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    Extracted from the Liberal Democrat manifesto.

    The NHS and social care services are in a state of crisis. The Conservatives have left them chronically under-funded, while need continues to grow and patient care suffers. Social care is facing a funding blackhole of £2 billion this year alone and more than a million older people are missing out on the care that they need.

    People are routinely left stranded in hospital after they finish their treatment because the follow up care and support they need is not available. Nearly two-thirds of NHS Trusts ended the last financial year in deficit.

    Yet Labour and Conservative politicians refuse to be honest with the public about the scale of the crisis or the tough decisions which are needed to protect these vital services.

    Liberal Democrats recognise that Britain’s health and social care services are our most treasured national institutions. Any party seeking to lead the country after this election should be prepared to take bold action to safeguard them. This isn’t about doing the easiest thing, it is about doing what is right and what is essential.

    Liberal Democrats will take five key steps in order to put our health and social care system back on a sustainable financial footing:

    1. An immediate 1p rise on the basic, higher and additional rates of Income Tax to raise £6 billion additional revenue which would be ringfenced to be spent only on NHS and social care services.
    2. Direct this additional investment to the following priority areas in the health and care system: social care, primary care (and other out-of-hospital care), mental health and public health. This represents the most efficient and effective way of spending these extra resources – ensuring they will have the greatest impact on the quality of care patients receive.
    3. In the longer term and as a replacement for the 1p Income Tax rise, commission the development of a dedicated Health and Care Tax on the basis of wide consultation, possibly based on a reform of National Insurance contributions, which will bring together spending on both services into a collective budget and sets out transparently, on people’s payslips, what we spend on them.
    4. Establish a cross-party health and social care convention, bringing together stakeholders from all political parties, patients groups, the public, and professionals from within the health and social care system to carry out a comprehensive review of the longer-term sustainability of the health and social care finances and workforce, and the practicalities of greater integration. We would invite the devolved administrations to be a part of this work.
    5. Introduce a statutory independent budget monitoring agency for health and care, similar to the Office for Budget Responsibility. This would report every three years on how much money the system needs to deliver safe and sustainable treatment and care, and how much is needed to meet the costs of projected increases in demand and any new initiatives – to ensure any changes in services are properly costed and affordable.

    Our longer-term objective will be to bring together NHS and social care into one seamless service – pooling budgets in every area by 2020 and developing integrated care organisations.

    Valuing the NHS and Social Care Workforce

    Our health and social care services’ greatest resource is their staff, working tirelessly under immense pressure. This Government has left them feeling embattled and undervalued.

    To support the NHS and social care workforce we will:

    • Guarantee the rights of all NHS and social care service staff who are EU nationals, the right to stay in the UK.
    • End the public sector pay freeze for NHS workers.
    • Reinstate student nurse bursaries.
    • Support innovation in how organisations can empower staff and patients, including learning from innovative social enterprises delivering community and mental health services.
    • Protect NHS whistle-blowers.

    GPs in particular have been put under considerable strain due to severe under-funding and neglect from the Conservatives, leaving many people waiting weeks to get appointments. GPs are the core of what the NHS is and they need support to ensure that the NHS is able to survive and thrive. We will:

    • Produce a national workforce strategy, ensuring that we never again experience a shortage in the numbers of GPs, hospital doctors, nurses and other professionals that the NHS needs.

    Equal Care for Mental Health

    In government, we fought tirelessly to reduce the historic inequality between the way physical and mental health are treated in the NHS and are proud of the strides forward we made. We legislated to give mental and physical health equality under the law. We introduced the first waiting time standards for access to treatment for mental health. We introduced the crisis care concordat which dramatically reduced the number of people who end up in police cells when they experience a mental health crisis; and we secured more money for children and young people’s mental health service. But we know that not enough resources reach front line services and that in the fight for parity of esteem, there is still a very long way to go. We will:

    • Ringfence funding from within the one penny Income Tax rise, to provide additional investment in mental health
    • Continue to roll out access and waiting time standards for children, young people and adults. This will include a guarantee that people will not wait more than six weeks for therapy for depression or anxiety, and no young person will wait more than two weeks for treatment when they experience a first episode of psychosis.
    • Increase access to clinically- and cost-effective talking therapies so that hundreds of thousands more people can receive this support.
    • Examine the case for introducing a dedicated service for children and young people based on the Australian ‘headspace’ model and building on many excellent Youth Information, Advice and Counselling Services.
    • Transform mental health support for pregnant women, new mothers and those who have experienced miscarriage or stillbirth, and help them get early care when needed.
    • Continue to promote and invest in the Frontline programme to fast-track exceptional graduates into children’s social work, as well as the Think Ahead scheme aimed at encouraging high-achieving graduates to pursue a career in mental health social work.
    • Ensure that no one in crisis is turned away, with new waiting time standards and better crisis care in Accident and Emergency, in the community and via phone lines. This will enable us to end the use of police cells for people facing a mental health crisis.
    • End out of area placements, ensuring those admitted to hospital for mental ill-health are able to be treated close to home.
    • Ensure that all frontline public service professionals, including in schools and universities, receive better training in mental health.
    • Roll out the Liaison and Diversion programme nationally, helping to identify people who have mental health problems, learning disabilities, substance misuse or other vulnerabilities when they first come into contact with the criminal justice system
    • Tackle stigma against mental ill-health, including by building on the good work done by organisations like Heads Together and changing the standard of proof in suicide conclusions in the Coroner’s Court.
    • Ensure that LGBT+ inclusive mental health services receive funding and support.

    Medical research is vital for developing new and better treatments. We will fight the threat Brexit poses to medical research funding. We support the principle that all medical trials using public facilities or resources should comply with the Open Trials standards, and that a fair proportion of all public funding for medical research should be focused on research into mental ill-health. We also favour the further development of open access academic journals.

    Home not Hospital: Joining up health and social care

    We need services that fit around people’s lives, not ones that force them to fit their lives around the care they need. This will become increasingly important as our population ages and the number of people living with long-term conditions continues to grow. It is also more cost-effective to support people to be able to live at home rather than endure lengthy stays in hospital. We must move away from a fragmented system to an integrated service with more joined-up care, and more personal budgets so that people can design services for their own individual needs. We believe this should happen from the bottom up, suiting the needs of local communities.

    The number of family carers is rising, including in the ‘sandwich generation’ who find themselves trying to care for their children and their parents at the same time. Carers are unsung heroes; we need to do more to help them. We will:

    • Finish the job of implementing a cap on the cost of social care, which the Conservatives have effectively abandoned.
    • Move towards single place-based budgets for health and social care by 2020, allowing local areas to decide how best to provide the full spectrum of care for their community.
    • Remodel the healthcare funding system to eliminate perverse incentives, by moving away from payments for activity and introducing tariffs that encourage joined-up services and promote improved outcomes for patients and better preventive care.
    • Ensure those who work in the social care sector are properly trained, with accessible career pathways, and are suitable to practice by introducing a statutory code of conduct backed up by a care workers’ suitability register.
    • Raise the amount people can earn before losing Carer’s Allowance from £110 to £150 a week, and reduce the number of hours’ care per week required to qualify.
    • Give the NHS a legal duty to identify carers and develop a Carer’s Passport scheme to inform carers of their NHS rights, such as flexible visiting hours and access to support.
    • Provide more choice at the end of life, and move towards free end-of-life social care, whether people spend their last days at home or in a hospice.
    • Evaluate the valuable work of hospices with a view to putting them on a more sustainable financial footing and allowing them to expand their services.

