Solidarity Magazine » Health Emergency Fri, 01 Mar 2013 19:29:19 +0000 en-US hourly 1 Don't swallow Lansley's pre-election pause Mon, 25 Apr 2011 12:19:30 +0000 Continue reading ]]> Sunday 24 April 2011

John Lister from the Morning Star

Don’t believe the headlines about a pause or a so-called “listening exercise.” Cameron and Lansley are forging ahead with their plans to break up the NHS into a competitive market, and to slice off a growing share of the NHS budget for private providers.

The pause in the process is designed to give Lib Dems long enough to see their party massacred in the local elections and scare them into agreeing to support Lansley’s Health Bill for fear that they trigger the collapse of the coalition.

To front up the so-called “listening” exercise, an NHS Future Forum has been set up. It is stuffed with high-profile supporters of Lansley’s plans. All five of the GPs on the panel are among the minority of GPs who signed up for Lansley’s suggested commissioning consortiums. The whole forum is under the chairmanship of Professor Steve Field, who controversially supported Lansley’s white paper back in July and has since been replaced as president of the Royal College of GPs by Dr Clare Gerada, who has criticised much of the Lansley plan.

The forum on “choice and competition” will be led by Sir Stephen Bubb, a one-time Labour councillor and now at the head the Association of Chief Executives of Voluntary Organisations.

Bubb is a vigorous advocate of competition and greater private-sector involvement in delivering healthcare. He led a challenge to Labour’s attempts to designate the NHS as preferred provider of community health services.

Other doctors, trust bosses, primary care trust and strategic health authority bosses and senior council officers among the 40 hand-picked appointees on the forum are likely to be influenced by their career aspirations. They are unlikely to listen to any articulate critics of the Lansley plan.

The whole process has been set up to waste a month, to give the impression of responding to public opinion – and then to press through the key elements of the plan with little if any actual change.

There is no indication that the principal objections raised at the Lib Dem conference a few weeks ago have been taken on board by the Tories, not least because the suggestion that the private sector can somehow be prevented from “cherry-picking” the most profitable services from the NHS is pure fantasy.

Cherry-picking is central to the private provision of healthcare. Even the so-called “non-profit” social enterprises will have to focus on delivering a surplus from their work and will be compelled in a competitive market to withdraw from services which cannot guarantee to deliver them a surplus.

The only guarantee against the private sector cherry-picking services and destabilising existing NHS provision in many parts of the country is to drop Lansley’s plans altogether and to focus resources on investing in NHS care related to local need.

That’s why it’s vital that Labour and the unions crank up the pressure to force the Con-Dems to ditch the Bill.

The price of cuts

The new financial year is already starting to reveal an even bigger round of damaging cuts in services across the NHS, with thousands more jobs facing the axe, many of them front-line staff, while remaining staff will also be hit by cuts in admin and management that will dump more tasks upon them.

Among the really massive cuts are a proposed 20 per cent cut in the workforce of the London Ambulance Service, most of them front-line staff without whom emergency services will be put at risk.

Another cut which the media has strangely failed to report is the plan to halve staff numbers in community mental health in east London, putting vital services at risk. Despite being dressed up as efficiency savings, virtually all of the job cuts are nurses and other front-line clinical staff.

The government now admits that at least 22 trusts with major PFI commitments are threatened with major financial problems as the tariff paid for delivering NHS treatment is reduced, new restrictions are placed on the numbers of patients that PCTs will pay for. Overhead costs of PFI projects keep rising year by year even while trust budgets decline.

And more attention is being paid to the number of treatments that are being excluded from NHS provision by desperate PCTs in the name of so-called “efficiency savings.” Waiting times have already sharply increased. The private sector is licking its lips in the wings, just waiting for more frustrated patients to go private.

All this keeps the NHS in the public eye. It’s up to the unions, local campaigners and the Labour opposition to turn this concern into action that builds pressure for a change of course.

Cuts of £20 billion can only be achieved at the price of devastating our health service. Who out there thinks that this is a price worth paying?


Choice costs an arm and a leg

I have just had a very interesting insight into the assumptions of the private sector at a conference of health journalists in Philadelphia.

It is clear that in the US the entire system revolves around the interests of the insurance companies and the private sector. Obama’s plan to create new affordable insurance provision for the poor relies on state subsidies to enable the poor to buy policies, which even then will only reimburse them for part of the cost of their treatment.

Interestingly a succession of speakers referred in discussions on the reforms to “medical loss.” This turns out to be the share of insurance income than is spent on patient care, cash which is therefore regarded by insurance companies as lost profit.

From the patient’s point of view the loss is the other way round, but even Obama’s reforms only seek to limit the amount pocketed by the insurance companies from premiums to 15 per cent of large company schemes and 20 per cent of the contributions paid by individual and small-scale insurance policies. Some companies are apparently up in arms at this constraint on their profits and are threatening to pull out.

In addition, under the Obama plans, insurance companies would be free to raise premiums by up to 10 per cent per year without having to face any inquiry at all, regardless of whether or not these increases are affordable by those who are to be compelled to buy health insurance.

