Category Archives: Campaign resources

Material designed to be practically useful in campaigns. More contributions very welcome!

NHS rally in York, 7.4.18

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The vast majority do not want the creeping privatisation, and the dismantling of the NHS as it was originally conceived by Bevan. At local level there is a growing resistance to the cuts to services.  However local protest, without well-argued and transformative policy and legal changes at the national level, pose little threat whilst the Tories are in power.  The Labour Party will set out its stall in the Manifesto before the next election to renationalise the NHS. This Briefing Note suggests practical and structured steps for doing this by elaborating on the draft NHS  Bill 2015.

  1. Key Questions for Labour on future NHS planning

The Labour Party Conference September 2017 endorsed Composite Motion #8 for the repeal of the NHS Health & Social Care Act 2012[1].  Delegates believed that the present marketization policies and funding cuts are destroying the NHS, and that these must be immediately reversed by the next Labour Government.  This is not yet formal Labour Party policy, and many MPs still seem to be unaware of the privatisation trajectory of Tory policy towards the NHS.

Draft NHS Reinstatement Bill 2015:

  •  fully restores the NHS as an accountable public service

  • reverses 25 years of marketisation

  • abolishes purchaser-provider split

  • ends contracting & outsourcing

  • re-establishes public bodies accountable to local communities

This Briefing Note concerns a grass roots campaign by Leeds KONP to actively engage with Labour MPs in the Yorks/Humberside region and start a conversation on why the NHS must be de-privatised (i.e. renationalised).  According to the records, in August 2017, only 4 out of 36 of Labour MPs supported the draft NHS Reinstatement Bill 2015 and the repeal of the 2012 Act.   We are asking them why and explaining what Composite Motion #8 actually means in practice.

The 2012 Act with its 470 pages and supported by secondary legislation is, as the people at the Labour Party Conference 2017 recognised, leading us to a US-style willingness-to-pay private health insurance system rather than one providing for all and funded through general taxation.  The problem for NHS campaigns is that this threat is only dimly understood which may explain why Labour MPs have not supported the draft NHS Reinstatement Bill 2015 prepared by Allyson Pollock and Peter Roderick.

In September ’17 Leeds KONP prepared an information pack for MPs in the region on the consequences of the marketising the NHS through the present top down reorganisation schemes, and the failure of the present Tory government to fund the service properly. These were sent out and meetings comprising informal conversations were requested. The results of these are similar – many  MPs see the NHS as a black policy box that is too difficult to look into.

During the first meeting, Jon Trickett (Hemsworth MP), welcomed grass roots action and suggestions for NHS policy prescription, and said a major concern is what immediate action should the Labour Party take on taking office.

Reasons why Labour MPs may not support the NHS Bill

  • Implications of 2012 Act are not well  understood

  • Too complicated and difficult without another top-down reorganisation

  • Support New Labour marketisation’

According to lawyers experienced in drafting Statutes, repealing the 2012 Act in full will take several years.  In the meantime the question arises on what to do on Day 1 to stop the rot.

This raises two further key questions:  what should the NHS look like in the future as a consequence of the repeal of the 2012 Act? and what should be done in advance of the next election to prepare for the repeal process?  The draft NHS Reinstatement Bill needs to be further elaborated in order to answer these questions.

This Note takes a structured Public Administration Reform approach that sees the law as part of an enabling framework for health services.  It assumes that the future NHS will be designed with social democratic rather than the present neo-liberal objectives of the Tories[2].

  1. The 2012 Act is a policy instrument for neo-liberalism

The market ‘reform’ policies now imposed on the NHS are derived from a political ideology,  rather than from an evidence-based evaluation of what works best in the health sector for the benefit of all.  They are set up as a virtual template through which health care policies are to be judged.  This template sees the market as providing a frictionless resolution to social inequality by denying that inequality matters.

The ‘reforms’ privatise public assets to promote capital accumulation, deregulate to ‘free up’ individual enterprise, enact  anti-union legislation, and shrink state responsibility and involvement in social welfare. Their justification is that they are believed to create competition, increase efficiency and reduce financial costs to (higher income) taxpayers.

These policies undermine the very social solidarity that has been supported by the NHS since its original founding, and perhaps this is the real purpose.  The Tories have absolutely no mandate for them in the 2012 Act.

In non-market institutions, such as the NHS with its essential public health dimensions, the 2012 Act establishes proxy markets to break down the services into discrete parts that ‘providers’ (in-house or private sector) can bid for.  However, the transaction costs of running the internal market (tendering, contracting, costs of regulation etc)  are estimated to exceed 10% of the NHS’ present annual costs and reversing marketization would at a stroke eliminate much of the funding squeeze that the NHS is experiencing.