    Better access to community services

    Most people’s experience of the NHS is their local GP, or the nurses and support staff who visit them at home or work in community clinics. Access to care in GP surgeries and closer to home is better for patients and will also help reduce pressure on hospitals, Accident and Emergency departments and ambulances. We will:

    • Promote easier access to GPs, expanding evening and weekend opening to meet the needs of local patients, encouraging online, phone and Skype appointments, encouraging GPs to work together in federations, and allowing people more choice.
    • Provide national support to struggling GP practices, preventing mass practice closures
    • Support GPs to come together to collectively provide services such as out-of-normal-opening-hours appointments
    • Use innovation funding to promote GP-led multi-disciplinary health and care hubs, including mobile services to keep people out of hospital.
    • Encourage GPs and other community clinicians to work in disadvantaged areas through our Patient Premium – which would give incentive payments to clinicians.
    • Ensure that any changes to the way pharmacies are funded do not leave local areas without reasonable access to a community pharmacist.
    • Review the rules for exemption from prescription charges to ensure they are fair to those with long-term conditions and disabilities.

    Helping people stay healthy

    It is better for patients and for the NHS if we keep people healthy in the first place, rather than just waiting until people develop illnesses and come for treatment, but 40% of NHS spending is on diseases that are preventable. We need to do more to promote healthy eating and exercise, making people aware of the dangers of smoking and excessive consumption of alcohol and other drugs, and helping to improve mental health and wellbeing. We will:

    • Move towards a health and social care system that empowers and encourages people to better manage their own health and conditions and to live healthier lives.
    • Publish a National Wellbeing Strategy, which puts better health and wellbeing for all at the heart of government policy.
    • Implement the recommendations of the O’Neill report on antimicrobial resistance to ensure responsible prescribing and investment in diagnostics and innovation.
    • Make Pre-Exposure Prophylaxis (PrEP) for HIV prevention available on the NHS.
    • Support effective public awareness campaigns like Be Clear on Cancer and learn from what works when designing new health promotion campaigns to change behaviour.
    • Keep public health within local government, where it is effectively joined-up with preventive community services, and re-instate the funding cut from public health budgets by the Conservatives.
    • Develop a strategy to tackle childhood obesity including restricting the marketing of junk food to children, restricting TV advertising before the 9pm watershed, and closing loopholes in the sugary drinks tax.
    • Encourage the traffic light labelling system for food products and publication of information on calorie, fat, sugar and salt content in restaurants and takeaways.
    • Introduce mandatory targets on sugar reduction for food and drink producers.
    • Reduce smoking rates, introducing a levy on tobacco companies so they fairly contribute to the costs of health care and smoking cessation services.
    • Implement the recommendations of the Keogh review to regulate cosmetic surgery and ensure that the NHS is not picking up the tab for private malpractice.
    • Introduce minimum unit pricing for alcohol, subject to the final outcome of the legal challenge in Scotland.
    • Develop a public health campaign promoting the steps people can take to improve their own mental resilience – the wellbeing equivalent of the ‘Five a Day’ campaign.
    • Support good practice among employers in promoting wellbeing and ensure people with mental health problems get the help they need to stay in or find work, with a ‘Wellbeing Premium’ to reward employers who take clear action to measurably improve the health of their employees.

    We will develop a just settlement for haemophiliacs who were given contaminated blood, and for their families.

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    At just over £7 billion, health and social care makes up 46% of the Welsh Government’s expenditure. And over the fourth term of the National Assembly health controversy was never from the headlines. This was, in part, inflamed by the fabricated claims of David Cameron in the run up to the UK general election that Offa’s Dyke had become a line between life and death in the UK.

    Since then two independent reports, by the Nuffield Trust and the OECD, has exposed Cameron’s scurrilous claims. They showed there was no substantial difference between the various health services across the UK.

    Delivering quality public services is becoming ever more difficult across all of the UK at a time of austerity and a politically motivated assault to reduce the role of the state. And the problem is all the more difficult in Wales with its older, poorer, sicker and geographically dispersed population. Suprisingly none of the party manifestos have chosen to present their policies in this wider context. The hostile background for public services is taken as a given. And only the Greens have made any substantial point about the continuing health inequalities that the NHS in Wales faces.

    Across the six main contesting parties (Welsh Labour, Tories, Plaid Cymru, Lib Dems, Greens & UKIP) there is a fair level of common ground on what the main issues are with many parties proposing similar solutions. But there are also substantial points of difference where the “hearts and minds” battles will be fought.

    Welsh Labour has the double challenge of defending its record while still showing that it retains the vision and capacity to continue to be the main party of government. It takes comfort from the 2015 Wales National Survey which shows continuing levels of satisfaction with the Welsh NHS of over 90% for GP and hospital care. However in many parts of Wales, particularly in the west and north, service change and re-configuration has been controversial and not always welcome.

    Welsh Labour’s spend on health and social care is £172 more per capita than it is in England. While waiting times are longer in some areas in others, like cancer, care is generally better than the other side of Offa’s Dyke. And in Wales there continues to be no prescription or hospital parking charges. As well new legislation has been introduced to modernise social care and organ donation.

    In the earlier part of this Assembly term health & social care spending was constrained due to Westminster cut-backs and the need to meet other priorities such education. The Welsh Tories, strained “might and muscle” to contrast this with the spending on health in other parts of the UK. However Welsh Labour was always able to convincingly deflect some of this criticism onto the Conservatives and Welsh Liberal Democrats by highlighting of the overall reductions in its budget due to the Coalition and then Tory austerity programmes.

    Plaid Cymru had the double luxury of being in opposition with no record to defend. They were at liberty to piggy back on any issue of their choice and to make political capital wherever difficult or controversial decisions had to be made. But this could only get them so far if they were to position themselves as being a serious party of government rather than being a mere “party of protest”. It is only in the last few years that they have begun to formulate distinctive policies which could be open to scrutiny and debate. And some of these ideas are now part of its election manifesto.

    While Plaid insist that their policies have been subject to an independent economic validation, much of its programme is based on the expectation to be able to make £300m annual health savings by the end of its first term. This seems very speculative in view of the Tory Governments continuing commitment to austerity budgets. Without finding a lot of extra resources Plaid’s capacity to deliver on its most ambitious and attractive commitments will remain uncertain.

    No party is offering to re-introduce a market for health care in Wales with a number of them, though not the Tories, making explicit commitments to no privatisation. Indeed the Tories do use the language of the market when they speak of local health commissioners without clarifying the status of health and social care providers. So they are keeping their options open.

    In contrast to all other parties which are promising structural continuity and stability Plaid is offering a major NHS re-organisation. It promises to establish of a national board for hospital services. This will inevitably reduce local accountability for decisions on acute and hospital care which has been a lightning rod for much discontent about the Welsh NHS. It also proposes merging community health with social care in a “regional combined authority” derived from local authorities. It is not clear over what period of time this will take place but it will inevitably distract staff from service delivery. It will however, in line with UKIP and the Tories, bring an element of direct democracy to the operation of local health organisations.