The margin retained by insurance companies to cover their extensive bureaucratic costs, advertising, other overheads and generous salaries to their chief executives – in addition to a profit margin for shareholders – is only part of the total wasted by the arcane US healthcare system.

Out of the 80 to 85 per cent that will have to be spent on patient care, a substantial amount will be squandered on inflated hospital and medical bills to cover the overheads of private hospitals and their bureaucratic administration.

At every level the patient, as an individual consumer of healthcare in the US, comes at best a poor second place to the commercial and financial concerns of a system supposed to be concerned with their health. Overall the US spends between 25 and 30 per cent of every health dollar on administration.

But it gets worse. The new insurance schemes to be offered under the Obama plan will offer varying levels of cover to compensate patients for the often huge costs of their care.

The minimum schemes – most attractive to younger, healthy adults – will cover just 60 per cent of costs. The most generous and most expensive schemes will cover around 90 per cent of costs. This means that millions of patients will have to pay money out of pocket to access healthcare even after the reforms. This is what the free marketers wanted.

As one speaker stressed “health care will still not be free: some people will be shocked at the scale of out-of-pocket spending.”

But while patient care may not be the priority, maintaining patient choice is seen as an important principle in the US health system – resulting in a baffling array of complex choices to be made by ill-informed patients struggling to understand the difference between literally hundreds of rival policies that look very similar.

One speaker, whose job is to help explain the insurance market to baffled consumers, actually said: “Health insurance is always going to be complicated – it’s never going to be like choosing one apple from another.”

In other words patient choice is by no means always a good thing. And in the US it can cost an arm and a leg.

John Lister is information director of Health Emergency.


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Kill Lansley's Bill – before it kills our NHS Mon, 31 Jan 2011 11:40:07 +0000 Continue reading ]]> 26 January 2011

by John Lister

The publication of Andrew Lansley’s enormous 367-page Health and Social Care Bill last week brought no significant surprises or changes from last summer’s white paper.

As expected, the Health Secretary has completely ignored all of the 6,000 responses which in any way criticised or challenged his plans to privatise virtually all the provision of health services in England, leaving the taxpayer footing the bill for care from a range of services delivered by for-profit or non-profit companies.

The growing body of professional opinion, including criticism or opposition from around three-quarters of GPs and almost every body of health-care professionals and every health trade union, the employers’ body the NHS Confederation, the British Medical Journal, the Health Service Journal, almost every think tank with any independent thought, the Commons Health Committee – and many MPs in Lansley’s own party – have all been ignored.

Why would he let evidence get in the way of rolling out an ideological policy, which rests on eternal Thatcherite hope that a free-market model and privatisation will eventually deliver, ignoring the bitter experience of costly failure of such schemes to work, especially in health care?

Lansley’s swivel-eyed obsession with driving through changes that almost nobody but the private medical companies that have donated to his campaign and Tory funds appears to support has even triggered a more vigorous response from Labour’s shadow health secretary John Healey.

He has correctly – if rather belatedly, given that these plans have been out in the open since last July – pointed out that “the purpose lies in opening up all parts of the NHS to private health companies, and taking what remains of NHS out of the public sector.

“It lies in removing the ‘N’ in NHS, so there are no consistent service guarantees for patients wherever they live and no consistent national contracts for staff. It lies in overriding service co-ordination and planning with competition.”

Spot on – but Healey stops at the point of labelling the Tory plan and showing how it represents a series of broken Tory promises. He makes no call for the kind of campaign that can build maximum popular opposition and try to stop these changes going through Parliament.

And even now that Labour has partially responded, there is no sign of the health unions – all of which, on paper, reject all of the key components of the Bill – getting together the kind of concerted campaign that could pile pressure on this wretched coalition government and possibly stop Lansley in his tracks.

The big unions have been going through the motions of opposition rather than mobilising their powerful communications and publicity teams to get the real scary facts out to their members on the ground and the wider public whose services are at risk – few of whom have the slightest idea from media reports of the scale of the threat facing the NHS.

Union leaders may argue that their members have not been pressing them for action, and this may well be true – because people who don’t know there’s a problem can’t get angry about it and therefore appear passive.

But why do they know nothing? Whose job is it to tell them? If the unions do nothing and our NHS is smashed up and its services privatised by Lansley, no excuses for today’s inaction will be good enough.

Why is there so little commitment to act? All of the unions are opposed to the privatisation and marketisation of health services – and these are the very core of Lansley’s Bill, despite the fact that a few GPs have been gulled into believing that ministers really want to give them more power over budgets.

The GPs are simply being used as a handy lever to force through changes. In fact, the extensive powers in the hands of the NHS Commissioning Board – itself to be largely driven by directives from the Health Secretary – and the massive constraints on spending and resources over the next few years mean GPs will have little real discretion to do anything but cut and ration services.

Even at local level, few GPs will have the time, training or inclination to engage in the complex work of commissioning services and tracking the spending of their share of the £80 billion NHS commissioning budget.

They will hand over most of this work, and with it most of the actual power, to management teams, in many cases private-sector management consultancies, which are even now licking their lips at the prospect of lucrative contracts.

