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    Is this the knife poised to finally kill the NHS and the post 1945 social settlement?

    Throughout the 80s under Thatcher, but particularly since the Health and Social Care Act (2012), contract after contract for health provision has gone to the for profit private sector. Sometimes the NHS has won contracts, sometimes the privateer, but overall during this last 6 years, our taxes / resources have been drained from public (NHS) to private providers. Stresses on the NHS have been exacerbated by cuts in financial support and staffing, increased demands and by immigrant doctors, nurses and other staff being unwelcome here following the Brexit vote, and it’s liberating a nasty racism. Remaining staff have been exemplary in trying to cope with these demoralising and exhausting situations, but burn-out is now common, staff are sick with stress, continuing to leave or just hanging on for their retirement. Working life for everyone is just not as good as it used to be. Most Trusts in England are now in deficit. Local Authority Social Care is almost non-existent now, again as the result of Thatcher’s immediate and savage cuts in the 80s, and the situation is worsened as local authority funding from central government has been slashed since 2010, and will disappear entirely by 2020. Yet somehow, these combined deficits are all supposed to transform the red to the black by combining health and social care. The latest vehicle in the alphabet soup of acronyms to assist this introduction is Integrated Care Organisations (ICOs) which come with a small money sweetener. However, this money is temporary; almost certainly a one-off as we know this government does not support the public sector and wants it demolished. As Oliver Letwin, the right wing Tory MP said the NHS will have gone by the next election if we win it.

    So how is this to happen? Since the Health and Social Care Act, Section 75 has REQUIRED commissioners to put out to tender everything that couldn’t be provided by the NHS, so hospital services like cleaning, diagnostics, catering etc… have gone already. Now, under the proposed ICOs, Section 75 regulations create rights for commercial providers to promote their interests by rules written by US corporations; these enable any private provider which FAILS to get a contract to compensation by the government if that service returns to the public sector. We have already a foretaste of this, as Virgin claimed and received compensation when it failed to get an NHS contract in Surrey (? Can anyone provide me with the specifics?)   In the past, the Labour Party, the Royal College of GPs and the BMA have demanded that these regulations be scrapped, since clearly the government could not afford to compensate privateers for every contract which had not been accepted – in fact, it would be a great fail-safe money-spinner to submit silly tenders with guaranteed compensation for no service costs at all, especially if those tenders are for 15 years, as is now commonplace! Do I recognise similarities to PFI? ICOs also require to be paid in full for a year BEFORE they actually provide any service, and that money is fixed irrespective of the number or complexity of the procedures they undertake. It looks very much like a ‘race to the bottom’, safeguarding profits by providing the least and cheapest they can.   Is this another echo of PFI? Originally, the commissioners were assured they would not have to use competition in health services, but this seems to have been forgotten and presumably disappears if Section 75 is implemented. When a public contract has been lost to privateers, the service, personnel, equipment and buildings cannot be mothballed, everything is dismantled, and that’s forever. We have so much evidence that privateers ‘cherry pick’ the services which are predictable, easy, most profitable leaving the complex and difficult to the NHS, and if problems arise at some stage in the private service, patients are immediately transferred to the NHS where comprehensive teams of specialist staff, not available in the private hospital, can meet all emergencies IF there’s a spare bed.

    There is no evidence that private services provide a better quality service, in fact, they are not as accountable, nor are they as monitored as is the NHS. Competition / marketisation has led to greater inequalities, increased inefficiency, higher costs and greater public dissatisfaction according to Robert Evans, the Prof of Economics at the University of British Columbia.

    Judith Varley 19.10.18

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    Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’


    Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

    With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.


    Reduction in prevention, cytology and mental health services

    Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

    More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.


    STI screening and HIV testing

    More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

    The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

    Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.


    PrEP availability and reproductive health

    The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

    At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.


    Impact of separation of HIV and GUM on staff and services

    Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

    Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

    Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.


    Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

    Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”


    Editor’s notes:

    1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
    2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
    3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

    For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or or Jo Josh, BHIVA, on 07787 530 922 or

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    Can I appeal to everyone, individuals and organisations, to get solidly behind the judicial review as loudly and forcefully as possible.

    I’d like to see all of us highlighting and publicising the judicial review in our various communications and campaigns. We are trying in Wirral.

    If the review succeeds entire awful council/CCG edifices of pooling and dissembling come tumbling.

    If the review doesn’t raise the required £18k we’re all doomed no matter how vocal our local and national campaigns!

    Come on! The price of a few glasses of wine/beer/flat white.


    Kevin Donovan


    For everyone who couldn’t make the Conference, here is Jessica’s speech to our Fringe meeting on the future of Women’s health that I referred to earlier in a members email.

    Jean Hardiman Smith


    Thank you for inviting me to speak to you today. My name is Jessica Ormerod. I run a research and information organisation called Public Matters with my lovely friend and colleague Deborah Harrington.
    Although we write about all aspects of the NHS and other public services, I have a particular interest in maternity. I have been writing about maternity issues for seven years since I was the chair of the maternity services liaison committee for Lewisham Hospital which coincided with our fight to save our maternity services. We won that fight but we have by no means won the war because as you know maternity services up and down the country are being closed and downgraded.
    But before anything else I want to paint the picture of what is happening to the NHS as a whole. Because every closed maternity ward, service or reduction in staff is the direct result of changes to the NHS that have been happening since the 2012 Health and Social Care Act. These changes are having a devastating impact on access to care. It is no exaggeration to say that we are witnessing the reversal of 70 years of universal, comprehensive and equitable care.
    The 2012 Health and Social Care Act put into place all the major elements for a step change in the privatisation of the NHS.

    A QUANGO called NHS England was formed as the Commissioner-in-Chief of the service, with over 200 subordinate local commissioning units. These commissioning units broke with the tradition of planning services, replacing it with buying in from public, private and voluntary sector providers. Areas of work are subdivided into contractable units and NHS public providers are obliged to compete. The loss of a contract means loss of income, which has a knock-on effect on the viability of the public sector, which is left with high cost acute care and a reduced income.

    In 2014 a new CEO was appointed to run the NHS in England. He created a new plan for the NHS, the Five Year Forward View and this was greeted by the establishment as a welcome antidote to what was seen as the fragmented mess left by the 2012 Act (this was only a mere 18 months on from it being enacted). But it’s important to recognize that far from being an accident, the Act achieved the fragmentation necessary for privatisation to be embedded at an organisational level, including many major health industry players taking key roles in the commissioning and policy-making process.

    At the heart of NHS England’s Five Year Forward View is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care are relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services.

    We could say the scope of this aspiration is far reaching or we could say it is pie in the sky. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service with much of the change becoming the responsibility of local authorities.

    The process of transforming the NHS in England, is based on close co-operation between successive politicians and Department of Health managers over many years with the US Health Maintenance Organisation or Accountable Care Organization principles of managed care. This process is continuing without any checks and balances of substance within the formal organisational structures of government. Politicians go to great lengths to deny both privatisation and US influence on the current changes.

    There is, however, a groundswell of resistance to the damage being done to the NHS and there is a lot of knowledge surrounding individual service contractions and closures, but little in the public domain about the overall programme of change. And that is what I am here to talk about today.

    The National Maternity Review, aka Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.
    44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems. Unlike the Integrated Care Organisations which are now under consultation, they have been put into place with very little fanfare or institutional opposition.
    As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England consistently refers to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.
    In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.
    But what makes maternity different from other services?
    Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.
    Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.
    Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP. They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.
    Currently women can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ – that’s a midwife-run facility on hospital grounds, or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services which is blood, air and surgeons. A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.
    Put this into the context that since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.
    Who is driving the changes to maternity?
    Surprise, surprise, Better Births panel includes private health providers and those private companies are working with government to re-write policy.
    Although most current providers are NHS hospitals, private providers are now being strongly encouraged. Local Maternity Systems set their own payment systems. This means that they can choose whether they pay via their geographical population or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.
    NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations – I don’t need tell you about this because you’re part of it! The sites were told to be bold and radical. Another incentive is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site.
    LMSs are encouraged to work alongside private providers in order to offer women a wider choice. As most women have previously been cared for by the NHS this simply means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this does actually reduce the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.
    Better Births tells us it is working on a new accreditation scheme for maternity providers. But in a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard.
    Private providers are required to have a contract with the NHS in order to receive payment via a Personal Care Budget. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will apparently encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. But it is decidedly unclear about how this can be achieved. The guidance talks about using Personal Care Budgets for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.
    Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.
    What does this all mean?
    Scale and pace have taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of this new policy.
    This is a top-down reorganisation of a national service with little to no consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.
    The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction!
    Clearly long gone are the years of epidemiological study, of public health planning, of consultation with experts.
    Better Births is based on consumer choice issues around personalised maternity care. There is a serious lack of evidence that this restructuring will give women the vital services they need. There are fewer services, obstetric departments are being stretched even further and technology is replacing face-to-face clinical care.