    Plaid also promise to abolish domiciliary care charges for the elderly within two years and dementia care charges in their first term in government with the abolition of residential social care charge for the elderly in a second term. In contrast the Tories propose a top limit of £400 / week on residential home charges and a £100k asset disregard. From April 2015 Welsh Labour have introduced a £60 cap on domicilliary social care charges and it proposes to double the Welsh asset disregard to £50k.

    The Tory Manifesto is a almost a wish list. It proposes a number of ring fenced funds to deliver a range of services including a £100m cancer patients fund. In the last Assembly the Tories championed a cancer drug fund similar to one in England with little acknowledgement of the many problems and revisions of the English scheme. By way of contrast Welsh Labour is offering a new £80m “New Treatment Fund” which will target improving access for a wider range of illness to a more varied range therapies. The Tories also promise no more hospital closures as well as re-opening a number of clinical units and departments which have had to close for safety and sustainability reasons over recent years.

    No more than Plaid Cymru affordability is at the heart of Tory proposals and like Plaid their “big pot of gold” is in efficiency savings with the exception of re-introducing prescription charges. They remain wedded to the UK government’s austerity programme and also propose, in the event of income tax varying powers being devolved to Wales, to reduce income tax and freeze council tax. This will inevitably increase resource pressurs on our public services including the NHS.

    The Liberal Democrats have the laudable objective of seeking to create “an NHS that has time to care”. Like a number of other parties it proposes to get rid of the mandatory “15 minute” social care time slots and to increase access to GP services. This will not only involve improved provision but also a greater use of information technology.

    There is a recognition across the board that achieving these objectives will demand more staff. Plaid sets the bar very high with a pledge to recruit an extra 1,000 doctors and 5,000 nurses. Apart from the cost involved such increases would be a 3-4 fold increase in current rate of medical recruitment and an even higher increase for nurses. Welsh Labour is already spending £85m on health care professional training and education and it is pledged to increase nurse training places by a further 10%.

    There are many areas of shared concerns across the manifestos. All are agreed that there needs to be more integrated health and social care delivered in a community setting. While the details differ, all parties agree that there should be more community based and shared multidisciplinary units across Wales where integrated health and social care can be delivered and to where traditional hospital service, particularly in areas such as cancer, can be transferred.

    All parties also recognise the need to improve the quality of care for people with mental health problems. The stigma attached to these conditions need to be challenged. Greater emphasis needs to be given to the times that patients wait for care with increased timely access to “talking treatments”. There needs to be greater equity between adult and children’s mental health services.

    All parties give a clear commitment to a range of public health measures, many of which, in the words of the Green’s manifesto, seek to remove the barriers to good health. Indeed it would be fair to say that the Green give a high priority to high level public health issues while being less speciific about operational issues which take up much of the NHS debate in Wales. This is in contrast to the Tory approach which seems to be obliviouss to the public health implications of policies which are creating greater poverty and social division in our society.

    So at one level in these National Assembly elections there is a suprising level of consensus on what are the big challenges. And in many areas there is consensus on the broad principles on which responses should be based. But there is also a wide choice in many areas. And even more so there is “the test of credibility” on the capacity of each of the parties to deliver on what they promise.

    Tagged | Comments Off on What is on Offer for Health and Social Care in the Welsh Assembly Elections?

    Recently the Guardian ran a long article: How to save the NHS – by the people who work for it. It makes sobering reading for those of us who follow the politics of the NHS. It is compiled by a series of people working in different branches of the English NHS. The coalition government’s reforms get a predictable roasting. A colossal distraction dumped on an organisation that wasn’t ready. Outsourcing contracts that make things worse, not better.

    But something else comes through very clearly. The mounting stress that the NHS is under, and the frustration that its workers feel that problems are not being dealt with at root. Prime amongst the causes is the increasing number of elderly patients with multiple conditions. This was no surprise; it has been predicted for years. And yet almost nothing was done to prepare for it. Smart new hospitals were built on the assumption that patients were younger, fitter people who would pass through them quickly. And the management culture that prevents anybody from looking at problems in the round, and that tries to reduce problems into mindless targets – well that goes back to age-old institutional divisions, and aggravated by more recent managerialism. In some ways there are too many managers, enforcing mindless targets; in others there are not enough – facilitating the kind of re-engineering and reallocation of resources that would reduce waste and solve real problems.

    What lesson do I draw from this? The NHS has to change. It needs to find new ways of working, and adapt its facilities accordingly. Simply sacking the managers and letting the patient-facing workers get on with it would solve nothing. It doubtless needs more taxpayer funding in the mix – but waste is rife and there are limits to extra taxpayer funding. None of the political parties (not even the minor ones) suggest raising any of the three main taxes: Income Tax, NIC or VAT, unless rises can be targeted to a small minority of wealthier taxpayers. There are clear limits to how far this kind of somebody-else’s-money approach is feasible, but no political appetite to raise general taxation. The NHS must either reform itself or collapse under the weight of extra demand, with the better-off turning to the private sector, and becoming even less willing to see their taxes used for free healthcare. This has already happened in dentistry.

    It’s quite easy to see elements of the reform process. Integration of social care; more emphasis on mental health and geriatrics; better public health; continued heat on the drug companies. Others will be less obvious, but will emerge from analysing problems with an open mind. But all large organisations have heavily inbuilt inertia. Reform will involve pain. Some services will be cut; many people will have their jobs changed. Such change requires strong leadership, who can persuade the persuadable, and override the suspicious. And here we must confront some awkward facts. First leadership is not going to come from politicians; they simply don’t have the knowledge or credibility. Second that leadership is going to come mostly at a local level. What needs to be done is to rework the tangled elements of many services by dealing with the people involved directly, face-to-face, and finding what works in each local context. What will not work is to call in an expensive set of management consultants to put together an over-engineered but nevertheless superficial national plan under a grand-sounding name (“World Class Integration” anybody?). Or arbitrary ideas, like pushing people out of hospitals and into the community, which may work as theoretical propositions, but are beset by a million practical problems locally. And yet this is the typical approach of initiatives originating from the Department of Health. Too many grand know-it-all experts; and too much use of management consultants.

    But if politicians can’t lead reform directly, they still have to give political cover for reform programmes that might take 10 years or more to work through properly. To do that the management of the NHS must be depoliticised. The politicians should set the broad strategic direction, supply the funding, and be part of a process of local scrutiny. But otherwise they should step back and defend the system. This sort of consensus building is not impossible. It has been achieved for old-age pensions, for example.

    And yet many campaigners who want to “Save” the NHS seem to want to do the opposite – to politicise the NHS so far that reform becomes a practical impossibility. They create alarm about cuts to local services, privatization, postcode lotteries and TTIP. They seem more motivated by anger, and fixated on political totems, than on trying to promote progress within the NHS.