Already in Hounslow in west London a consortium of all the borough’s GPs have handed control over GP referrals to hospital treatment to UnitedHealth, the US-based profit-seeking company.

It will have a brief to cut spending and will do that by effectively overriding GP decisions and contradicting “patient choice.”

Increasingly the options for rationing care, and proposals on which services to exclude from NHS treatment in the quest for the £20bn “efficiency savings,” will be drawn up by private-sector managers working for GPs.

Only the final rubber-stamping of cutbacks will ensure that GPs are left to carry the can for any bad publicity.

The GPs will also be working under other constraints. Brutal European competition laws will oblige them to open up any service for competitive tender and Lansley’s Bill insists that this must mean that “any willing provider” – for-profit or non-profit – must be allowed to bid.

Worse, for the first time clinical care will be opened up to competition based on price. Soon the lowest-priced bids will win, driving a new race to the bottom on quality of clinical care, just as surely as it did with hospital cleaning when Thatcher’s government loaded the dice in favour of cowboy cleaning firms in the mid-1980s, triggering two decades of MRSA and other infections.

And just to make sure that the private sector gets to move in across the board on health care, all limits on the income foundation trusts are allowed to make from private medicine are to be lifted, as a new European directive opens up a new era of health tourism, and NHS budgets are frozen, with the “tariff” of payments hospitals are paid for NHS treatment reducing year by year.

With more private patients and less public funding, foundations will be obliged to prioritise the paying customers, leaving NHS patients as less attractive prospects.

But we now know that all this will take place behind a wall of silence.

Lansley’s Bill makes clear that unlike primary care trusts and strategic health authorities, which all meet in public and publish their board papers, the GP consortiums and the NHS Commissioning Board that will replace them will be secretive bodies meeting behind closed doors with no press or public allowed access.

Secretive foundation trusts will replace the last NHS trusts.

And the so-called scrutiny proposals are also a sick joke. Stooge “health and well-being” committees will replace councils’ “oversight and scrutiny committees” and “local healthwatch” will be the latest even more toothless replacement for the lost powers of community health councils.

Neither of these bodies will involve more than a token garnish of patients or public or hold anyone to account for anything.

That’s the way Lansley and the Thatcherite coalition want your NHS – the best part of £100bn of taxpayers’ money controlled by closed bodies subject to no serious local scrutiny, steered by private management consultants and under pressure to award a growing share of spending in contracts to private providers.

All the closures and economies will be in the public sector, all the growth and profits will go to private providers.

Rampant and growing inequalities and a postcode lottery will predominate as various consortiums come to varying decisions on what services should be provided and what should be axed.

The public and most union members have been left in the dark by feeble and lazy media reporting and even more feeble political and trade union opposition.

This has to change. One bright light on the horizon is the TUC demonstration against cuts and privatisation on March 26.

Our challenge is to ensure that is not the culmination or the end of a campaign but a trigger for an even stronger fight to kill Lansley’s Bill.

John Lister is director of Health Emergency.

From the Morning Star

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London A&E closure 'puts 500,000 lives at risk' Fri, 28 Jan 2011 17:23:19 +0000 Continue reading ]]> Khiran Randhawa, Health & Social Affairs Correspondent London Evening Standard

27 Jan 2011

Half a million patients’ lives will be put at risk by closures at a London hospital, MPs and campaigners warned today.

Chase Farm in Enfield will lose its A&E and consultant-led maternity units under plans approved by health chiefs.

Patients will have to travel to the already overstretched Barnet and North Middlesex hospitals, which could add up to 45 minutes to journey times.

MPs and campaigners say yesterday’s decision will leave the 500,000 patients treated by all three hospitals suffering.

It comes only weeks after Queen Mary’s in Sidcup became the first hospital under the coalition Government to close key departments.

The changes were first attempted in 2007 and now, after a government-ordered review backed by local GPs recommended the plans should get the go-ahead, NHS London has rubber-stamped the decision.

Nick de Bois, Conservative MP for Enfield North, said:

“This is just another level of bureaucrats who have a grim determination to push through a plan which is not wanted by the people of Enfield.

Barnet and North Middlesex are overstretched, they are absolutely packed, so where will the extra people go? Even Chase Farm has had to close its doors temporarily because of demand. The A&E, due to its close proximity to the M25, is crucial. It will put patients at risk.”

He added he would fight the decision, and is part of a group of MPs and councillors due to meet Health Secretary Andrew Lansley on March 7 to ask him to halt the plans.

John Lister, director of campaign group London Health Emergency, said:

“These closures will have a knock-on effect on other hospitals. The capacity is not there to deal with demand. These are merely cash-driven cuts, they are not part of a bigger plan to centralise services and expand neighbouring hospitals. It is the patients who will suffer.”

Chase Farm’s A&E unit will be replaced by an urgent care centre. A review is under way into whether there should be a midwife-led birth unit.

Ruth Carnell chief executive of NHS London said: “Local doctors have told us that the clinical case put forward almost four years ago has only increased in strength.”