    On the other hand, it embeds private care and fee-for-service. And, most importantly of all this is not how a national public service works.


    Privatisation has been the economic policy of successive governments since the 1970s. All the major infrastructure, utilities and manufacturing industries which had been brought into public ownership in the immediate post-war period have been sold off, as single share offers, wholesale private transfers, or partial staged transfers. Privatisation has been developed through the remaining public services, with local authorities increasingly turning into commissioning hubs rather than direct employers, education transferring its assets and management to the private sector through the Academy programme and courts, prisons and more being owned and run by the private sector. 

    That privatisation is government policy is not in question. The question is how far that has affected the NHS.  

    Privatisation of the NHS began as far back as 1983 when the cleaning services started to be put out to tender. That has had fairly disastrous consequences with the spread of ‘superbugs’ being attributable to the cleaners no longer forming part of integrated core teams on wards.

    Other privatisations, including IT services, facilities management, out-of-hours GP services and the 111 service, have had patchy results; some have been a waste of money, some have failed to show any benefit over public provision, some, like the cleaning services, have been cheaper but a lower standard. Interestingly these privatisations are not discussed or presented as ‘privatisation of the NHS’, or part-privatisation, although they clearly are.

    The NHS is the sum of all the parts that make it function, not just its clinical services. This intellectual sleight of hand of naming private-sector takeover of asset ownership and management, ancillary and backroom services as normal business practice or ‘just outsourcing’ rather than service privatisation has allowed a significant part of the NHS to be privatised without being acknowledged as such.  

    The House of Commons Library briefing on privatisation defines the need for a competition regulator as one of the essential features of the move from public to private provision. Regulators have been brought in over the last 20 years via various bodies up to the current position of the CQC and NHS Improvement, reflecting the need for market regulation. 

    The Health & Social Care Act (2012)

    The Health and Social Care Act (2012) continued the process of privatisation. It has become commonplace to describe the Act as a mistake. But given that privatisation is the dominant economic policy, the Act is not a mistake, it is merely a continuation of that policy.  

    Privatisation is embedded in the Act in several ways. It removes the NHS in England to arm’s length from government. The relationship between the state and the service changes with the responsibility of provision lying outside the government department. The government’s remit alters significantly from being responsible for provision and planning to providing a Mandate and a funding stream to NHS England and authorising the NHS ‘kite-mark’ through NHS Identity.  

    NHS Identity’s website gives advice and regulations about using the brand to the NHS family, which includes public, private and voluntary sector partners. 

    The Act also created the Clinical Commissioning Groups (CCGs). Section 75 3(a) of the Act imposes requirements relating to competitive tendering for the provision of services. 

    The interpretation of this provision is a source of contention with the government arguing that the clause gives CCGs choice about tendering out services and the CCGs feeling that they are open to legal challenge if they do not tender. The CCGs and Section 75 are the engine that powers the privatisation of clinical services. The constituent members of the CCGs – GPs – do not have the collective skills to carry out the complex procurement process of putting services out to tender. They use Commissioning Support Units such as Optum, the UK subsidiary of United Health of America, to perform this function. 

    The CCGs are also not bound to supply the same range of services nationally. They have some core clinical responsibilities but can put restrictions on others according to their financial needs. This can lead to situations where hospitals request patients to check with their commissioner to ensure they will cover payment before they start treatment, otherwise they have self-pay and insurance options available. In all but name this makes the CCGs act as local insurance groups to their registered patients, rather than service providers with common service standards set at national level. 

    Trusts and Foundation Trusts are also empowered by the Act to increase the amount of private patient income they can earn. The Act specifies that they must earn the majority of their income from NHS funding. But that is interpreted as meaning that up to 49% can be from other sources. This can include rent from retail spaces and car parks as well as private patients.  

    The Five Year Forward View

    Simon Stevens, CEO of NHS England, produced a Five Year Forward View (5YFV) for the NHS in England in October 2014. This is largely presented by the media, politicians of all stripes and think tanks, such as The King’s Fund, as a way of integrating services to end the fragmentation caused by the 2012 Act and to bring an end to the split between commissioners and provider organisations. In 2013, immediately after the implementation of the Act, The Better Care Fund was rolled out as a series of local programmes under different names; ‘Better Together’, ‘Fit for the Future’, etc… Its stated intention is to shift the focus from acute hospital settings into local authority based social and community care.

    The 5YFV started with a series of Vanguard testbeds and will end with Integrated Care Systems and possibly Accountable (or Integrated) Care Organisations.  The stated intention of the 5YFV is to shift the focus from acute hospital settings into local authority based social and community care. In other words, even though they have different names, the two programmes have exactly the same aim.

    This illustrates that the HSCA 2012 was not a mistake but is in fact a continuation of policy. That is why the findings of Michael Mansfield’s 2015 independent inquiry into Shaping a Healthier Future in NW London is still relevant. It highlights how this programme is moving services away from those areas most in need of them towards high-density, more profitable areas.

    The reality of the 5YFV is that it is a re-shaping of the NHS to fit with a predicted permanent reduction in funding levels. It is based on a reduction of the total number of fully functioning blue-light A&Es from the 144 A&Es in England in 2013 reduced to somewhere between 40-70. These will be large major trauma centres. There will be no more than two for each of the 44 Sustainability and Transformation areas (STPs) which were announced in December 2015 as part of the implementation of the 5YFV. Some STPs will only have one. This is the case in Northumberland, an early adopter of the system. 

    Other hospitals are having their A&Es downgraded and services transferred to the trauma centres along with their income. When campaigners are fighting across the country to save their local A&Es they are really fighting against the 5YFV. Acute and emergency care is being separated from elective (planned) care. Planned care is more attractive to the private sector as it is low risk and high income. It is one of the areas of clinical care included in the ‘7.9%’ of privatisation quoted in the Health and Social Care Select Committee’s oral evidence session. 

    The 5YFV also envisages using the sale of property as a form of pump-priming of the changes. The Naylor Review (part of the 5YFV process) goes further in working on the transfer of services out of owned properties into rented accommodation, built and managed by the private sector. 

    The 2012 Act also created NHS Property Services Ltd, the ‘PropCo’, which took ownership of all the properties previously in the stewardship of the Strategic Health Authorities and Primary Care Trusts. The PropCo is a private company, currently wholly owned by the Department of Health & Social Care. It also charges commercial rents. 

    The 5YFV encourages the separation of midwives from the hospitals to form their own companies to provide midwifery in the community. It contains plans for the widespread use of vouchers for maternity and personal health budgets for the disabled and those with other long-term health needs. These vouchers and budgets can be spent in the private or public sector. 

    Privatisation: an economic policy

    Analysing the overall effect of privatisation in the NHS will take time. Whilst there is little evidence of an increase in health insurance schemes, there is evidence that more people are turning to self-pay options to avoid waiting times. For a cultural change to happen people have to accept the principle that there will be things outside the ‘NHS menu’ that they will have to pay for – that cultural change hasn’t happened yet.

    Descriptions of how little impact the private sector has currently had on the NHS avoids the issue of how little unmet need is being created by the reconfigurations. It is in the unmet need that the principles of universal and comprehensive care are being lost.

    The report from the Health and Social Care Select Committee on Integrated Care is absolutely explicit about the need to retain ‘choice’ of providers and to avoid the ‘danger of creating airless rooms in which you simply have one provider who is there for a huge amount of time’.

    This is the economics of privatisation and it needs to be addressed at parliamentary and legislative level. The Health and Social Care Committee recommends new legislation. On the current trajectory that will mean the introduction of ACOs.

    The battle to promote the principles of public service as public good still has to be fought and won if the privatisation agenda within the NHS is to be brought to a halt.

    The NHS [Reinstatement] Bill will be presented under the 10 Minute Rule by Eleanor Smith MP on 11 July 2018.


    I have not blogged about the NHS for quite some time. In fact the last occasion I explicitly did so was when Wendy Savage and I were campaigning together in 2011 to strangle the Health and Social Care Bill at birth (our talks to students still reside somewhere on YouTube). I remain sceptical and confused about the BMA’s slipshod, innocent or opportunistic failure to act decisively. I was alongside many others literally yelling at them through a megaphone even as they reached their momentous resolution to step aside and raise the white flag. In doing so, as Wendy and I had both tried to spell out, they effectively condemned the NHS as we had come to revere it through the post-war, social democratic or welfare statist era. The post-2011 careers of the principal decision-makers should be researched? Who won? Who lost?