    Two wrongs don’t make a right. The coalition was wrong to dump such an ambitious a top-down reform on the NHS. It was wrong to pursue its reforms in such a politically arrogant way. The government should have taken Labour’s imperfect structures and evolved them; piloting different reforms locally to reduce bureaucracy, engage clinicians and achieve better integration. Progress would have been slow at first, but surer. And it would have lowered the political temperature. But it would be wrong again to tear all these reforms up. Surely some changes are needed – especially over the competition and outsourcing. What is worth keeping about the reform is the way it places a distance between the politicians and the people running the service. This framework may not be perfect, but surely it is best to move forward through evolution, not another reorganisation.

    The problem with Labour’s campaign to “weaponize” the NHS and turn it into a key political battleground, and its politically motivated and gimmicky manifesto pledges, is that it distracts from the real work that is needed: devolved reforms led by clinicians. We could have yet another 2 year hiatus. The NHS can ill-afford that.

    Matthew Green is a member of the London Liberal Democrats executive, and has been part of Liberal Democrat policy panels on wellbeing and the economy. The views expressed above are his own. He blogs at


    Integration and flexibility: those appear to be the watchwords of a new consensus that is emerging about the future of the NHS.

    They were the key words that appeared in the Lib Dem public services policy in 2014.  They are also the words that Andy Burnham uses to describe his commitment to a new NHS.  They are also the words used by Lib Dem health minister Norman Lamb to describe his policy at the Department of Health.

    Lamb’s approach has meant in practice a major handbrake turn for the policies pursued by Conservative ministers at the beginning of the coalition. They are also a departure from the inflexible tramlines of NHS thinking laid down by successive Labour ministers during the Blair-Brown years, which emphasised centralised targets, privatised suppliers and PFI contracts.

    I am not a spokesman for the Lib Dems.  I am not even a member of their policy committee, though I was member of the commission which wrote the party’s new public services policy.

    The new policy of integration is being done from the bottom up, partly because nobody knows what model will work best – even if one answer means anything in a diverse nation like ours, where different models work for different people.  Bottom up experiment and innovation makes sense to Lib Dems because centralised re-organisations, as we know to our cost, are disruptive and alienating.

    Integration is also only possible when devolution of power happens, as it is in Manchester and Sheffield.  Because it is only when we can put together budgets across public services that we have any hope of providing the kind of flexible, human-scale and above all effective system that the NHS needs if it is going to be sustainable.

    Where I would take issue with Andy Burnham is as follows:

    1. Burnham gargles with the word ‘flexibility’ at the same time as he proposes a whole raft of new targets and rights for people – including the right to get a GP appointment within 48 hours, without apparently learning what happened last time this happened – and apparently without realising how it is the centralised targets imposed by New Labour that has caused much of the inflexibility that now makes the system as expensive as it now is.
    1. It isn’t good enough to pretend that fewer, bigger providers will be enough to integrate the system. There is no point in integration if it drives out diversity.  If we are going to tackle chronic conditions – which the NHS does so badly at the moment – we will need a diversity of suppliers, some of which are bound to be from outside the NHS.  Diversity is vital if the NHS is ever going to support a diverse population.  Not everyone is the same, and it has been the major error by Labour over previous generations that has shaped our services as if they were.
    1. Burnham’s concentration on the Health and Social Care Act 2012 misses the point about it. For one thing, he forgets to mention that it wasn’t passed as intended.  The original draft was blocked by the Lib Dems and what remained simply accelerated the contracting out of services that had begun under Labour (but added in some safeguards to prevent conflicts of interest and to rule out competition on price).  For another thing, there are elements of the new law that must be kept, particularly the involvement of local government in healthcare, if it is ever going to be integrated with social care.

    I was asked to write this article to examine whether there was any prospect of co-operation between Labour and the Lib Dems over the NHS. It is a peculiar question with a paradoxical answer, made more peculiar by the contradictions at the heart of Labour’s current position on the NHS.

    On one hand, the Labour record on the NHS stands in the way of co-operation.  Labour may not have invented PFI contracts, currently extracting resources for the NHS for large new hospitals which may or may not be effective at that size, but they turbo-charged them.  They also didn’t invent centralised targets, but they drove them forward and expanded their power throughout the Blair and Brown years until they had sapped the NHS of its initiative, and shifted resources, energy and imagination into innovative ways of meeting the targets rather than treating patients.

    On the other hand, there is clearly room for co-operation given the two parties’ shared commitment to the idea of the NHS – enacted by Bevan (Labour) and imagined by Beveridge (Liberal) – free at the point of use, managed in the public interest, and a shared commitment to reach beyond that to go beyond its role now of tackling symptoms and begin to tackle the causes of ill-health too.

    There is a potential joint endeavour here – and to deliver the twin Lib Dem priorities of support for mental health and support for carers. What stands in the way is not policy, but it is the habit the Labour party has of flip-flopping on its position on health according to whether they are in government or opposition.  The two stances bear very little comparison.

    But if they can stick to it after the election – the new era might just come to fruition, and it’s called flexibility and integration.

    David Boyle is a former member of the Lib Dem federal policy committee and the independent reviewer for the government’s Barriers to Choice Review.

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    Jeremy Hunt, Andy Burnham, Norman Lamb and Julia Reid.
    King’s Fund organised the debate chaired by the BBC’s Sarah Montague.

    Comments Off on The NHS debate

    Liberal Democrats recognise that good health is vital for everyone’s quality of life and that the government has a responsibility to both help people stay healthy, and to ensure that there is provision of high quality care for if and when they fall ill.

    In government we have protected the NHS budget in real terms but we recognise that in the future this will not be enough in order to ensure the provision of high quality health care for all. The NHS must be both protected and improved; we must focus more on preventing illness and disease instead of just treating problems when they arise and as the population continues to age, and long term conditions become more prevalent this shift will become more and more necessary as pressure builds. This is why we are committed to ensuring that the NHS budget will rise by at least inflation in the next parliament. The importance of getting NHS funding right cannot be overstated and in recognition of that in 2015 we would commission a Fundamental Review of NHS finances to assess the pressures and the scope for efficiencies. This would enable us to set multi-year budgets that will give the stability necessary to maintain and improve the standard of NHS services, whilst ensuring that access is based on need, not on ability to pay, and that the NHS remains free at the point of delivery. Pressure on NHS finances would be alleviated by tackling the causes of ill health before problems develop, to that end we would do more to promote healthy eating and exercise and raise awareness of the dangers of smoking, excessive alcohol consumption and other drugs.  We would also invest in research and set ambitious goals to improve outcomes for the most serious diseases like cancer and dementia

    We have also started working towards ending the disparity in the quality of healthcare an individual receives dependent on whether their condition is physical or mental. Whilst our understanding of effective treatment is increasing still, too often, mental health patients are treated to a second class service. We have improved access to talking therapies but we want to go much further by ensuring that mental health patients are treated just as fast as those with physical health problems. By improving access and waiting time standards as well as establishing a world leading mental health research fund we would deliver genuine party of esteem between mental and physical health. We would improve the mental health of children by promoting wellbeing throughout schools and ensuring that they can access the services they need as soon as a mental health problem develops.

    We also need to make sure that health services fit around people’s lives rather than the other way round; an integrated rather than fragmented service that suits the need of local communities. To aid this process we would reform the NHS payment system to encourage better integration of hospital and community care services, including the pooling of local budgets. This would allow for more use of personal budgets for people who want them and better access to services to help people get care closer to home. We would also encourage GP’s to improve access and availability of appointments, in and out of hours, as well as to work in more disadvantaged areas.