NHS policy is now led by Ministerial advisers who are hired to shape the neoliberal ‘reforms’ and who are skilled at using the templates.  Also by international management consultants who have learned their trade with the Bretton Woods institutions leading structural adjustment in the developing world since the 1980’s – with their budget cuts and the consequent collapse of public health care services for those who cannot afford private medicine. In this respect, the SHA report, that NHS privatisations had their origins in the 2012 World Economic Forum in Davos, shows only that we are now regarded by international capital as part of the global under-developing world.

The damage caused by this marketization approach is undermining the whole premise of good management – which is to encourage integration rather than disintegration.  It results in:

  • fragmention as different hospitals and other facilities compete with each, other, rather than collaborate, for patients and market share
  • a lack of a whole systems approach to prioritising policy around chronic disease and the wider public health
  • an inability of the health departments at all levels to manage relationships and confront powerful vested interests
  • the loss of management knowledge and discretion over decisions which are set out by consultants – leading to poor decisions.

Since 2012 the government has imposed a plethora of ‘reforms’ to the NHS which are leading to uncertainty in planning the services, cuts and rationing, and which are privatisation by stealth.

They are presently being challenged by concerned individual citizens and organisations through the Courts.

In particular the present proposal for Accountable  Care Organisation (ACOs) are a final step setting the grounds for franchised, outsourced, commercialised health services run for private profit and not the public good.

Reversing the inevitable consequences of the 2012 Act will also mean reversing the internal institutional damage caused to the NHS itself. Measures to do this must be addressed in the new NHS Act to be introduced by Labour because doing nothing is not an option.

Privatisation by stealth

  • Sustainable Transformation Plans – any possible imagined benefit completely negated by imperative to make massive savings
  • 14 STP areas now subject to Capped Expenditure Process – further financial squeeze will lead to dangerous and arbitrary reduction in services
  • STPs to become American style ACOs; first 8 now signed up (ripe for sale?)
  • Cash limited budget imposed by NHSE, grossly inadequate for needs of local populations
  • Naylor – selling off NHS estate; ‘Project Phoenix’ saddles NHS with escalating PFI repayments
  1. Steps in Repealing the 2012 Act in Parliament

The draft NHS Reinstatement Bill 2015 is not a blueprint but it does outline the general purpose, direction, and scope needed for the repeal measures that have now been endorsed by the Labour Party Conference. These must be elaborated into proper law-making practices with well-formed objectives and priorities. Within Parliament itself statute drafting is usually preceded by a report from an independent cross-part advisory committee(s).

Leeds KONP has prepared a simple flow chart to show the steps in repealing the 2012 Act.  These steps are standard for the preparation of (any) new legislation in Parliament.

Significant portions of the legal process will be prepared by Whitehall but it is difficult to imagine civil servants thinking creatively through the ‘renationalisation’ of the NHS.

So the Labour Party must do its thinking in advance of taking power and be prepared for bitter fights every step of the way from the Tories, and resistance from vested interests in the Civil Service and amongst senior NHS planners who have set up the present privatisation programme.

We should be aware that, if the NHS Reinstatement Bill is not enacted before a subsequent election the Tories will, if they win, simply revert to the 2012 Act.

The standards procedures for statute preparation requires the establishment of a government department policy team tasked with the job.   This may take up to 10 months so the ‘what to do on Day 1’ is a serious question.

A consultation document is usually prepared (Step 4: ‘Green Paper’) to allow external and expert critiques to be made of the proposals.

The White Paper (Step 5) sets out the clear policy intent of government and provides the terms of reference for the detailed drafting of the Bill by Parliamentary Counsel – acting under the directions of the government department responsible for the Bill (Step 6: Prepare Bill).  At this stage, the draft NHS Reinstatement Bill 2015 will provide a useful checklist.

  1. Elaborating on the draft NHS Reinstatement Bill 2015 

Laws in public services are designed to shape legal relations between the different agencies of government and its citizens, and to set out mandates and responsibilities for each. They define the scope and limits of the decisions that can be made by government agencies – and rules on how the decisions may be made. They impose duties and standards of conduct, and confer powers that encourage general habits of ‘good’ management practice.  The 2012 Act has enabled privatisation and marketization following neo-liberal principles. The new NHS legislation will enable social democratic principles.

Therefore repealing the 2012 Act means reversing the neo-liberal agendas of the last 40 years and re-establishing social democratic principles through a law that enables these principles and the practices that result.

The draft 2015 Bill is not a blueprint and may usefully be elaborated to set out the principles, policies and proposed institutional architecture of a future NHS ready for consideration when the next Manifesto is written.