    In this offering I draw on a paper co-authored with Sasha Scambler and Ewan Speed and published in Social Science and Medicine. It represents an extension of an argument I have been pushing for some time. I have maintained that not only the national distribution of longevity and health but also the planning and delivery of health care have been undermined and perverted by the very predictable implementation and extension of the Health and Social Care Act of 2012.

    Trading on a plea for forbearance, I must refer once more to the greedy bastards hypotheses (GBH), namely, the announcement that it is the rich who – mostly indirectly, but issuing nevertheless from an expedient strategic amorality – restrict and sometimes totally cut the supply of oxygen from those asset flows conducive to health and well being and threaten the NHS.

    So how to understand the prospects/plight of the NHS? I will offer a summary (sociological) analysis before committing to a series of personal/political interventions.

    In the 1970s the American abrogation of Bretton Woods and the emergence of the Eurodollar freed up money capital from national regulation by central banks; plus the international recession drew banks deeper into the global arena. The word financialisation was used to encompass not just this deregulation and internationalisation, but also a shift in the distribution of profits from productive to money capital, and to a reorientation reaching deep into industrial corporations towards the financial sphere. Within banking, deregulation precipitated capital centralization in banks with ‘global tentacles’, whose activities ranged from financial production to speculation in derivatives, while institutional investors controlling capitalized deferred wages became important centres of allocative as well as strategic power. This was all before the global financial crash of 2008-9.

    The greedy bastards referred to above comprise a small proportion of the 1% who have profited most, and obscenely so, from post-1970s ‘financial capitalism’. A cabal or hard core of CEOs/directors of largely transnational corporations, major rentiers, and, most conspicuously, financiers or ‘banksters’, now provide financial capitalism’s cutting edge. They epitomise fine-tuned class action (or ‘class warfare’). We are witnessing a new breed of ‘super-rich’ pitted against a squeezed middle, enlarged ‘precariat’ and a US-like category of the abandoned. Their class supremacy has been accomplished via the purchase of power from Britain’s political elite (whether New Labour, Coalition or Tory), which has in turn become more controlling of its publics, even repressive. Britain is now ruled by a governing oligarchy or plutocracy. Capital buys power, and in financial capitalism it gets more for its money than during the preceding postwar era.

    In the early Thatcher years, attempts were made to introduce ‘corporate’ management structures to the NHS, leading commentators to talk of a ‘new managerialism’. Her commitment to markets prompted the NHS and Community Care Act of 1990. The resultant ‘internal market’ sat on a spectrum somewhere between a bureaucratic ‘command and control’ economy and a private fee market. If it was closer to the former it was also a sign of things to come.

    Thatcher’s displacement by Major saw the introduction in 1992 of the Private Finance Initiative (PFI). This allowed for the private sector to build (and own) new hospitals and other health care facilities, which they then leased back to the NHS at often exorbitant rates on the back of 20-30 year deals. It was a convenient arrangement for the political elite since PFI building and refurbishment did not appear on government books (they represented an investment of private not public capital). Blair and Brown lovingly embraced PFIs from 1997 to 2010. As Alyson Pollock presciently noted, one day the chickens would come home to roost. And they have: PFIs are a major contributor to the indebtedness of many an NHS Trust, the more so given the cuts or austerity measures following the financial crash.

    The 2010 election resulted in a Cameron/Clegg coalition that backtracked on a (Tory) pre-election promise not to engage in a top-down reorganization of the NHS. Health Minister Lansley published a White Paper ‘Liberating the NHS’ a mere 60 days after the election. It was the product of protracted and insistent pre-election private sector lobbying. This was followed by the Health and Social Care Bill that opened the door for a root-and-branch privatisation of health care in England. It was a long, complex and devious Bill. There were five main ‘rhetorical’ themes: strengthening commissioning services; increasing democratic accountability and public voice; liberating provision of health services; strengthening public health services; and reforming health and social care’s arm’s length bodies. Five organizational changes were mooted: by April of 2013 the existing 192 primary care trusts to be abolished and GPs to join commissioning consortia; consortia to control 80% of NHS budget; services to be purchased from ‘any willing provider’; all NHS hospitals to be foundation trusts by 2014; and commissioning to be overseen by an NHS ‘financial regulator’, Monitor. Like many others, critics like Wendy Savage and I were not fooled. Why would the new commissioning consortia be better than primary care trust commissioning? What would the role of private companies be with regard to commissioning criteria? What would be the role of Monitor in European law? How would patients have ‘more choice’? Where would the efficiency savings come from? Would the pursuit of efficiency savings be at the expense of quality?

    A period of ‘consultation’ and debate was extended. The medical profession, a reluctant recruit to the original concept of an NHS, questioned and subsequently opposed the Bill. Then it folded. They were ready to take industrial action to defend their pay and conditions but not to safeguard a public NHS. Public protests were similarly ineffective and the Bill became an Act in March of 2013. Later in 2013 the coalition pushed a (strategically re-written but equivalent) ‘regulation 75’ through the Houses of Parliament, removing residual obstacles to the unfettered promotion of for-profit health care.

    A number of comments are in order here. Neither the Tories nor the coalition had a mandate to ‘reform’ the NHS in the way they did. Moreover it was a reform carried out against the background of Brown’s efficiency savings announced in mid-2009 and amounting to £15-20bn in three years starting April 2011. The reform was opposed by the medical, nursing and other health professions; polls showed widespread public concern; and a series of campaigns and protests were sidelined and ignored. Although a small number of health professionals and academics were recruited to the coalition cause, there is no doubt that ‘best evidence’ on comparative health care bore testimony to the regressive nature of the Health and Social Care Bill/Act: this was ‘policy-based evidence, not evidence-based policy. Finally, it emerged later that for-profit providers were not only lobbying the Tories before the election, but were intimately involved in the thrust and composition of the Bill (e.g. via the Future Forum). They were lining up to takeover NHS services. The leading private providers – H5, accounting for 80% of private hospitals and 85% of private beds – formed an alliance as early as December 2010. Much of this ‘secret’ activity was portrayed as ‘internal to the NHS’ rather than as external lobbying.

    We are already experiencing the predictable short-term effects of the Health and Social Care Act, with ill-equipped and predatory for-profit providers taking over services and benefitting from the NHS ‘brand’. The ‘revolving door’ is also well oiled. Alex Scott-Samuel has taken a medium to long-term view, anticipating that: the NHS will become a subcontracting operation privileging competing private providers; that services of ‘low clinical priority’ will cease to be free; that a market for health insurance will emerge, affordable for the affluent, which will drive up costs (administrative, fees, private profits); and that the development of personal health budgets will lead to personal charges as commissioning groups come to operate on an individual basis in order to be compatible with the insurance companies (i.e. an end to ‘population-based pooling of risk’).

    In short, the Health and Social Care Act was always going to be and is an unmitigated disaster for which the BMA in particular was a shameful accomplice. PFI debt, cuts and privatisation are destroying perhaps the most just, efficient and effective – ‘imperfect’ – health care system in the world.

    The point of this blog is to ask why. It seems clear enough. The super-rich greedy bastards who fuel our governing elite or plutocracy – that is, those who buy, hold and use power to their advantage – now have sufficient sway in financial capitalism to open up (even) the NHS for profiteering. Follow the career trajectories of Lansley and his successor Hunt (and a few Blairites). The privatisation of the NHS, and the future commodification of health care, might have been halted by a BMA-led campaign provoking a crisis of legitimation for the power elite, but that opportunity was lost. We need to recognise that if capital can purchase enough power, it will pursue accumulation via, to borrow Wallerstein’s phrasing, ‘the commodification of everything’. It’s a class/command issue. If we ignore this sociological/structural dimension, we become ideological co-optees and deny ourselves the theoretical capacity to explain and counter regressive policies. To paraphrase Bill Clinton, ‘it’s class warfare, stupid’.


    Scambler,G, Scambler,S & Speed,E (2014) Civil society and the Health and Social Care Act in England and Wales: theory and praxis for the twenty-first century. Social Science and Medicine 123 210-216.