    With these commitments Liberal Democrats know that we would be taking a big step towards truly delivering health and wellbeing for all.


    Delivering healthcare fit for a liberal democracy in the 21st Century.

    This policy document was prepared for a Liberal Democrat Policy Working Group after wide consultation among healthcare professionals and health policy experts. It has wide support within the Liberal Democrat Party but has not been endorsed by the Party or the Party Leadership.

    Liberal Democrat logo

    Problems the NHS is facing:

    • Doctors and nurses are burdened with ever increasing bureaucracy
    • Targets have led to box ticking rather than taking care of patients
    • Services are less and less joined up from the patients’ point of view
    • There is less and less money to spend

    All these issues put pressure on staff to deliver according to contracts, targets and statistics.

    As a result staff morale is plummeting and the quality of care is seriously under threat.

    We propose to:

    • return the focus to care of the patient
    • give Local Health Boards the power to ensure care is integrated and co-ordinated
    • give genuine choice to patients and their GPs
    • make savings in bureaucracy amounting to 25% of projected NHS expenditure.

    The National Health Service in the United Kingdom owes its existence to the vision courage and determination of three great politicians. David Lloyd George, prepared the ground with his 1911 National Insurance Act, and William Beveridge, who made the intellectual case for its creation. It was introduced in 1948 thanks to the determination and courage of the Minister of Health Aneurin Bevan. At a stroke, the United Kingdom provided health care for everyone, making it one of the first countries to do so. In contrast, some of its continental neighbours, which clung to their inherited social insurance systems, took much longer to achieve universal coverage, and the USA still fails to provide universal care.

    The beauty of the system designed by Beveridge was its simplicity. Funded by taxation, there was no need to create separate, costly, and complex mechanisms to collect the money to pay for it. Access to all meant that there was no need to create an expensive, intrusive, and discriminatory system to check entitlement to care. Public sector provision reduced the scope for opportunistic behaviour by those who would seek to profit from illness, while encouraging a strong public sector ethos characterised by commitment and altruism.  Indeed, although he could not have realised it, Beveridge’s thinking was far ahead of its time. It was only many years later that economics Nobel laureates would provide the theoretical and empirical basis for his ideas, such as Kenneth Arrow who, in 1963, showed why markets in health care fail and Oliver Williamson who showed the problems that arise in markets where the product cannot easily be specified and there is scope for opportunism (features that characterise much of health care).

    The result was a health system that was widely admired internationally and has been emulated by others. When Southern European countries, such as Spain, Italy and Portugal saw the need to reform their health systems in the 1980s they looked to the United Kingdom and other systems that employed a similar model[i]. Their decisions have been justified; the UK, along with these similar systems, consistently rank very highly in international comparisons such as those conducted by the New York based Commonwealth Fund,[ii] [iii] [iv] and the OECD.[v] [vi]

    OECD ranking of health systems

    This does not mean that the NHS does not need to change. It does, as does every health system. The NHS faces demands caused by more expensive technology and drugs (the main driver of rising costs), ageing populations (who are not necessarily more expensive but who do have more complex problems), and changing expectations (although also often exaggerated). Nor has the NHS been perfect; it has been criticised for too much centralisation and some high profile lapses in quality of care. Yet those who call for constant change seem unaware that it has been changing. Indeed, it has been among the most successful health systems in responding to the growing challenges of chronic diseases, with outcomes in diabetes among the best in the world, and its response to the emergence of HIV/AIDS is widely admired. The UK was also in the forefront, internationally, in the move to day surgery. But there is always more to do.

    And the NHS could have done better in some ways. It has had an historic problem with waiting lists, though these were largely eliminated between 2000 and 2010. In some cases services were less responsive to the expectations of patients than they should have been. Cancer outcomes, which depended on access to very expensive equipment and specialist expertise, lagged behind those in many other countries, as did some causes of death amenable to timely and effective care. Of course there were a number of reasons but perhaps the most important was that the NHS had been run on the cheap. Although the intrinsic efficiency of a tax-based, publicly delivered system meant that it was cheaper than more market-oriented systems, successive governments were unwilling to devote the resources it needed. Spending was consistently well below the European Union average as a share of GDP[vii] whilst retaining 100% public coverage. Indeed, once spending increased, in 1999, waiting lists fell, outcomes improved, and satisfaction among the public reached an all time high.

    International spending on health

    Despite having performance that was good by international comparisons the last thirty years has seen repeated reorganisations in the pursuit of greater efficiency. This might be acceptable had those reorganisations been based on evidence that they would make things better. But they weren’t. Running through them was a quest to encourage a plurality of providers using market competition, despite the mass of evidence of market failure in healthcare particularly in terms of reducing health equity and quality[viii] [ix].  Worse, many of the changes were introduced without an electoral mandate and without consultation of those who work in the system and have undermined the very public service ethos which has underpinned the NHS.

    Paradoxically, these changes have made it more difficult for the NHS to adapt to the very pressures they were meant to address. We know that the existing pattern of hospital provision needs to change. Some hospital facilities are in the wrong place, and with increasing sub-specialisation and the importance of consultants of different specialties having close contact and support from other specialties some reconfiguration is essential. Quality healthcare increasingly needs to be delivered from larger units. The very nature of a competitive market promotes duplication and fragmentation. To have competition between providers there must be more than one provider. Opening the market to ‘any qualified provider’ is designed to increase the number of providers. As each provider is autonomous they will choose what services they offer. A provider cannot be forced to deliver a service that they are unwilling or incompetent to provide. Fragmentation is incompatible with either efficiency or high quality. The meaning of ‘local’ in terms of healthcare provision is changing. Yet it is now becoming impossible to bring this change about in a sensible way. Take the proposed downgrading of Lewisham Hospital, a decision that made no sense and was overturned in the courts, with the judgement suggesting that the Secretary of State failed to understand the legislation his predecessor had introduced. Or Poole and Bournemouth, where almost everyone agrees that two hospitals should merge, except for the competition authorities charged with creating a market where none should exist. Local services need to be under local control and aggregated to a level more appropriate to the provision of a full range of integrated services. Only by doing this can we deliver integrated care both to individuals and to  local populations. (See proposal 1.)

    Using targets and contracts in the pursuit of efficiency takes the focus off the needs of the patient. In effect the system may become more efficient at delivering something that is not fit for purpose: it is not what the patient wants or needs. This creates a great increase in activity, but it is non-productive activity; described by John Seddon as ‘failure demand’.[x]

    Even worse, the huge transaction costs involved in creating an artificial market are sucking resources out of the NHS at a time of unprecedented pressure on government resources.

    NHS administration costs prior to the introduction of the internal market were 5%.[xi] After 1981 and the introduction of the internal market administrative costs soared; in 1997 they stood at about 12% and by 2010 costs had risen to 14%.

    NHS Management costs

    Between 2000 and 2010, as the Labour government placed more and more contracts with external providers, the number of NHS managers increased twice as fast as the number of doctors[xii] and five times the number of nurses[xiii].