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Lansley's NHS Bill would be "a disaster for local accountability" Tue, 25 Jan 2011 22:01:44 +0000 Continue reading ]]> Health reporters and editors of local and national news media are urged today to lend their voice to the growing numbers of health professionals, academics and campaigners opposing Andrew Lansley’s controversial Health and Social Care Bill, now before Parliament.

Pressure group Health Emergency sounds the alert in a detailed 6-page Press Briefing on the 367-page Bill and its implications. It warns that Mr Lansley’s plans threaten to reduce information on health services to the media and local public, and leave patients with less knowledge and influence n local decisions than ever before.

The Bill, which only applies to England, proposes to scrap existing bodies such as Primary Care Trusts and Strategic Health Authorities which are at present required to meet in public and publish Board papers to press and public.

These would be replaced by a single, remote NHS Commissioning Board, and a network of GP consortia: but the Bill would allow each of these bodies to meet in secret, and publish no Board papers. They would not even be obliged to consult the pubic on changes including cuts and closures of local services.

With NHS Trusts also to be abolished and replaced by Foundation Trusts, most of which also meet behind closed doors and publish minimal information, it becomes possible for far-reaching changes to be pushed through while local people are kept in the dark.

“The first you will hear about your local A&E closing or a change of provider for a local service will be through a Press Release – after the decision has been taken,” says Health Emergency Director Dr John Lister.

“And there will inevitably be cuts, because the NHS is being compelled by the government to make an unprecedented £20 billion in “efficiency” savings by 2014.”

Journalists will no longer be able to track local changes, find financial information or check out stories using Board Papers. Instead carefully laundered annual accounts will be presented once a year to a token “public” session, while information will be closely managed, and the media fed a diet of carefully-spun PR handouts.

“This level of media black-out would make it extremely difficult even to frame questions under the Freedom of Information Act,” warns Dr Lister.

Health Emergency also dismisses Mr Lansley’s gestures towards public scrutiny:

“We can tell which way the system is going from the way new GP consortia have already been set up around the country with no prior consultation or debate with patients and public,” says Dr Lister.

“We can expect them to continue with just as little concern for their patients’ views as they decide which services to cut, and what treatments to withdraw from the NHS to save money.

“Ministers have claimed there would be scrutiny through new council Health and Wellbeing Committees, but the Bill makes clear these would be stitched up between council officers and consortia with only token public involvement, and the so-called “Local Healthwatch” bodies are feeble local committees controlled by the Care Quality Commission, charged with giving information and advice.”

Dr Lister concluded with an appeal to journalists and editors to protect their access to information on health services:

“If there is to be no genuine public scrutiny in the spending of £80 billion or more of NHS budgets, it opens the door to corruption and mismanagement.

“The wider public depends upon the media for information on their health services, and can only be properly informed if journalists are allowed to access information and pose awkward questions of those in control.

“It’s time for editors and health reporters to speak out, before the shutters come down and we are all left in the dark.”

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BMA’s historic mistake on White Paper Wed, 11 Aug 2010 14:54:54 +0000 Continue reading ]]> An Open letter from John Lister of Health Emergency to Dr Hamish Meldrum, Chair of the BMA Council, in response to his letter to BMA members, available at:

Dear Hamish Meldrum

As a campaigner who recently had the pleasure of working as a researcher supporting the BMA’s Look After Your NHS campaign, it was with great sadness that I read your letter to BMA members explaining your organisation’s decision not to join the widespread and growing opposition to the government’s White Paper on the NHS, but instead to “critically engage with the consultation process”.

This decision will certainly delight the Health Secretary, and those who share his declared objective of turning the NHS from a public service, largely publicly provided, into a “social market” in which ’in most sectors of care, any willing provider can provide services“ (White Paper page 37).

By contrast it will dismay the many BMA members, members of the public and other health workers who, like me, were pleased to support the BMA’s Look After Our NHS campaign, and the eight principles it endorsed, and who will see the decision to go along with the White Paper in this way as a retreat from these principles.

It is surely also quite extraordinary that your discussion of the issues which concern the BMA in what you describe as a “curate’s egg” of a White Paper makes no mention at all of the colossal and quite unprecedented £20 billion spending cuts (“efficiency savings”) which are quite explicitly written into the proposals, to be achieved by 2014 (Page 5). To discuss the White Paper without mentioning this crucial factor is rather like discussing a zoo as a space for empowering animals — without mentioning the existence of cages.

It is clear that, far from being empowered to improve services for patients as they might wish, if the White Paper is implemented GPs will, for the next few years at least, find themselves being used repeatedly to wield the axe on a range of popular services, take public responsibility for the closure of local hospitals and facilities and the rationing of care on financial grounds, and be blamed for large scale job losses — including consultants and other medical staff.

With no PCT bureaucrats or SHAs to carry the can for unpopular decisions, GPs will find themselves exposed time and again to hostile public opinion and even tabloid press coverage: their very motives in undertaking this role will also be widely called into question, especially when it is such a reversal from the previous, popular BMA stance.