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    Legal and Policy Briefing for the Second Reading of the National Health Service Bill 2015-16 in the House of Commons, on 11th March 2016

    The NHS in England is being dismantled. This is the result of Parliament over 25 years applying market ideology. The main Acts which made this happen were the:

    • NHS and Community Care Act 1990: introduced the internal market into the NHS; split purchasers from providers, so that the planning and delivery of services was to be undertaken by separate bodies, with the money flowing between them; ended direct management of services by health authorities with the creation of ‘NHS trusts’ as self-governing accounting centres (bodies corporate) with borrowing powers, and their own finance, human resources and PR departments; brought in GP fund-holding, which delegated budgets to individual GP practices enabling them to be commissioners or purchasers of services and to retain surpluses.
    • NHS (Private Finance) Act 1997: empowered NHS trusts to enter into externally financed development agreements;
    • Health Act 1999: introduced Primary Care Trusts;
    • Health and Social Care (Community Health and Standards) Act 2003: introduced NHS foundation trusts and their regulator, Monitor;
    • NHS Act 2006: de-coupled the Secretary of State’s duty to provide and secure services in accordance with the Act, from the duty to promote a comprehensive health service;
    • Health and Social Care Act 2012: abolished the duties of the Secretary of State to provide and secure services in accordance with the Act, and to provide listed health services throughout England, replacing the latter with a duty on over 200 new clinical commissioning groups to make contracts for those services for persons for whom each Clinical Commissioning Group is responsible; established the NHS Commissioning Board (NHS England); prospectively abolished NHS trusts, with the intention of them all becoming NHS foundation trusts; allowed NHS foundation trusts to receive 49% of their income from outside the NHS; created “public health” functions as two legal categories split between the Secretary of State and local authorities, and carved them out of the NHS; introduced virtually compulsory contractual tendering for providing NHS services; extended Monitor’s role as an economic regulator with functions aimed at preventing anti-competitive practices.

      Summary of main Clauses of the NHS Bill

    Clause 1: restoring the founding principles and excluding EU and international trade, competition and competition rules.

    The Bill would reinstate the Secretary of State’s legal duty to provide the NHS in England, abolished by the Health and Social Care Act 2012 (Clause 1(1)). It would be delegated to local Health Boards, to NHS England with its regional committees and to local authorities (see especially Clauses 6, 8 and 9 below).

    Taken together, these and other provisions of the Bill will have the effect of taking the market and pricing tariff out of the NHS. The uncoupling of resource allocation from service provision through the pricing system and market competition would be discontinued, and resource allocation would return to being on the basis of all-inclusive geographic populations, not membership of a group. Commissioning would focus on the essential tasks of assessing needs, planning to meet those needs, setting clinical standards, matching funding to delivery, capturing information to support the various stages of the cycle, and ensuring accountability, without commercial contracting except in the most exceptional circumstances when absolutely required. At the same time the billions of pounds saved from administration of the market will enable new positions to support and enhance planning information and direct clinical care including employing more doctors, nurses, therapists and support staff and restoring much needed services such as mental health and therapy services.

    Clause 1(3) provides a primary legislative framework for integrating health and social care services (see further Clause 9 below).

    Clause 1(4)(a) declares the NHS to be a “non-economic service of general interest” which is aimed at exercising the UK’s competence to provide, commission and organise health services free from any constraints in the EU Treaties; and declaring the NHS to be “a service supplied in the exercise of governmental authority as a service supplied neither on a commercial basis, nor in competition with one or more suppliers” is aimed at excluding the operation of the World Trade Organization’s General Agreement on Trade in Services (Clause 1(4)(b)). This is supplemented by Clause 23, which is aimed at preventing the Transatlantic Trade and Investment Partnership (TTIP) and other international agreements affecting the NHS without the approval of Parliament, the Scottish Parliament, the National Assembly for Wales and the Northern Ireland Assembly.

    Clauses 2-5 contain provisions intended to frame restoration of the founding principles. These include particularly the duty of the Secretary of State to provide key services throughout England.

    Clause 6: re-integrating public health into the NHS and allowing delegation to local authorities, Health Boards, and to a re-constituted Public Health England and NHS England Public health functions were carved out of the NHS by sections 11 and 12 of the Health and Social Care Act, supplemented since by regulations. (The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013 (S.I. 2013/351), amended in 2015 (2015 No. 921).)  For example, the Secretary of State’s public health functions include vaccination, immunisation and screening, whilst services to promote healthy living, such as sexual health services, are the responsibility of both local authorities and the Secretary of State. A general power to provide services to prevent, diagnose and treat illness – previously only a function of the Secretary of State – was conferred on local authorities; a power that may be exercised as a result of the ‘devolution deals’ that will be implemented through secondary legislation under the Cities and Local Government Devolution Act 2016. Regulations now require local authorities to provide or make arrangements securing provision of open access sexual health services in their area by exercising the public health functions of the Secretary of State to make arrangements for contraceptive services; and by exercising their functions relating to preventing the spread of and treating sexually transmitted infections.

    Clause 6 re-integrates these functions into the NHS by returning them to the Secretary of State. These would then be delegated in accordance with regulations to local authorities and Health Boards in accordance with joint proposals that they would prepare under Clause 9; and to Public Health England and to NHS England reconstituted under Clause 7 as Special Health Authorities. The re-constituted NHS England’s functions would be performed via regional committees (Clause 8).

    The reason for this ‘re-integrate, delegate and propose’ approach is to acknowledge the view that public health and many community services should be delivered through and by or in conjunction with local authorities, whilst restoring these services as an integral part of the NHS. The fact that a service was designated as a ‘public health service’ and provided by a local authority would not be a basis for permitting charges.

    Clause 9: Health Boards would plan and deliver services, and be jointly responsible with local authorities for public health and integration of social care

    Health Boards would plan and deliver health services on behalf of the Secretary of State on the basis of bottom-up proposals prepared by local authorities with NHS England, clinical commissioning groups, NHS trusts and foundation trusts and approved by the Secretary of State. Patients, clinicians and other staff, voluntary organisations, trade unions and academics would be empowered to participate in preparing the proposals which would be finalised over two and a half years and would be required to minimise disruption in accordance with regulations.

    Having assisted in developing the proposals for Health Boards, clinical commissioning groups, NHS trusts and NHS foundation trusts would be replaced by the Health Boards (Clauses 13-15), and NHS re-constituted (Clause 7); and the regulator, Monitor, would be abolished (Clause 18).  Health Boards would also be responsible jointly with local authorities for bringing forward proposals in accordance with regulations for the planning and delivering public health services, and integrating health and social care services.

    Integration of health and social care requires careful consideration, and ideally its own primary legislation (not only regulations), as in Scotland. ( Public Bodies (Joint Working) (Scotland) Act 2014.)  The original distinction, which sought to balance the interests of hospitals and local authorities, was created by the NHS Act 1946 and the National Assistance Act 1948, and has been fairly described as “a fudge”. (Bridgen, P and Lewis, J. Elderly people and the boundary between health and social care 1946-91: whose responsibility? Nuffield Trust, 1999.)  The broad formal differentiation was between free nationally-provided health services and means-tested locally-provided social services. Over time this fudge has been exploited in various ways to enable a shift from NHS-funded to means-tested local authority care, using policies such as Care in the Community, closure of NHS long-stay beds and NHS day care provision, and introducing continuing care criteria which enabled the NHS to discontinue NHS care by time limiting care or redefining eligibility.

    There is much genuine concern that integration would lead to the provision of means-tested – and reduced – health services. Changes proposed by the Bill in the location of functions through delegation do not extend to changes in the power to charge, and health services must remain free. We support the principle of free publically provided social care, but this is an issue which ideally requires further primary legislation.

    Contracts with and/or grants to voluntary organisations would be permitted.

    Administration of medical, dental, ophthalmic and pharmaceutical services would also be the responsibility of the Health Boards (Clause 10).

    Clause 12: the Secretary of State would be given a limited power to give directions

    The Secretary of State would have a general but limited power to give directions to Health Boards and NHS England (and others). He or she would be obliged to have regard to the desirability, so far as consistent with the interests of the health service and relevant to the exercise of the power in all circumstances, of protecting and promoting the health of patients and the public, and of the bodies being free to exercise their functions in the manner that they consider best calculated to promote the NHS. Neither could the power be used to interfere with the professional independence of health service staff. Their professional autonomy and right to participate in scientific and public debate on matters relating to health and the needs of their patients would be guaranteed as happened prior to 1990.

    These directions must be contained in regulations, except in a genuine emergency, so that the exercise of executive power would be open to Parliamentary scrutiny and procedure. This provision is a modified version of the duties of autonomy (the hands – off clauses) introduced by the 2012 Health and Social Care Act and which would be abolished by Clause 2.

    Clause 16: Transferring staff should not result in large redundancy payments for technical job losses

    After consultations with trade unions, the Secretary of State would be required to make regulations to set out the terms and conditions applying to the transfer of staff. These include entitlement to redundancy payments, particularly for senior staff whose job loss is technical rather than real. The Bill will not affect the vast majority of staff engaged in clinical care, and those skilled in the essential tasks of commissioning will still be required.