    Both Conservative and Liberal Democrat Parties criticised the increase in NHS management costs under Labour and the current government claimed that the Lansley reforms would reduce management costs. Unfortunately that promise is most unlikely to be delivered[xiv]. Far from reducing the number of NHS organisations the number has increased not least because PCTs were replaced by CCGs which have a smaller geographical coverage. This will increase costs as economies of scale in commissioning could be lost.[xv] All the evidence suggests that increasing market competition and complexity will increase administration and management costs.[xvi] This increase in cost is accompanied by no increase in choice, quality or equity.

    In the US In 1999, administrative spending consumed at least 31.0% of health spending[xviii] [xix]. Billing alone cost up to 13%. It is worth noting that the billing costs in healthcare providers are ten times the average of all businesses in the US.[xx] There is an inherent complexity to the business of delivering healthcare.Administrative costs in countries with a purchaser/provider split and a mix of state and private insurance tend to be higher still, purchaser costs alone typically amounting to around 20%[xvii] .

    In March 2010 the Health Committee report on Commissioning concluded that ‘the purchaser/provider split may need to be abolished.’[xi] (See proposal 9.)

    Governments have frequently claimed that the NHS did not need more money, but that it need to use what it had more efficiently. We understand that we cannot have something for nothing. The NHS must be properly resourced and seek maximum efficiency. OECD countries typically spend 8% of GDP on healthcare. The Conservative government between 1980 and 1989 presided over a decline in net UK spend on health from 5% to 4.5% of GDP at the same time as requiring frequent costly management changes and increased bureaucracy. The Labour governments between 1997 and 2010 increased spend on the NHS from 5.3% to 8.5%. The spend was concentrated on revenue and minor capital. By 2010 waiting lists were low and public satisfaction in the NHS was at an all-time high. Unfortunately the Blair/Brown partnership has saddled the NHS with crippling debts though numerous ill-conceived Private Finance Initiative (PFI) schemes.[xxi] [xxii] [xxiii] In the mistaken belief that debts incurred under PFI schemes would not appear as government debt, hospitals were forced to undertake building schemes financed by complex long-term contracts. At a time when the government could borrow at 6%, PFI schemes were committed to paying around 16% and also had to take on long-term service-contracts for services that may well be irrelevant well within the life of the contract. Hospitals need to be relieved of the crippling repayments required by PFI schemes. (See proposal 10.)

    And it is not even clear that any of this will work in the way that it was sold to the public. The current system was meant to place GPs in the driving seat of the NHS. Yet, once a few of them had been persuaded to support this idea so as to get the Bill into law, they find themselves under sustained attack, portrayed in government briefings as the problem, not the solution. Inevitably, many are walking away, leaving the commissioning process to be swallowed up by the soon to be privatised Commissioning Support Units. These units bring additional cost burdens to the NHS and as private companies have no democratic accountability. (See proposal 13.)

    It was also claimed that the reforms would increase patient choice, allowing them to decide where they would like to be referred for treatment. In reality, an increasing number of Commissioning Groups are not even giving them the choice to have treatment at all, refusing referrals for conditions such as hernia, varicose veins and hip or knee operations. The only choice patients have then is to pay for treatment or to go without. (See proposal 11.)

    A further threat to the introduction of integrated care arises from the breakdown in professional co-operation that used to exist between and within specialties. International studies of similar reforms have shown a decrease in health care equity.8 (See also Francis report 29.)

    Public Health is another area of concern. Despite claims to strengthen Public Health[xxiv] [xxv] the result has been fragmentation and confusion. Parts of Public Health are now with CCGs, parts with Local Authorities, parts with Public Health England (a new agency within the Department of Health). There are more senior public health professionals working in hospital trusts than in Local Authorities and CCGS combined[xxvi]. In addition the Secretary of State has new responsibilities for Public Health. There must be concerns about the ability of such a fragmented organisation to co-ordinate planning for whole populations or to the control of infections such as TB. The UK has almost the highest incidence of TB in Western Europe.[xxvii] (See proposal 7.)

    It is a matter of great concern that the pursuit of market competition is militating against the delivery of good quality integrated care. At a time of ageing populations and multiple pathologies delivering integrated care is increasingly important and rightly recognised as being so. Market competition acts as a barrier to the rapid dissemination of good practice, impedes the free flow of information about patients from one provider to another and inhibits the co-operation of specialists across providers. Sir David Nicholson, chief executive of NHS England has said that the new competition rules are a barrier to delivering quality in the NHS[xxviii]. The Torbay model of integrated health and social care – which is held up as an example of best practice –  has been referred to Monitor as potentially anti-competitive. Would-be private providers are able to invoke the law to obstruct good practice. The appalling lapses of care seen at Stafford were in large part due to the misguided pursuit of business models demanding a balance between income and expenditure. The Francis report draws attention to the way in which competition had eroded collegiality and trust[xxix].

    The fragmented NHS driven by market competition is also a barrier to fairness and equity. There has always been a tendency for areas of high population density to benefit from a wider range and greater supply of services. There is evidence that increasing use of competition is increasing levels of inequality.8 25 Experience of other privatised services has also show an increased concentration of services in centres of high population at the expense of more rural parts of the country.

    These concerns, to deliver a high quality, integrated, equitable and efficient healthcare service all drive our current proposals.


    Our proposals for the NHS are straightforward, evidence-based and simple. They build on the best features of the current NHS and embrace long-standing principles of equity, localism and choice.

    1. We will bring together all the NHS Trusts and Foundation Trusts in a locality under the management of a Local Health Board. This will create a single organisation that delivers integrated care covering hospital, community and mental health care.
    2. Health and Well-being Boards (H&WBB) have local representation but no power to deliver. Clinical commissioning Groups (CCG) bring clinical expertise but have no democratic accountability. We would establish Local Health Boards each covering a population of around 1,000,000. Initially these Local Health Boards would draw their membership from the current H&WBBs and CCGs. Over a period of five years Local Health Boards would move towards a more directly democratic composition.
    3. The assets of all NHS Trusts and Foundation Trusts would transfer to the Local Health Board for that area thereby allowing local services to be developed and delivered  in the way most suitable to that locality.
    4. Local Health Boards would directly manage the contracts for local pharmacies, opticians, dentists and GPs[xxx]. In APMS[xxxi] practices, GPs and all staff would be directly managed by the Local Health Board.
    5. Local Health Boards would be grouped into regions and would be overseen by a Regional Health Authority who would distribute resources to each Local Health Board based on a capitation allowance for the whole population of that locality.
    6. Regional Health Authorities would in effect combine some of the functions of the current regional offices of NHS England and specialised commissioning hubs run by NHS England. Specialist Services that cannot be safely or appropriately delivered for a population of around 1,000,000 would be provided by the Regional Health Authority who would arrange for such services to be delivered from within one or more of the hospitals in that region. The number of Regional Health Authorities is yet to be agreed. NHS England has four regions, 10 specialised commissioning hubs and twenty-seven Areas. There are six BIS offices, and there used to be nine regions in the NHS.
    7. A supra-regional specialty committee would be set up nationally with members appointed from each of the Regional Health Authorities. This committee would agree arrangements for the provision of those services that are so rare that they can only be provided or planned for on a national basis.
    8. We shall consult more widely on the further integration of Public Health, but as a first step local Directors of Public Health would become members of the Local Health Board.
    9. We would abolish the market in healthcare within the NHS thereby removing the need for tendering, commissioning and contracting, monitoring contracts, invoicing and paying of bills. This is expected to save around 25% of expenditure.
    10. All PFI debts held by NHS Trusts would be pooled and held nationally in line with recent Treasury guidance[xxxii]. This would remove the distortion between different hospital trusts and make it easier to refinance, re-negotiate or pay off the debts.
    11. Patients would be given the choice, through their GP, of being referred to any consultant in the country. As no money changes hands there would be no need for complex contracting arrangements and whether or not the referral and treatment goes ahead would depend solely on the capacity of the receiving hospital to take on the work.
    12. These proposals would address the greatest single threat to the ability of the NHS to deliver a high quality and affordable service to all. But they do not address all the problems in our current complex and fragmented care services. There remain barriers and boundaries between health and social care and between hospital and community services.   These barriers make for inefficiency in the service and frequently prevent the patient or client from receiving the care that they need. A major block to the integration of health and social care has been the fact that health care is provided free of charge, whereas social care is means tested. The implementation of the proposals of the Dilnot commission would largely address this issue. We would, therefore set up a commission to explore a system redesign to enable community care, social care and hospital care to be provided in a genuinely seamless way. Only then will the Local Health Boards truly earn the description of Local Health and Well-being Boards.
    13. By removing the burden of commissioning and contracting and by introducing direct management of hospital trust the workload of some NHS bodies would be radically reduced. Some bodies would in effect have no function. We shall discuss further before abolishing these quangos, but likely candidates would include: NHS England, and many of its substructures (it currently has its 4 sectors, 10 specialised commissioning hubs and 27 teams.) Monitor, the 17 Commissioning support units and the Trust Development Authority.

