen in response to today’s figures.

Owen – former health minister and leading critic of the Coalition Health & Social Care Act – told OurNHS that the way forward was clear:

“We have to return to an NHS that provides comprehensive care across each geographical area, as spelled out in the NHS Bill.  This Bill is now before the House of Commons in the name of Caroline Lucas and supported by Jeremy Corbyn.  The progressive alliance in Parliament now must be supported by all the Royal Colleges and anyone committed to evidence based medicine.  The evidence is now before us all that Foundation Hospitals have been a disaster.  The Health and Social Care Act must be changed and the NHS Bill is the way to do it.”

Caroline Lucas told OurNHS today, “Our fragmented, marketised NHS is in crisis.  This latest failure highlights the urgent need for a change in direction.  We need to return the NHS to its founding principles and reverse the creeping marketisation of the last 25 years.  That’s why I’m calling for MPs from across the political spectrum to be part of saving our health service by supporting my NHS Reinstatement Bill.”

Deborah Harrington, spokesperson for the National Health Action Party also weighed in with support for the bill, saying:

“It took a series of legislative changes to get us where we are today, on the brink of losing a precious and vital service available to us all.  We need legislation to restore it to health and end these daily reports of financial ‘failure’.  We need the NHS Bill tabled by Caroline Lucas.”

Harrington explained further:

“This is murder disguised as accidental death. If the public want to continue to have healthcare free of the fear of huge bills or insurance payments they need to stand up for an NHS back in public ownership and free of the threat of bankruptcy, a term which should never have been allowed to apply to our public services in the first place.”

Professor Sue Richards, Chair of Keep Our NHS Public, savaged Health Secretary Jeremy Hunt, saying his government was “responsible for massive mis-spending in bringing the market into the NHS”.

Richards highlighted how restoring the government’s duty to provide comprehensive healthcare across the whole country is a key feature of the NHS Reinstatement Bill that Keep Our NHS Public supports.  The duty to provide comprehensive healthcare was abolished in the 2012 Act, allowing the government to blame underfunded local hospitals for ‘local decisions’ when they make cuts or simply fail to provide quality, timely services.

Richards elaborated: “It is not just that Hunt is not up to the job.   It is also that he thinks the job of Secretary of State has been abolished by the Health and Social Care Act 2012, and that he can wring his hands and blame others, without having to step up and take charge.   MPs should call Hunt to account for the state of NHS finances and the deteriorating performance in patient care.  Let’s reinstate the Secretary of State’s responsibility for the NHS, and sack him if he continues to fail.”

GP Charles West – co-author of a rebel Lib Dem report into the true costs of running the NHS as a ‘market’ -accused the three main political parties of a “pathetic spectacle” at the May General Election, saying they were “falling over themselves to promise small amounts of additional money to the NHS whilst simultaneously weighing it down with expensive and unnecessary bureaucracy.  The pseudo-market imposed on the NHS has been reliably estimated to cost £20bn a year.  Even if George Osborne comes up with the £8bn he has promised it will not solve the problem, it will simply pour more money into the hands of the private providers and management consultants who are gathering like vultures round a corpse.”

West concluded: “There is a straightforward and simple solution to the problems faced by the NHS. It lies in the National Health Service Bill tabled in July.  Up till now the leaders of Labour, Conservative and Liberal Democrat Parties have preferred to administer larger and larger doses of the very medicine that has done so much harm to the NHS.  It will be interesting to see if recent changes of leadership will bring a new wave of common sense.”

Privately, many senior NHS campaigners express frustration that so far under the Corbyn opposition, there has been little shift in tone in Labour’s NHS message.  They will be hoping for a greater confidence soon from Labour (and indeed the Lib Dems and Nationalists) in being prepared to challenge the old mistakes and Blairite market arrangements.

There are a few encouraging signs around Corbyn’s willingness to talk about the Private Finance Initiatives that are costing the NHS dear.  Joel Benjamin of People Vs PFI said that it was “absurd” that the “5 year plan” for the NHS made “NO mention of PFI, even though NHS trusts will pay out close to £10bn in PFI repayments over this period, and 2/3 of NHS trusts in financial stress have PFIs.” 

The current predicament of Trusts and Foundation Trusts was entirely predicted by those who worked on producing the NHS Reinstatement Bill – and it’s suddenly more relevant than ever.  The Bill is due to be read in March 2016 – but is unlikely to get a proper hearing unless Corbyn, who signed it as a backbencher, can bring the full weight of his new leadership role into play behind it.

Winter is coming.  The NHS is dreading it.  Will politicians offer it some hope for the spring?

 

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