    However, the inescapable down-side of the Bill is that there will be the unavoidable loss of a number of jobs directly connected with administering the market bureaucracy and promoting competition, such as managing commercial contracting and billing, as well as positions in finance, human resources and the marketing and press departments. This is particularly distressing because most of the jobs that would be lost would be those performed by people with clerical, accounting, media and similar skills, many of whom will not be particularly well paid. Their positions need to be addressed with the greatest sensitivity and flexibility, in close consultation and cooperation with trade unions, in bringing about a just transition. This should involve proactive opportunities for redeployment and re-skilling. Involvement of trade unions in the design of the Health Boards is also intended to help keep job losses to the absolute minimum.

    Clause 17: local accountability would be ensured by Community Health Councils

    Community Health Councils, with the duty of representing the interests of the local public in the health service, would be re-established. Since 1990, there has been a progressive downgrading of the systems and mechanisms for local accountability alongside growing complexity resulting from the increasing fragmentation of services and the different responsibilities of local authorities, CCGs, trusts, foundation trust boards, Monitor, NHS England and the Care Quality Commission for commissioning and providing NHS funded services. The Bill simplifies those structures and restores area responsibilities. Further consultation will be required to enhance representation of the public, patients, local authorities and trade unions in order to strengthen local accountability.

    Clause 19: preventing NHS foundation trusts from reducing services

    This Clause, whilst not technically necessary within the scheme of the Bill, highlights the need to prevent NHS foundation trusts reducing NHS services and disposing of assets.

    Until April 2013, Foundation Trusts were required to provide “mandatory services” listed in their authorisations. From April 2013 until March 2016, these services were listed as “Commissioner Requested Services” (CRS) under their licences. From April 2016, CRS will be re-designated, and Monitor has said that it expects services CRS – i.e., mandatory services until April 2013 – to be reduced.

    Buildings and equipment needed to deliver CRS must be identified on an Asset Register, with restrictions on their disposal. Reductions in services designated as CRS will give NHS foundation trusts greater freedom to dispose of them or use them for other purposes such as for private patients. This is particularly worrying in the context of the ability of NHS foundation trusts to obtain 49% of their income from outside the NHS.

    It is also very worrying and unacceptable that Monitor has stated that “[i]t is not intended that the [CRS asset] register should be a public document so the licensee can apply appropriate measures to ensure its confidentiality”. (The asset register and disposal of assets: guidance for providers of commissioner requested services. Monitor, April 2014.) These are NHS assets and the public must have the right to know what they are.

    Clause 20: national terms and conditions would apply

    This Clause is intended to ensure that the UK-wide ‘Agenda for Change’ system under the auspices of the non-statutory NHS Staff Council that has been in place since 2004 would apply to all staff employed by those who provide NHS services. Recognising the NHS as a national service and the desirability of staff being able to move freely between its constituent parts without suffering detriment would help ensure fairness, equity and equal value for NHS staff and good patient care. This Clause would not affect those staff not currently covered by the Agenda for Change system such as hospital doctors and dentists and very senior managers.

    We are aware that currently junior doctors have been told by the Secretary of State that a national contract will be imposed on them. If they do not agree to this, Foundation Trusts have the ability to and may decide to offer locally negotiated terms and conditions of service thereby introducing local pay bargaining on a foundation trust by foundation trust basis. Under these contracts junior doctors would be required to treat both NHS and private patients regardless of their own moral position on the NHS and its values. Junior doctors must be protected from exploitative employers and not be used to facilitate new inequalities.

    Clause 21 – Centralisation and reduction of PFI obligations

    The Private Finance Initiative (PFI) in the NHS has placed excessive financial burdens on NHS trusts and NHS foundation trusts which detrimentally affect their ability to deliver services to patients.

    Clause 21 would transfer financial obligations for the buildings and maintenance under NHS PFI agreements to the Treasury, which would have the duties to assess and publish the obligations, and to explain to Parliament how it proposed to reduce them. This would include publication of detailed information on interest rates, equity returns, refinancing deals and subcontracts, so that all public money would be auditable.

    Service contracts linked to PFI for ancillary and other services would not be renewed, as these services would be directly provided and managed in-house by Health Boards. Adjustments would need to be made to the resource allocation formulae as required to reflect differences between Boards, for example, in maintenance, capital charges and other obligations. (In time, the capital charging system should also be abolished.)

    Since the Bill was tabled, one potential limitation in the Clause as currently drafted that has been pointed out is whether it would ensure a return to the public sector of any property and other assets that PFI deals may have transferred to or vested in the private sector; this should be covered and can be addressed at the committee stage of the Bill. Concerns have been expressed that taking the debts away from trusts would render them a more attractive privatisation prospect; this cannot occur under the Bill as trusts will no longer exist and will be replaced by Health Boards.

    However, one clear limitation of the Clause is its applicability only to NHS PFI deals. We think there is merit in a new Bill to propose ending PFI deals across all sectors.

    Clause 22 – Abolition of new charges for migrants and overseas visitors

    Sections 38 and 39 of the Immigration Act 2014 enable the imposition of new charges on certain categories of persons.

    Section 38 empowers the Secretary of State by order to require certain migrants to pay a charge for NHS services, known formally as “an immigration health charge”, payable in advance when applying for leave to enter or remain in the UK or when applying for entry clearance. The Immigration (Health Charge) Order 2015 has now been made under this section, imposing since April 2015 an annual immigration health surcharge on people applying for a visa to enter the UK to work, study or join their family for more than six months, or to extend their visas for a limited time. EEA nationals are excluded. Australians and New Zealanders were also initially excluded, but the government has announced that they will be included from April 2016. Exemptions apply to about a dozen categories of person, such as those who are seeking asylum, are identified as a victim of human trafficking, and have suffered certain domestic violence). This charge is currently £200 per person per year, or £150 for students. Children and other dependants are also charged at these rates.

    Section 39 of the Act has the effect of extending the categories of persons who can be regarded as “overseas visitors” and so in the words of the Explanatory Notes to the Act, “ensuring they can potentially be charged for health services throughout the UK.” It provides that people needing leave to enter or remain and not having it, and people who have limited leave to enter or remain, are not to be treated as ordinarily resident. This includes people who have lived in the UK and paid taxes for several years. (These charges are now imposed under The National Health Service (Charges to Overseas Visitors) Regulations 2015.)

    These sections offend against the fundamental principles of the NHS. They are also potentially in violation of the United Kingdom’s long – standing international legal obligation under the International Covenant on Economic, Social and Cultural Rights to respect, protect and fulfil the right to health without discrimination, and so would be repealed.

    Moreover, the complexity of both sets of the 2015 Regulations makes determining the people who must pay or who do not have to pay a bureaucratic nightmare; and it is highly questionable whether the rules will raise more money than the costs of administration.

    Clause 24: allows flexibility in timing of implementation of the Bill

    The timescale for implementation is flexible over a twelve-month period, save for clause 1 which would come into effect on royal assent. Further flexibility is provided by allowing proposals for Health Boards to be prepared and finalised over two and a half years, and not replacing CCGs, NHS trusts and NHS foundation trusts until after they have assisted local authorities with those proposals.

    Clause 25: further amendments and repeals are necessary

    Many more amendments to and repeals of existing legislation than are mentioned in the Bill would be needed. It was originally proposed that these would be included in a parallel Act of consequential provisions, as was done in 2006. However, as that Act does not exist currently as a Bill, Clause 25 proposes that this would be done via regulations. These amendments would include, for example, abolition of Healthwatch.

    Professor Allyson Pollock and Peter Roderick, Queen Mary University of London.  The authors of this Briefing are the co-authors of the Bill.

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    The National Health Service in England is being dismantled. But you wouldn’t know it from listening to the radio or reading the newspapers. As so often, you have to look beyond the headlines about pressures on funding and the junior doctors’ dispute to find out what’s really going on. In 1990, Kenneth Clarke introduced an internal market into the NHS, following on from the ‘options for radical reform’ set out by Oliver Letwin and John Redwood in 1988. It had three pillars: GP fund-holding (delegating budgets to individual GP practices); the replacement of health authorities by ‘NHS trusts’ (self-governing accounting centres with borrowing powers, and their own finance, human resources and PR departments) and the splitting of purchasers from providers (the planning and delivery of services was to be undertaken by separate bodies, with the money flowing between them). In its 1997 manifesto, New Labour promised to ‘end the Tory internal market’. It did get rid of GP fund-holding (only to reintroduce it later as Practice Based Commissioning), but otherwise took the Tories’ ideology even further by introducing, in 2003, the market-oriented ‘NHS foundation trusts’ and their regulator, Monitor, as well as scaling up the Private Finance Initiative. Clarke was able to say on the sixtieth birthday of the NHS in 2008 that ‘in the late 1980s I would have said it is politically impossible to do what we are now doing.’