Perhaps you may be concerned that if the BMA did not get involved, the private sector might simply step in and take charge. But this is clearly not the case: Mr Lansley desperately needs the fig-leaf of BMA (and especially GP) involvement to lend any degree of credibility to his highly controversial proposals.

As private consultancy Tribal have pointed out:

The success or failure of this initiative depends on whether GP support for the proposals can be secured. The first test is whether GPs will be willing to form consortia without excessive financial incentives, given the significant responsibilities associated with managing tax-payers money.”

Again, later in the full document, Tribal note that:

This problem will become acute if the GPs fail to respond with enthusiasm to Mr Lansley’s invitation. Even with the power to direct, achieving both the timetable and the desired impact requires the positive engagement of a majority of GPs. There will doubtless be enthusiasts but will they constitute a majority, will they provide sufficient apostles to lead 500 consortia?”

(Tribal 2010: ’Liberating the NHS’ – The next turn in the corkscrew?, page 10)

It is also important to recognise that as a formula for a new, competitive health market, ALL of the White Paper proposals fit together as an interconnected whole, and ALL are therefore important to the government. This makes it almost impossible to imagine that ministers will be willing to make any serious concessions, let alone the level of compromises which might, as your letter suggests, enable the BMA to “mould these proposals into a set of solutions that can benefit our patients and the working lives of doctors”.

Your letter gives no idea of what the BMA might do if it fails to achieve any of its (as yet undefined] objectives in “moulding” the White Paper, and finds the end result unacceptable. What credibility will it have with other health unions or the wider public if it is forced to make yet another abrupt U-turn after it has so seriously undermined the opposition at the outset?

And where in the White Paper does it give any grounds for the BMA to believe that the government might agree with you that “for commissioning to be successful, there must be the fullest engagement with secondary care colleagues. . .”? In fact the strengthened powers for Monitor and repeated reference to the Competition Commission in the White Paper make it clear that any such engagement is to be ruled out in the new, even tougher competitive market framework, which would pit GPs as commissioners on one side of the divide, and their professional colleagues in provider organisations on the other.

It is not at all clear how if the BMA had taken a hard line of opposition through the brief consultation period it would, as you claim,“greatly increase the risk of bringing about the adverse outcomes that many of you fear”.

There is no sign so far of compromise from Mr Lansley. On the contrary the prospect of pulling the BMA in behind the proposals and splitting the ranks of health workers has strengthened the government’s hand, giving ministers confidence to stand firm, making it more likely that they will discount other opposition from health unions as ’self-interested’.

In fact it is far from clear that a majority even of GPs are convinced that the White Paper offers them any positive way forward. The wafer thin vote in favour of commissioning at the LMC conference, and the 68% poll against it on DNUK suggest that a firm lead from the BMA, explaining the issues and reaffirming its principles, could easily carry a majority for demanding Mr Lansley think again.

And this kind of solid front could make it very difficult for ministers to press through with reforms that only a few right wing think tanks, neoliberal academics and self-interested private sector employers can be seen to endorse2.

There are signs that you and your colleagues are aware of the contradictory position you have now put yourselves in, by “engaging” with policies that only months ago you were correctly campaigning against. BMA News reports that the same BMA National Council which took this unfortunate decision also reaffirmed its support for the Look After Our NHS campaign. You, too, insist in your letter that you are not deserting these values:

Quite the reverse. We believe it is only by responding critically to the challenges and the potential consequences of the government’s proposals that we can defend the founding principles of the NHS and the principles underpinning our campaign.”

I am sure you and others are sincere in believing that it is possible both to “engage critically” with Mr Lansley and uphold your principles. But this is simply not the case: even a passing glance at the eight principles3 shows immediately that they are all quite incompatible with Mr Lansley’s vision for the NHS.

Principle 1 argues correctly that “Comprehensive and universal services can only be ensured by public sector services delivering treatment on the basis of clinical need, not ability to pay”: yet the White Paper makes clear that existing NHS Trusts will be compelled to become Foundation Trusts, while Foundation Trusts (together with their assets currently valued at £15. 8 billion) will in turn, if Mr Lansley has his way, be removed from the NHS balance sheet – ceasing to be public sector organisations.

The White Paper states clearly that in future Foundation Trusts “will be regulated in the same way as any other providers, whether from the private or voluntary sector” (page 36). The removal of Foundation Trusts from the NHS has

Criticism has spread well beyond the ’usual suspects“ of opposition parties, the left and the TUC health unions. Both the Lancet and the BMJ have carried major and convincing critiques of the proposals: Sir David Nicholson has made it clear that he doubts the timescale and the viability of the proposals, although he is now committed to driving them through.

The NHS Confederation has published a general critique of such sweeping reforms in the last ten years, pointing to the swift succession of organisational changes and the flimsy evidence of success; Civitas and others have been critical and warned of the likely implementation costs of the White paper proposals.

Even Chris Ham of the King’s Fund has been reluctant to lend more than minimal support to the Lansley plan.

The principles are expanded in more detail in the BMA pamphlet NHS Reforms are damaging our health service, available at: http://lookafterournhs. org. uk/wp-content/uploads/doctor-final- 270110. pdf potentially serious consequences for their staff, including consultants and hospital doctors, who would no longer be NHS employees, and new members of staff who would as a consequence be outside NHS pay scales and review bodies, pensions and other important terms and conditions.