    These proposals will empower patients and the healthcare professions. They will increase local involvement and give a sense of local ownership in the managing of the health services. They will enable the delivery of a fair and equitable service to all patients regardless of geography or medical specialty. They will facilitate a truly co-operative and integrated service as different specialists and hospitals will no longer be in competition with one another; patients can be treated by the specialist most able to help them and the sharing of knowledge and expertise can become routine. Finally, and importantly they will save money.



    [i] Canada, Australia, New Zealand and Scandinavia.

    [ii] Davis et al. Mirror mirror on the Wall: an international update on the comparative performance of American healthcare. Commonwealth Fund May 2007

    [iii] Davis et al. Mirror mirror on the wall: How the performance of the US healthcare system compares internationally. Commonwealth Fund June 2010

    [iv] Davis et al. Mirror mirror on the wall: How the Performance of the U.S. Health Care System Compares Internationally. Commonwealth Fund June 2014

    [v] OECD. UK ranked number 1 in Unmet care need due to costs in eleven OECD countries, by income group, 2010 Health at a Glance 2011: OECD Indicators-

    [vi] OECD. UK ranked number 1 in Out-of-pocket medical costs 2010, Health at a Glance 2011: OECD Indicators

    [vii] OECD. Health expenditure as a share of GDP, 1960-2009

    [viii] Bambra, Garthwaite, and Hunter, All Things Being Equal: Does It Matter for Equity How You Organize and Pay for Health Care? A Review of the International Evidence Int. J. Health Serv. 44(3):457-477, 2014

    [ix] Footman, Garthwaite, Bambra, and McKee Quality Check: Does It Matter for Quality How You Organize and Pay for Health Care? A Review of the International Evidence Int. J. Health Serv. 44(3):479-505, 2014

    [x] Seddon J, Systems thinking in the Public Sector: Triarchy Press. passim.

    [xi] House of Commons Health Committee HC 268-I Published on 30 March 2010





    [xvi] Woolhandler S, Himmelstein D, Competition in a publicly funded healthcare system BMJ 2007;335:1126


    [xviii] Himmelstein D U, Woolhandler S, & Wolfe, S. M. Administrative waste in the US health care system in 2003: International Journal of Health Services, 34(1), 79-86.

    [xix] Woolhandler et al Costs of Health Care Administration in the United States and Canada: N Engl J Med 2003;349:768-75.


    [xxi] Gaffney D, Pollock AM, Price D, Shaoul J, PFI in the NHS – is there an economic case? BMJ 1999;319:116

    [xxii] Gaffney D, Pollock AM, Price D, Shaoul J, NHS capital expenditure and the private finance initiative—expansion or contraction? 1999;319:48

    [xxiii] Smith R,  PFI, perfidious financial idiocy,  BMJ 1999;319:2

    [xxiv] Healthy Lives, Healthy People: our strategy for public health in England DoH Nov 2010

    [xxv] Davies S, Marsland A Public Health System Reform: DoH 20 June 2011

    [xxvi] Faculty of Public Health. Personal communication.

    [xxvii] WHO ‘Global tuberculosis report 2012’

    [xxviii] Iacobucci G, Competition is holding back quality improvements, says NHS boss  BMJ 2013;347:f5862


    [xxx] The majority of GPs are employed under General Medical Services contracts (GMS) and are independent contractors within the NHS. This would not change. GMS GPs employ their own staff.

    [xxxi] Alternative Provider Medical Services

    [xxxii] HM Treasury: A new approach to public private partnerships Dec. 2012


    By Chris Bowers, Lib Dem parliamentary candidate for Brighton Pavilion

    Liberal Democrat logo

    It’s possible that not everyone who recognises the acronym ‘NHS’ knows what the letters stand for. Maybe that’s not such a bad thing, because I’ve always felt the National Health Service is a bit of a misnomer.

    To me, the body that administers our basic medical needs is not so much a health service as a National Sickness Service. We don’t use it when we’re healthy, only when we’re sick. True, in recent years it has done a lot of good work on screening for illnesses, but even that is to check whether a sickness is there – it’s not actually promoting health.

    That’s why one of the less trumpeted parts of the Liberal Democrat manifesto is, for me, one of the most important. Alongside our commitment to give an extra £8bn to the NHS by 2020 and increase current funding in line with inflation over the next five years, and give a £250 annual payment to carers, there’s a commitment to preventing illness.

    There are many ways of preventing illness, but the main two are healthy eating and regular exercise. On both, the country needs some serious attention to detail. We have allowed the food companies to label processed foods as ‘healthy’ when they are often anything but (I have learned to distrust the label ‘no added sugar’ as it normally means something has sweeteners which can be worse than refined sugar); pressures of time rob people of the space to cook which in turn encourages processed foods; and we have taken away many ways in which people can take easy exercise, like selling off playing fields.

    I’m often pressed to explain the fundamental difference between the Lib Dems and Labour, given that I believe both to be ‘progressive’ parties motivated primarily by a wish to create a fairer society rather than by self-interest. But one big difference is that I believe the Lib Dems celebrate the individual more than Labour, albeit in the context of a cohesive society in which the least fortunate are looked after and everyone has a fair chance.

    That’s why I’d love to celebrate the pursuit of individual health as a positive thing. Let the NHS push for cycle lanes so people leave the car at home and cycle to some of their local destinations. Let the NHS promote yoga and swimming clubs, and walking in the hills. Let the NHS celebrate ‘cook your own healthy food’ initiatives, from local adult education classes to Jamie Oliver. And much more.