    Then came Andrew Lansley’s Health and Social Care Act 2012. No longer does the government – or anybody else – have a legal duty to provide hospital services throughout England. The hundred or so NHS trusts were all prospectively abolished, and a plan set out to transform them (if not to close them down or sell them off) into foundation trusts. The 150 or so foundation trusts had their private patient income cap abolished and were permitted to receive 49 per cent of their income from non-NHS sources. About 113 private providers have since been licensed by Monitor, and tendering for services has been made virtually compulsory. ‘Public health’ has been carved out of the NHS, and shared between local and central government. Meanwhile, Lansley, having stood down as an MP before the election in May, has been given a peerage and hired as a consultant to Bain & Company, which, according to its website, ‘helps leading healthcare companies work on the full spectrum of strategy, operations, organisation and mergers and acquisitions’. The appointment at Bain was signed off in July 2015 by Baroness Browning, who chairs the Advisory Committee on Business Appointments – herself a consultant to Cumberlege, Eden and Partners, ‘a specialist consultancy to the health sector’ led by Baroness Cumberlege. You couldn’t make it up.

    We are now at a crucial time in the wrecking process. Under the 2012 Act, clinical commissioning groups (CCGs) buy services from providers, especially from NHS foundation trusts. But the trusts are no longer obliged to provide particular services. Since April 2013, their services have fallen essentially into two categories: Commissioner Requested Services (CRS), and the rest. Services designated as CRS are subject to ‘continuity of service’ restrictions on the trust’s ability to cut or alter them. Monitor has the power to make the trust provide CRS services for a specified period, but cannot stop them being cut once that period expires. Trusts also need to have Monitor’s consent before they sell off buildings and equipment used to provide CRS. Services that are not CRS are not subject to these restrictions. So the more services that are not designated as CRS, the more freedom an NHS foundation trust has to do what it likes – so long as 51 per cent of its income comes from NHS services.

    When the 2012 Act was implemented, the services that foundation trusts had to provide under the previous rules were automatically designated CRS for three years, until April 2016, in their new licences. But Monitor said then that the planning and purchasing responsibilities of CCGs include ‘designating a range of services that local commissioners believe should continue to be provided locally if any individual provider is at risk of failing financially. We call these Commissioner Requested Services.’ CCGs are supposed to imagine that the foundation trusts they contract with could financially fail and to use a four-stage Designation Framework to come up with a new list of CRS by April 2016 on the basis of that imagining. ‘We expect the number of services that are designated as Commissioner Requested Services to decrease as a result’ of CCGs doing that, Monitor says, because if a trust goes bust it is expected to provide fewer services than it would otherwise. In other words, services that were mandatory until April 2013, and which for three years afterwards will have had some protection from ‘continuity of service’ conditions, are expected to decrease. This is an instance of applying powers supposed to ensure continuity in order to bring about discontinuity.

    Halting the demise of the NHS in England won’t happen without a new law. The National Health Service Bill, scheduled to have its second reading in the House of Commons on 11 March next year, would prevent the specific sleight of hand I have described from going ahead, as well as reversing 25 years of marketisation. It was tabled in June by the Green MP Caroline Lucas, and is supported by Labour (including Jeremy Corbyn and John McDonnell), as well as by Lib Dem, SNP and Plaid Cymru MPs and the British Medical Association.

    The question now is whether Labour under Corbyn will end its support for the market in the NHS and get behind the bill. The shadow health minister, Heidi Alexander, is still finding her feet, but the signs are not good. Unlike McDonnell, she has not brought in new political advisers. She is being advised by those who advised Andy Burnham, and judging from a meeting I had with her very recently New Labour thinking on the NHS is for now still very much in place. Ross McKibbin, writing in the LRB of 8 October, expected Corbyn’s leadership to end in tears. If that turns out to be the case, one reason may well be that Corbyn just wasn’t able to translate the support he has in the party into parliamentary backing.

    First published in the London Review of Books.

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    Back in 2011 there was thought to be a consensual political narrative on the NHS: no pointless reorganisations. However, David Cameron was soon persuaded by his old mentor Andrew Lansley to bring in market oriented reforms and, supported by the `orange book’ LibDems he did just that. However, the story of those reforms are not the focus of this article (see here for information on the reforms). The Health and Social Care Act of 2012, which was widely anticipated to be a disaster in waiting, has been a disaster in actuality.

    The re-organization that has followed the Act led to an extremely complex organizational and governance structure which has been distracting to the NHS, to say the least. It has taken place during a period of financial turmoil resulting from a fixed budget and the Quality Innovation Productivity and Prevention Programme (QIPP), which is itself linked to cost and efficiency savings in the order of £20billion over the next parliament.

    What’s more the leadership of commissioning has been stripped out at a time when major service change is needed. Things are so bad that even the King’s Fund (who were cautiously optimistic about its introduction at the time) have been critical of its outcomes. Lansley was reshuffled out of the job by September of 2012 and Jeremy Hunt was brought in to `steady the ship’. By 2014 it became clear that the Health and Social Care Act couldn’t be made to work so a face saving solution had to be found.

    The incoming Chief Executive of the NHS, Simon Stevens has subsequently been quietly sidelining the reforms and Jeremy Hunt, seemingly bereft of ideas himself has been supporting him. This has taken place quietly, because politically the Government cannot openly accept the failure of the reforms.

    The QIPP challenge has been redoubled and Stevens put forward a plan whereby if the Government funded £8bn a year then the NHS would reform to achieve the rest of the £20bn Government requirement. One of the first steps in the Stevens process was to create Units of Planning around each `health community’ in November of 2014. These new bodies (which have different names in different places) comprised of the CEO’s of all the NHS and local authority social services in each health community area and it has the job of planning health and social services and has the authority to make decisions on behalf of the individual health and social care organizations. It can make decisions that will be binding on all other health organizations. It’s very unwieldy and certainly has its own governance issues, but it’s there. This quietly sidelines the Health and Wellbeing Boards that are meant to be setting local strategy (though many of the same players are present).

    A second change Stevens has brought in is to bring about shared commissioning, between CCGs and Area NHS Teams,  of primary care services. In practice there is little shared about the commissioning. I chair a Primary Care Commissioning Committee of a CCG and we are being performance managed by NHS England. This creates a conflict of interest issue within the CCGs as the GP membership organisation is now responsible for commissioning GP and community health services. In short, the CCG is increasingly taking on the roles that the old Primary Care Trusts used to do and the freedom of clinical commissioning groups is being reigned in to an extent by the new developments.

    However, it’s the Five Year Forward View (FYFV) (and the separate devolution agenda) that sets out the new direction and, yes, this is essentially reforming the reforms. The NHS budget as a percentage of GDP is set to fall from its high of 9% in 2009 to under 7% of GDP by 2021. Against this, the projected demographic related demand points to a £30billion funding gap by 2021 and when compared the EU average looks miserly. In a real sense FYFW was the NHS’s response to this funding reality with the government putting up £8 billion a year and the NHS finding the rest via reforming services. These reform models have very recently been put into operation as Vanguard sites.

    The NHS has realized that the diversity and lack of system leadership brought about by the reforms is damaging to what really needs to be done to transform services and to increase efficiencies, which is to integrate health and social care services. The NHS itself is seen as too big to do this so responsibility is being devolved to local communities. The FYFV is essentially inspired by `the Valencia model’. In Valencia all health and social care services have been contracted to a single (private as it happens) provider who has taken on the management of all the services within the health system and it’s been heralded as a great success. The NHS is essentially adapting the model in its FYFV.

    It proposes a small number of models, but essentially two stand out. The first one is the Primary and Acute Care Systems  where one organization will take responsibility for all services within a defined health community. This could be one NHS organization or a new organization that comprises all the organizations within that community. It can be pictured as the local District General Hospital running everything from the Hospital itself to GP services to mental health services and community care services within a single organization.

    The other key model is the Multi-Specialty Provider Service. Here groups of GP practices would expand, bringing in community health services and hospital specialists within a single organization within an area to provide integrated out of hospital care. The Vanguards are set to devolve their capitation funding to the new organizations (which they can’t legally do at present) – which will make the CCGs themselves redundant. So I would argue that CCGs are on their way out.

    Indeed, the CCGs and Hospital Trusts were completely side-lined (and without consultation) when the whole NHS budget of Manchester was given to the Local Authority to manage from 2017 provided they elect a mayor. This was a surprise announcement by George Osborne earlier this year. I have heard from reliable sources that Simon Stevens wasn’t consulted when this decision was made. Cash strapped councils around the country are now clamoring to do the same and the Cities and Local Government Devolution Bill is currently wending its way through parliament to allow them to do just that.