But privatisation of health care on this scale has never occurred in any health service anywhere in the world, so nobody knows the possible consequences for the future of patient care. It is most surprising that the BMA should vote in favour of participating in an experimental change that has so little evidence to support it, and which poses such a long-term threat to a large section of its own members.

Principle 2 of the BMA’s campaign for a public NHS argues for an NHS which is “publicly funded through central taxes, publicly provided and publicly accountable”: but of course the White Paper does not even guarantee the first of these. It conspicuously avoids the issue of tax funding, while it also makes clear that few, if any NHS services will remain publicly provided after 2013, when NHS Trusts will be officially wound up. And it gives no clear mechanism by which the service will be publicly accountable.

The early signs on accountability are not promising: none of the sweeping changes being brought forward now by Mr Lansley and the ConDem coalition government have been subject to any prior public debate, let alone put forward clearly to the electorate: and if previous governments are any indication, the extent to which the public will be given any opportunity to shape the changes in advance of far-reaching top-down legislation is likely to be minimal.

The best opportunity to force ministers to take note of public opinion and that of health care professionals and others would have been for the BMA to work with those who are challenging the proposals, rather than to allow itself to be tied in — however “critically” – with the plans themselves.

Principle 3 of the BMA’s campaign calls for a significant reduction in commercial involvement in the provision of health care, and principle 4 looks for public money to be used for “quality healthcare, not profits for shareholders”. However that is not the position of the White Paper, which explicitly rolls back the (belated, but welcome) commitment by Andy Burnham last autumn that the NHS should be the “preferred provider” of services.

Lansley’s White Paper repeatedly argues instead for the use of “any willing provider” – an open invitation to for-profit private providers to bid for services. We have already seen (and campaigned against) the negative consequences of such bids, in the money wasted on Independent Sector Treatment Centres, primary care, and other sectors of the NHS. In each case, the costs are higher or quality of service lower than NHS provision.

To make matters even worse, the White Paper’s organisational changes will effectively close off the option of NHS providers continuing in England after 2013, in what Kingsley Manning of Tribal has called a “revolutionary” denationalisation. To make the direction of travel quite clear, the White Paper also explicitly proposes to abolish the “arbitrary cap on the amount of income Foundation Trusts may earn from other sources” – i. e. private, commercial medicine. Especially in the context of the frozen or declining revenue budgets for NHS and Foundation Trusts over the next five years, this too opens the way for a downsizing of public sector activity and an increase in “commercial involvement”.

BMA Principle 5 restates the value of “co-operation, not competition”, emphasising the risks to patient care, and calling for greater integration and collaboration. Again, no objective reading of the White Paper can find anything in it which is consistent with this approach.

The key principles embraced by Mr Lansley centre from start to finish on the creation of a competitive market, in which the power is put in the hands of commissioners, and providers are obliged to compete with each other. Principle 6 calls for the NHS to be “led by medical professionals working in partnership with patients and the public”. But it’s clear that the scope within the White Paper for such partnerships will be extremely limited: GPs will have restricted managerial resources to assist and advise them in the allocation of large commissioning budgets 4, and limited time and capacity to conduct their own interaction with any wider public alongside their own clinical work.

If rumours that there will be around 500 consortia in England are correct, the average size for a consortium will be around 80 GPs, or 3-4 per existing PCT area: this leaves ample scope for widely different local pressures and issues between different GP practices in different areas within consortia. Nor is it clear how GPs can really be accountable to their own patients, when they will also be under pressure from GP colleagues to press through decisions that balance the books for the whole consortium, in the context of £20 billion of cuts.

To add to the potential confusion, the White Paper makes no reference to neighbouring consortia having any obligation to cooperate with each other — for instance over the resourcing of services from a shared local hospital — after the mechanisms for wider planning of services (SHAs and PCTs are to be abolished. There is a real danger of a new parochialism, and a new postcode lottery on availability of treatment, with widening inequalities even within PCT areas — and contradictory decisions on the future of local provider services. Do GPs really want to carry responsibility for the unpredictable consequences of this potentially anarchic situation?

Principle 7 seeks value for money,“but puts the care of patients before financial targets”. With the overriding obligation on GPs as commissioners to carry (the Health Service Journal suggests that the consortia management budgets could be as little as one third of the present management spend by PCTs (Ju1y22:7) through £20 billion of cuts by 2014, the White Paper makes it difficult to ensure that this principle could be consistently upheld in any area.

Principle 8 sounds an important warning over the need to commit to “training future generations of medical professionals”. But the SHAs which currently plan medical and professional training are to be abolished. Thousands of training places are already set to disappear for both doctors and for nursing staff, with University staff posts also at risk.

The fragmentation of the NHS, especially once Foundations are “off balance sheet” and obliged to run as businesses outside of any guaranteed framework of funding or government support, also throws the long term future of training and education of professionals into serious doubt.