    Then it would really be worthy of its name.


    The political parties have not yet produced their manifestos for 2015.  This is a round up of  their current statements about health policy.

    Labour’s Health and Care Policy is in detail on this site.

    The Conservative Party website doesn’t seem to say anything about health at all, and nobody in the Conservative Party now wants to talk about the Health and Social Care Act of 2012.

    Liberal Democrats say  Tories and Labour have put the NHS at risk. It was Liberal Democrats who stopped Conservative privatisation plans and reverse some of Labour’s policies which meant private health companies got special favours. In fact, Labour paid private companies £250 million for operations they didn’t even perform. Liberal Democrats have made sure that can never happen again.

    The Green Party produced a very lengthy policy statement in 2010, which has been recently amended.  It deals at length with health as well as with treatment.

    It’s difficult to work out what UKIP policy is.  Their website isn’t very helpful. What it says about health is:

    • Open GP surgeries in the evening, for full-time workers, where there is demand.
    • Locally-elected County Health Boards to inspect hospitals – to avoid another Stafford Hospital crisis.

    But next to them there is this rather ambiguous graphic:

    Approved Health Insurance

    Louise Bours, the UKIP candidate in Heywood is quoted as saying: ‘UKIP will ensure the NHS remains free at the point of delivery and need. A two tier national health system, where those with money can opt to pay for enhanced services will never be acceptable’.  The party would abolish Monitor and the Care Quality Commission which regulates hospital care quality and replace them with  local health boards run by clinicians.

    The Scottish National Party stresses:

    • Protecting the health service
    • Shorter waiting times
    • One stop cancer diagnosis
    • Cleaner and safer hospitals
    • More flexible access to healthcare

    Plaid Cymru, like Andy Burnham, believe health and social care should be merged and provide a fully integrated service.

    In summary – apart from the Tories, who are keeping quiet – all politicians are signed up to the NHS as the national religion. Everyone wants to see a free comprehensive service. They all want to protect the NHS and every building it’s ever used. But with the possible exception of Labour, nobody wants to talk about the problems facing the NHS.  However, on the bright side, most political parties are prepared to talk about mental health – which was not the case a few years ago, and more are prepared to talk about wellbeing and public health than used to be the case.



    1 Comment

    Dear xxx

    Thank you very much for your recent email with regard to the new regulations from the Department of Health – Statutory Instrument 257 under Section 75 of the Health and Social Care Act 2012.

    I wish to assure you that we Liberal Democrats have absolutely no intention of allowing the Conservatives to smuggle any new privatisation into existence through the process of implementing the Health and Social Care Act.  We worked hard during the passage of the Health and Social Care Act to secure a commitment from Ministers that CCGs would not be forced to competitively tender services unless they believe it is in the interest of patients.

    The regulations laid before Parliament by the Government seek to create a tendering process that balances the desire for CCGs to be able to make the decisions they think are in the best interests of the patients, with the need to ensure that, where tendering does take place, companies are not able to gain an unfair advantage over the competition. The regulations do already contain a number of safeguards.  For example, in making decisions on suppliers, CCGs must act in a way intended to improve quality of services, rather than simply cost.  CCGs must also consider how to provide services in an integrated way, meaning they do not have to fragment services if they don’t want to.

    However, while I believe that the Government’s intention in the regulations is in line with the commitments made during the passage of the Health and Social Care Act, I also understand why many people are concerned that the regulations are not clear enough.  I also understand the concern that the regulations could lead to CCGs feeling they must tender all services or risk being investigated by Monitor. It is vital that the regulations provide the clarity that both CCGs and the public need about commissioning options available to CCGs.

    That is why my Liberal Democrat colleagues in the House of Lords, led by Baroness Jolly, the Co-Chair of our Health Committee, have met with Health Minister Earl Howe, to discuss ways that the regulations may be improved.  Ministers have been very open to making changes and will work closely with Liberal Democrat Peers to make sure that the regulations not only meet the letter of the agreement made during the passage of the act but the spirit of this agreement as well.  I will continue to pay close attention to this work, as it develops and I am confident that, through this process, the final regulations used to govern CCGs will provide the new groups the tools they need to provide high quality, locally led, services while also protecting against unfair behaviour when tendering does take place.  I shall continue to work closely with my colleagues both in the Government and in the Party to erect firm barriers against any kind of abuse of the statutory orders that has triggered the outcry from the 38 degrees organisation.

    I have also attached the more comprehensive briefing that has been provided to challenge the media hype that always surrounds policies for the NHS.

    With best wishes

    Yours sincerely

    Tim Farron MP

    NHS Regulations: CCG Tendering

    Summary of the Issue

    The Government recently tabled the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013. These regulations set out the legal framework under which both the NHS Commissioning Board and Clinical Commissioning Groups (CCGs) tender services. There is strong concern that the regulations require these bodies to hold open competitive tendering process for all services they commission. This would go against commitments given by Ministers during the passage of the Health and Social Care Act that CCGs would not be required to competitively tender services on a compulsory basis.

    Key points for response

    •  The National Health Service (Procurement, Patient Choice and Competition) Regulations 2013 are intended to set out the legal process under which CCGs will be required to conduct competitive tendering process.  This is important as tendering is a complex area of law. Regulation is needed to fulfil the commitments given by Ministers while ensuring that providers don’t gain an unfair advantage over their competition or that anti-competitive behaviour doesn’t take place.
    •  It is vital the CCGs are able to act in the best interest of patients and the NHS.  While competitive tendering may be appropriate for various different types of services, it should not come at the expense of providing services the CCGs feel are in the best interest of patients.  It is important to remember that tendering does not just include health specific services, but may also include back office functions such as stationery where people would expect CCGs to look for the very best price.
    •  Liberal Democrats and others worked hard during the passage of the Health and Social Care Act to secure commitments from Ministers that CCGs would not be expected to competitively tender services unless they felt it was in the interests of patients.
    •  Without proper regulation of the tendering process, we would repeat the same scandal as the Labour’s NHS where private providers were given preferred status over NHS providers. This led to huge waste, including paying private providers £250 million for operations that were never even performed.
    •  The regulations do contain a number of safeguards to ensure that the CCGs do not automatically have to tender services.  These include requiring CCGs to consider the need for services to be provided in an integrated way, which may mean not tendering a contract where this would fragment service provision, and a caveat allowing anti-competitive behaviour by CCGs where this is ‘beneficial for people who use such services’.
    •  However, while we understand that the Government’s intentions in the regulations is to give effect to the commitment they made, we also understand why many people feel they are not clear enough and could led to CCGs feeling that they have to act in particular way.
    •  That is why Liberal Democrat Peers, led by Baroness Jolly , the Co-Chair of the Party’s Health Committee, have met with Earl Howe, the Health minister in the House of Lords, to discuss how the regulations might be improved in order to ensure they are clear on the expectations on CCGs.  This process is ongoing.
    •  Some letters have asked MP’s and Peers to highlight the importance of these regulations to the Secondary Legislation Scrutiny Committee.  This issue has already been raised by Lib Dem Peers with the Select Committee.  It is now important that the Committee is allowed to do its job and come to its own conclusion on the regulations.
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