    If funding within the NHS is challenging, it is many times worse in the social care sector and there are no additional funds heading in that direction. However, the prospect is raised of the Local Authorities being able to raid the NHS budget to fund social care, as Roy Lilley has argued. There is already experience of the Public Health Budget (devolved to Local Authorities from 2013) being raided to fund core Local Authority services as long as some health impact can be demonstrated. I’d expect to see this intensified once Councils have their hands on the whole of the local NHS budget for their area.

    Certainly more needs to be done to protect social care services and there is an impact on length of hospital stay if a social care package takes time to be put in place prior to discharge. There is also their role in prevention – for example, of falls etc amongst the elderly in the community. But this won’t be shared budgets. There will be a raiding the NHS budgets in ways I don’t think envisioned by Simon Stevens in the FYFW. Indeed, indications from the National CCG forums are that there is already discontent and in-fighting in the Manchester devolution over proposed restructuring and budget reallocations – though nothing has hit the press yet.

    However, the Stevens plan is running into other problems already. Hospital Trusts in particular are not performing as well as anticipated. The Kings Fund highlights that the Hospital sector has only made a 0.5% increase in productivity over the last 5 years. This won’t cut the mustard and threatens the projections within the FYFW. What’s more these productivity gains have been made on the back of massive overspending by Hospital Trusts – up to £822m million deficit in the last financial year which is 8 times that posted in the previous year. The plan is therefore already facing challenges. Moreover, on the ground, it’s seen as yet another plan that’s been imposed from above with short timeframes and minimal consultation. In short it’s not owned by the Trusts or the clinicians within them which will impact on the enthusiasm with which they are implemented. Even in the primary care sector lean working techniques which may allow GPs to see more patients in a day (and reduce the number of A&E attendances in a PWC projection) are sometimes viewed suspiciously by overworked GPs as wanting them to work harder for the same money. Magnify this right across a reform weary health sector and a what’s in it for me attitude may well arise especially as contracts and wages are themselves altered as part of the reforms.

    There are other elements of Health Policy over the first 100 days since the election that are also impacting on the NHS. The Government’s commitment to a 7 day a week NHS and to run 8am-to 8pm GP services bring the Department of Health head on with the consultants the GPs and the junior doctors as they try to renegotiate their contracts. It is not just vested interest here as the Clinicians don’t see these 7 day working proposals as evidence based. No government has yet managed to successfully bring in new health policies when all three branches of the medical profession are aligned against them. But the 7 day working proposals pale almost into insignificance though when set to the backdrop of the FYFW and the devolution agenda. What is interesting is that the Government has decided to fight all these battles at once rather than pick them off one at a time. Machiavelli would have been shocked.

    So there are definitely stormy waters ahead, but there isn’t a plan B. We live in an interesting time for health policy.

    This was first published by Discover Society




    The historical and social significance of the National Health Service (NHS)

    Social change is now so rapid that it is hard to make sense of it let alone learn from it. The opening sentence of this report is a measure of that. The first words: ‘The NHS may be the proudest achievement of our modern society’, while seeming to assert the value of the NHS, fail to reflect its full significance.

    Our pride in it is beyond doubt – no ‘may be’ about it.  It is impossible to overstate the importance of the NHS: It needs to be spelled out that the NHS is an evolutionary social development which has changed the lives of everyone in this country, “our country”, and peacefully effected change in “our” society so profound that we do not recognise it, or fully remember the circumstances in which it arose.

    For example, optimism in 1945 was less important than the clear-eyed determination to eradicate pre-war squalor, ignorance and fear: of sickness, of the cost of medical treatment and of the loss of livelihood that it entailed.

    Only those people now well into their seventies can remember that the sacrifices of war had not been left behind in 1945: despite rationing, food and fuel shortages were critical and the scars of the blitz still dominated urban landscapes. The pre-war housing crisis had been exacerbated by the devastation of the air raids. The country, “our country”, was bankrupt.

    It is against that background that the present condition of the NHS should be considered. It faces new problems and challenges, of course, but its condition cannot be described as critical, still less insupportable, considering that we have recently managed to meet the costs of two long-drawn-out wars (supported by both major political parties), and the bail-out of irresponsible bankers – all money down the drain.

    By contrast, the relatively small amounts needed to maintain and develop the NHS have beneficial effects, now as in the past, not just on the nation’s health, but on its prosperity, as the post-war experience shows. The NHS creates employment and expertise in many fields as well as health. It increases the disposable income of the general population by removing the burden of personally financed health care. (c.f. The USA). A healthier, longer-lived population is almost the least of the benefits of the NHS. We cannot afford to waver in our commitment to universal health care – publicly funded and provided.

    Tackling Changing Health Issues In A Changing World

     Our values haven’t changed, but our world has”. The two cannot be separated. Our values have changed, not in relation to the almost universally beloved NHS, but in response to changes in the world. The new challenges of longer life have still to be fully addressed at all levels. As for health problems “of our own making”, once problems reach the proportions cited in this report (60% of adults are overweight or obese, 30% misuse alcohol, 20% still smoke) they can no longer be seen solely as personal, but as public issues. (C. Wright Mills).

     It is beyond the remit of the NHS to deal with such complexity: it derives from the unchallenged pressures and persuasions of a commercialism and consumerism so insidious and pervasive that they fail to attract the critical analysis and counter measures that are needed even in relation to life-threatening issues like obesity and alcohol misuse.

    The Stevens Report perpetuates this myopia. It is the business of government to deal with this situation, not the NHS. Some may say that this sounds like a ‘Nanny State’ approach. In fact such measures would attack the infantilisation of everyone (by mass advertising and the mass media) which is breaking the back of the NHS. The propaganda lessons of the Second World War need to be redeployed in improving national health. Clever merchandising skills cannot be left solely in the hands of those selling us stuff that does us no good, simply for profit

    The task is too huge and important to be left to cash-strapped Local Government, elected mayors and an overburdened NHS: it is a major national issue for Central Government. If the NHS is to be able to cope with the challenges of longer life expectancy, a benefit for nearly all of us, the adult population needs to be enabled to behave like adults: the commercial interests profiting from unhealthy life-styles can only be challenged effectively by Central Government. It is now the case that local authorities have a statutory responsibility for improving health, but it is responsibility without power, the reverse of the case with the media.

    As in the 19th century, preventive health measures are more important than medicine in improving the nation’s health; then it was sewage and water supply; now it is tackling the problem of over-consumption: problems of affluence not effluence : just as damaging.

    The NHS – A healthy workforce promoting public health?

     The NHS is urged in the report to improve public health by promoting health in its workforce and making itself an exemplary employer. As well as setting a standard for all employers, it suggests that sickness absence would be reduced saving a great deal of money. But the report overlooks the unhealthy effects of long working hours and excessive shift work that are the result of 20,000 unfilled vacancies in the NHS. These cannot be unrelated to deteriorating pay and conditions of work as a result of pay freezes and cut-backs.  These government created conditions do not help to make the NHS an exemplary healthy employer. Better food on night duty etc. cannot solve the problem.

    Parallel to this, while emphasising the central role of the care sector in future health care, the report ignores the plight of care workers in the private sector on less than the minimum wage (150,000 according to King’s College Care Workforce Research Unit) dependent on food banks for a healthy diet, while 370,000 are on zero hours contracts in the name of ‘productivity’. (Norman Lamb, Care Minister). But has anyone ever met a ‘hard up’ private care home owner or shareholder? The report does not consider these issues in urging a better integrated Health and Social Care system.

    Funding Issues And Organisational Change

     The five year forward plan betrays the same lack of incisiveness (even blandness) throughout: an evasion of the nub of the problems the NHS is valiantly facing.

    While generously recognising the successes it has achieved against the odds (e.g. quoting improved cancer and heart disease outcomes; the Commonwealth Fund Report’s endorsement), the Stevens report fails to make explicit some of the main causes of the major funding challenges confronting it, e.g. the extortionate costs of the Private Finance Initiative (PFI), the implementation of the 2012 Health & Social Care Act and competitive tendering, still less to consider ways of dealing with those problems. The longer standing administrative costs of operating the ‘internal market’ within the NHS (the 1992 purchaser/provider split) are similarly ignored.

    An issue nowhere addressed in recent reports, including this one, is the costs the NHS has incurred as a result of out-sourcing ancillary services, the first wave of privatisation dating back to the 1980s. In every area of Britain, there are people who have made private fortunes delivering services that were previously in-house (cleaning, supplies etc. etc.). It is arguable that causal links can be made between that process and infection in hospitals. Agency nursing is another hugely costly means of dealing with staffing shortages related to erosion of pay and conditions for full-time nursing staff.