By 2013 the NHS Commissioning Board would be the only, drastically reduced, surviving element of today’s NHS: can we be certain that this will be able to ensure that self-managing Foundation Trusts concerned with their own balance sheets and financial pressures — let alone the panoply of “any willing providers” — will invest sufficiently in training and development of staff? Conclusion

In summary, it is clear that the BMA decision represents a very serious mistake, and is clearly incompatible with the previously declared principles and campaigning profile of the BMA. It runs the risk of putting GP members as commissioners into conflict with members working in hospitals and other providers, dividing the organisation itself, while also splitting the BMA from the broad body of opinion of health trade unions and professionals.

It is most unlikely that this stance will be viewed with much respect by health ministers, who will simply regard it as a strengthening of their position — and an indication that if they keep the pressure on they can get their way with the BMA.

And it seems that there is no fall-back position to be adopted if the gamble of “critical engagement” falls flat, and the government presses on with those aspects of the White Paper that the BMA regards as unacceptable. It is also worrying that you have not identified any “red line” issues where you are determined changes must be made as a condition of involvement, or bottom line objectives to enable the BMA to determine the success or failure of your “critical engagement”. This vague approach seems more likely to lock the BMA into the process regardless of the outcome of its engagement with ministers.

The BMA is to be applauded for having taken a firm and principled position for the last few years in challenging New Labour’s market-style policies and upholding the principles of the NHS. It is unfortunate that the change of government appears to have brought a retreat from this position, and concessions to policies which are far more extreme in their scale and implications that any previous NHS reforms.

I’m sure I don’t need to remind you that in 1946 the BMA chose badly and wound up on the wrong side of the debate in opposing the launch of the NHS in 1948.

The last to come round at that time – long after consultants and hospital staff had been persuaded of the advantages of a national career structure, training and standards – were the GPs, many of whom did not change their position until after the NHS had been formed and almost the entire population had immediately signed up for it. You will be aware that for many decades this error haunted the BMA’s links with other organisations. But it seemed that this had finally been overcome with the BMA’s vigorous defence of NHS values against New Labour’s proposals. Indeed it was remarkable that earlier this year the BMA contingent on the national demonstration in defence of public services, in which you took part, was bigger and more vigorous than some of the TUC health unions with larger membership.

Sadly it seems that the current stance of the BMA could result in the GPs again lining up on the wrong side of the debate, as the current government contemplates the definitive reversal of Bevan’s nationalisation of the hospital network, which laid the groundwork for the NHS.

I very much hope that the BMA will take immediate steps to strengthen the very limited critique which seems to inform the current policy, and will soon recognise the need for a shift of direction. If not, the organisation will again be discredited – for effectively abandoning its key principles in the vain hope of future influence over a government that does not share them, and is firmly set on an opposite course, to the detriment of doctors, health workers and patients.

John Lister PhD
London Health Emergency
August 3 2010

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Staked out for the vultures Thu, 15 Jul 2010 16:44:42 +0000 Continue reading ]]> By John Lister information director of Health Emergency

The new coalition government white paper Liberating the NHS could reduce the National Health Service in England from one of Europe’s largest single employers, with around 1 million staff, to near zero by the time of the next general election.

Tens of thousands would face redundancy through wholesale cuts in “bureaucracy” or lose their jobs through so-called “efficiency savings.”

Hundreds of thousands more could find themselves effectively privatised and transferred to non-NHS employers in the biggest shake-up ever to hit this popular public service.

The NHS itself, which currently spends £105 billion, will remain in name only as a “brand,” transformed from a major public service into little more than a central fund drawn from general taxation.

This cash mountain would be used to commission a variety of services delivered by non-NHS organisations in a competitive health-care “market” in which a growing number of private providers, including multinational corporations, would be encouraged to operate.

Continued central funding would ensure that patients would mostly not be required to pay for services at point of use, preserving the illusion of continuity of the NHS, while even more non-profit and profit-seeking providers slice off lucrative portions from the public budget.

At present the NHS is divided internally into three sectors.

“Commissioners” of services operate locally through 152 primary care trusts and 10 strategic health authorities. These hold or allocate budgets for the various sectors of health care.

“Providers,” a network of local NHS trusts covering acute, mental health, community care and ambulance services, together with local community services agencies

129 free-standing NHS foundation trusts. These work outside the main NHS management structure and are accountable to an independent regulator, Monitor.

The majority of staff working in all these organisations are NHS employees, enjoying nationally negotiated pay scales and terms and conditions including sick pay and pension entitlements.

In addition around 60,000 family doctors, general practitioners (GPs), work largely as independent contractors to primary are trusts, delivering primary care to a defined list of patients. They work with teams of nursing and other staff, some of whom are employed directly by the GP practice and some through PCTs.

Several years of efforts by the new Labour government have failed so far to persuade more than a small minority of GPs to take on the responsibility of “practice-based commissioning,” in which they would shape the policies and spending decisions of their local primary care trust.

The new white paper would completely reorganise this structure. The “commissioning” bodies (PCTs and SHAs) are to be scrapped altogether with the loss of tens of thousands of managerial and administrative jobs.

The public health function of PCTs is to be hived off to local government and the Department of Health itself would be reduced to a small rump organisation.

The commissioning role is instead to be taken over by GPs, who will be obliged to participate, working through local consortia of GPs and, if necessary, forcibly incorporated into a consortium.

It is clear that these consortia would need to enlist substantial additional expertise and administrative assistance, either from former PCT or SHA staff or from private-sector management consultants who in many PCTs have been playing an increasingly influential role for some time.

But while NHS employment among commissioners is set for near-extinction by 2013, the providers too will increasingly be forced out of the NHS.

Foundation trusts, already detached from the mainstream NHS, are to be pushed even further by the white paper proposals to become “social enterprises.”

They would be encouraged to set their own pay scales and lift restrictions so they could expand provision of private medicine and their links with the for-profit private sector, “regulated the same way as any other providers.”

Health Secretary Andrew Lansley is also known to favour shifting foundation trusts “off balance sheet” from the NHS and allowing them to run as normal companies, regulated by Monitor.

This raises the prospect that new staff recruited to foundation trusts would be employed outside the NHS, its pensions and terms and conditions. Existing staff would initially have their terms and conditions protected, but there is little doubt that growing numbers of trusts would soon set about changing these contracts.

There is no escape for NHS employees. The white paper stipulates that all remaining NHS trusts are either to become foundation trusts, or be taken over by foundation trusts, by 2013, when their current legal status will be repealed.

Community health and primary care services, currently run at “arm’s length” from PCTs, would also be systematically put out to tender and either reorganised as “social enterprises” outside the NHS, taken over by foundation trusts or by “any willing provider,” whether for-profit or not.

This would be imposed on staff from above. We already know that virtually every sector of the workforce that has been allowed to vote on whether or not to join in a social enterprise has voted by 90 per cent or more to reject the idea. The hostility to private companies would be even greater.

All of these moves to whittle down the NHS to a bare minimum handful of employees will also take place in the context of the fastest and largest spending cuts in history.

Lansley’s white paper makes clear that the £20 billion target for “efficiency savings” is to be achieved by 2014, two years earlier than previously planned.

Such a massive and unprecedented squeeze on spending could only be carried through by axing tens of thousands of staff, closing beds, wards and hospitals, and massively increasing the workload of the staff remaining.

However it’s by no means certain that things will go the way Lansley expects. His apparent master stroke of handing commissioning to GPs is itself highly controversial even within the government.

The Treasury in particular attempted to prevent the plan to hand £70 billion in commissioning budgets to GPs with no managerial or commissioning training or experience.

The department’s fear is that GPs in many areas will take the line of least resistance, avoiding making unpopular cuts and closures which might antagonise their own patients – making it almost impossible for cutbacks to hit the £20 billion target.

In addition the previous track record of GP commissioning, when the previous Tory government imposed the controversial system of “GP Fundholding” in the early 1990s, was that many GPs did precisely that.

Under that system GPs held back £1 for every £6 they were allocated for patient care, leaving millions unspent. Administrative costs elsewhere in the NHS were forced sharply upwards, with an estimated £500m of additional bureaucracy as each trust was obliged to negotiate one by one with a variety of fundholding practices.

And even the new white paper admits that under fundholding the varying priorities from one GP practice to another brought a “postcode lottery” for patients, with widely varying access to health-care.

Despite this, the system is set be made even more arbitrary by the scrapping of any form of planning, along with many performance targets and any incentive to co-operate, collaborate and share best practice.

Now, as then, the apparent power given to GPs is being backed up with a blunt threat that they have to drive the cuts and rationalisation and stay within financial limits, warning that any GPs or providers that go bust will be allowed to fail in a ruthless, competitive marketplace.

On top of this threatened workload is the introduction of patient “choice,” backed up by voluminous information which will no doubt delight some of the sharp-elbowed middle classes, but will confuse and irritate many other less confident and articulate patients. Most just want to be able to access good quality care from their local NHS provider.

But it is far from clear that GPs, even if they want to, would have the time to work through the exhaustive process of offering each patient this choice of not only which hospital or provider to use but which consultant to see, let alone provide detailed studies to back it.

In London and elsewhere the pressure for “efficiencies” in primary care has been for GPs to spend less time, not more with each patient. The white paper makes this almost impossible to achieve.

Will GPs be persuaded to take on this work, which ministers have made clear would not be rewarded by any extra pay? The British Medical Association has waged a strong campaign against a market in health-care, but with GPs themselves divided on the issue it is not clear how it will respond.

The other big question is how strongly the TUC health unions will resist this root and branch attack on the jobs, pay and conditions of their members and the dismemberment of the NHS as a public service, which builds on all the worst aspects of Labour’s “reforms.”

One thing is clear. If the white paper is carried through, the new system will eviscerate the NHS, wiping out much if not all public-sector provision, and installing the untrammelled competitive market in place of any form of planning, co-operation or collaboration.

It will offer a bonanza for private providers and ring the death knell for any serious attempts to implement policies aimed at reducing inequalities in health.

It can and must be stopped.

From the Morning Star

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