    These key financial drains are ignored. They make an enormous contribution to the financial predicament of the NHS, and they mark only the tip of the iceberg of the costs of more recent privatisation.

    The 2012 Health and Social Care Act has unleashed unprecedented, hugely expensive, unnecessary and unpopular changes on our comprehensive and publicly funded NHS. This was done by a coalition government after the dominant partner had promised no top-down reorganisation in its election manifesto; the junior partner had pledged commitment to the public NHS and its Party Conference voted against the Health and Social Care Act weeks before it colluded in passing that Act. No one outside Parliament voted for that legislation; It was an attack on democracy itself. The results go unmentioned in this Report.

    Health care, correctly delivered, is not and never can be a commercial undertaking. All diversion of tax funded resources (e.g. into profits, dividends, bonuses, etc) represents treatment denied and is directly harmful to patients and injurious to the common good. Recognition of this is the basis of public support for the NHS.

    While omitting mention of all these issues and developments, calculations of billions of pounds are bandied about in this report, figures plucked from the air with no firm link to reality. When the NHS was founded, the average wage was roughly £5 a week.  Inflation takes care of most debt. We can afford the NHS, especially if more effort were to be made to retrieve unpaid taxes – another factor omitted from this text. We spend the least on healthcare as a proportion of GDP of all G7 countries (as Stevens acknowledges) and have the second lowest number of hospital beds per capita in Europe. Ring-fencing a budget that doesn’t meet our needs is meaningless.

    In Conclusion

    Overall, the problem with this report is its failure to grasp the full social and economic significance of the NHS in all its complexity. The range of its activities is enormous: ‘from cradle to grave’ it attempts and largely succeeds in meeting the health needs of a large, complex, rapidly changing, post-industrial society as it invents and responds to new technology and evolving culture and life-styles. Depth analysis should encompass finance and economics, cultural factors, and management, especially of change and cross-boundary working, logistics ….the list is endless. Miraculously, the NHS deals with all these factors and it WORKS.

     The 5 year plan is unconvincing because it skims the surface of the issues it does address, and fails to raise the core questions. Perhaps the omissions are unsurprising, given Steven’s roles in the private sector over the previous two decades.

    The structure of the NHS prior to the Coalition Government’s Health and Social Care Act:

    NHS structure 2011

    Following the changes it now looks something like the diagram below ~ in the words of David Hunter, Professor of Health Policy and Management at Durham University (to whom we are grateful for the use of these slides) – “a complete dog’s breakfast, as the NHS performed well already, the changes increased bureaucracy and the case for competition, which the coalition increased, remains unproven”.

    NHS Structure 2012

    The Way Forward – An Alternative View

    The NHS is now becoming a key election issue as the public begin to realize what is at stake, and the media can no longer afford to turn the other way. Cameron has been forced to say he did not understand the Lansley Bill and its implications. A look at the second diagram explains his incomprehension.

    Direct assault on the NHS has always been politically impossible – better by far to introduce ‘reforms’ that sound as if they are rising to the challenge (even if the Prime Minister himself doesn’t understand them). Few will be taken in by Steven’s representation as the saviour of the NHS. Contrary to his assertion, experience with adult social care suggests that further contracting out of NHS services is likely to see exponential growth, unless stopped by the electorate. We must repeal the Health and Social Care Act, increase NHS funding to meet the growing need for health care, stop unsafe closure of services to save money, renegotiate crippling PFI debts and give a fair deal to NHS workers. If Simon Stevens’ heart is in the public sector can we hear him pledge support to these objectives?

    Concrete Proposals

    Whatever the legislative strategy of the incoming government after the 2015 General Election, its first goal must be to address the worst excesses of the 2012 Act: This can be done without reconfiguring the whole of the new system (a process that would be eye-wateringly expensive, utterly demoralising for NHS staff and damaging for patients).

    The following points are the simplest and most easily accomplished measures that will ensure the survival of the NHS as a publicly provided service:

    1. Responsibility for health care should revert to the Secretary of State.
    1. The 2013 regulations which restored the pressure on CCGs (rejected during the passage of the Bill) to put services out to tender should be cancelled. (Any Qualified Provider).
    1. The power and centrality of Monitor should be curtailed.
    1. GPs with private, commercial health company interests should be ineligible for membership of CCGs (or anything that replaces CCGs)
    1. The private, commercial health company interests of MPs and Peers should be publicised.
    1. The clause allowing NHS hospitals to raise up to 49% of their income from private care should be revoked and replaced by the previous arrangement.
    1. The impending US/EU Trade Agreement, the Transatlantic Trade and Investment Partnership (TTIP), should, at the very least, exempt Health Care from its measures (as is the case in Canada).
    1. Private Finance Initiatives (PFIs) should be swiftly renegotiated and measures adopted to reduce the excessive NHS debt that has resulted from them

    These suggestions would restore the essential nature of the NHS, and give a breathing space where longer term reforms could be allowed to develop in full consultation with service providers and users.

    The interest and concern that has been generated by the present government’s destructive policies can be harnessed to inform genuine public debate about the future of the NHS, involving lay and professional opinion, a process which could re-invigorate democracy itself.

    The NHS is the crowning achievement of British democracy, along with the defeat of Fascism. We must not now let it fall into the hands of anything-but-democratic multinational corporations.

     Defend our NHS York and Leeds Keep Our NHS Public

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    From the New Statesman..
    It emerged this morning that Labour MPs took the extraordinary step of blocking the publication of the Health Select Committee report into the NHS – because the conclusions backed up government reforms. I have just been handed details of this report, and it’s clear why Labour wanted it suppressed: it contradicts the party’s attack message. Here are the main points:

    No sweeping privatisations: there has been little increase in private sector providers since 2010.
    Nor has there been an extension of charges or top-ups during the current parliament, and that these are not planned.
    Less red tape: a general trend of declining administration costs in the NHS.
    No evidence that the Transatlantic Trade and Investment Partnership poses a threat to the NHS.

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    The Socialist Health Association was amongst the first to come out and resolutely oppose the Equity and Excellence Liberation nonsense that eventually became the Health & Social Care Act.  At the start of the long fight to oppose the Bill only a minority actively opposed it, led by Labour and the major trade unions; far too many who should have known better gave the Bill a muted welcome.

    The SHA was clear in its analysis that the aim of the Bill was to start the move of the NHS onto a regulated market basis following the path set by the Tories in respect of the utilities. Over time it would have ended the NHS as we know it. It was designed to favour greater entry of private providers in all parts: provision, and commissioning and back office support.  It made market competition (initially on price, which was dropped) the driving force for change in the NHS.  For the first time it brought compulsory competitive tendering for clinical services. The Bill’s apologists openly boasted that it removed political control over the NHS just as it removed accountability and direction.

    Most never believed the private sector would take over all, or even most, of NHS services but they could have been allowed to cherry pick the ‘profitable’ bits. They were expected to extend their entry into primary and community care and that has happened.

    It was a long fight and there were two opportunities to kill the Bill.  If the GPs had clearly stated they wanted no part of it (they did not want to be commissioners) the Bill was doomed – but the GPs did not say that and GP based organisations were amongst the supporters. Then much later on once some of the flaws became blindingly obvious the collective voice of the Royal Colleges could have fatally wounded the Bill – but after much prevarication the great and the good of the professions found they did not have strong enough objections.

    So we got the Act and, as the Kings Fund and others point out. we got an expensive and unnecessary reorganisation.

    The NHS in 2010 needed direction and a period of stability to try to deal with austerity as best it could.  Social care was in a mess.  What was needed was reform and investment in social care and a strong policy direction towards integration.  We got a bigger integrated mess.

    Arguments that the Act reduced management costs and improved quality don’t stand up to any serious analysis.  Similarly claims that the private sector is poised to take over all services are still also untrue.

    So where now?

    Well perhaps the last thing we need is another top down imposed reorganisation.  We also have to stop thinking of the NHS as somehow outside the rest of the public services, outside any democratic control with its own unique structures.  And we have to genuinely start to accept patients and communities as assets.

    So that does not mean no change, it means changes take place locally at different rates looking at the whole system not just the NHS.  It means bringing planning of services under democratic control and firmly within the family of public services.  It means allowing changes to take place without external interference from competition rules or regulations.  It means integration in all its meanings.  It means personalisation of services in all its meanings. It needs new solutions not a return to some mythically golden era.

    The Ten Year Plan announced by Labour moves in the right direction but until the funding issues are resolved it may be too ambitious even for a ten year horizon.

    Having won the battle of ideas and relegated competition and markets into a more sensible place the new big arguments are about making social care far more effective, making whole person care a reality and finding ways to bring stable funding.