The shape of the NHS proposed by a future Labour may be described in Steps 1 to 3 as shown in the flow chart.   They need to be prepared at this stage using broad brush approaches as speed is of the essence.

Leeds KONP has endeavoured since October to meet with Yorks/Humberside MPs to establish an informal discussion on the reason why the draft NHS Reinstatement Bill 2015 has not been taken up by MPs.

Findings so far suggest that many MPs simply do not grasp the trajectory set by the Tories for the NHS, the costs and extent of the privatisation measures, nor do they have an understanding of the different management options between privatisation and old-style central planning.

Therefore the 3 Steps below must both persuade and inform.

Step 1: Establish Policy Principles for reinstating the NHS must consider the high level and core social democratic principles to be pursued by the Labour Party and establish the criteria and policies for determining what the future NHS shall look  like in a social democracy.  This requires a clear policy compass or direction.

In practice, if we don’t start with basic policy principles then we end up trying to change bits of the 2012 Act at the margins thereby ignoring its underlying assumptions.

An example is set out below of principles established by the Bevan Commission 2008-2011 which was commissioned to ask what Bevan would do with the NHS  Britain if he was alive today:

  • Principle 1: Universal access, based on need  (Bevan 1948)
  • Principle 2: Comprehensiveness, within available resources (Bevan 1948)
  • Principle 3: Services free at the point of delivery (Bevan 1948)
  • Principle 4: A shared responsibility for health between the people & the NHS
  • Principle 5: A service that values people (as citizens and employees
  • Principle 6: Getting the best from the resources available
  • Principle 7: A need to ensure health is reflected in all (health and social) policies
  • Principle 8: Minimising the effects of disadvantage on access and outcome
  • Principle 9: A high quality service that maximises patient safety
  • Principle 10: Patient and public accountability

These demonstrate that more is at stake than simply providing services free at the point of use as in Principle 3 above. The Bevan Commission was reconvened in 2016 for NHS Wales and has produced a consolidated list of policy principles

Many of the principles demand a fundamental re-think  about how the NHS has evolved over the last 20 years and imply quite profound changes to the way the NHS is to develop in the future.

This re-think is not to be had from consultants from the big audit bureaus who have little knowledge or sympathy with the renationalisation of the NHS.

Step 2:  Develop Position Statements on key issues within a renationalised health sector and its various agencies and subsystems – which comprise the pyramid of health facilities and associated services that deliver personal health services and non-personal health actions.

These will include standard categories adopted in structured Public Administration Reform programmes:

  • Enabling Framework for Institutional, Policy, Legal /Regulatory and Fiscal Issues
  • Organisation-level and management issues
  • Citizen Representation issues

These are a complex but have been well written about over the last decade[3]

Day 1 Questions include:  what parts of the 2012 Act may be immediately repealed by Ministerial Decree before the new NHS Act is enacted; what to do about the ruinous PFI contracts; where to find health planners committed to the new NHS Act;  how to tackle certain professional interests who are happy to have their mouths stuffed with gold; etc

Step 3:  Design Institutional Architecture to implement the new NHS Act on the ground.  The draft 2015 Bill sets out an organisation structure based on Regional Health Boards accountable to local governments.  The NHS Boards would encompass a public service and cooperative ethos as opposed to the rational choice ethos promoted by the present 2012 Act,

This requires strong political leadership and judgement that balances values and interests – and the people doing this require an understanding of what is involved.

The structures, processes, financial controls all have to be designed to overcome the ‘wicked problems’ inherent in public services[4]. There are other organisational options regarding subsidiarity, scale, function, etc that deserve re-examination.

  1. Action Planning for Steps 1, 2, and 3

There is no shortage of material dealing with the NHS and its condition, and what is to be done. For the purposes of the next election and Labour’s Manifesto Steps 1, 2, and 3 may usefully be addressed by people who have been campaigning for an end to privatisation in the NHS through a  Working Group.

There are many different groups and individuals within academia, citizen organisations, political groups etc , each with a different and valid emphasis on what is most important. Gaining a consensus at this stage is less important than identifying the key issues, especially regarding Step 2: Position Statements as developed from the draft 2015 Bill and from issues that have arisen from the Composite Motion #8.

This would provide a clear view on the long term development of a renationalised  NHS, on the assumption that this is only the preliminary stage in the longer term thinking needed.

It will also provide a clear view on how to address critical Day 1 Questions.

The result of this would be a Discussion Paper that contributes to the preparation of the next Labour Manifesto on the nHS.

[1] See arguments in:  www.nhsbillnow.org/labour-and-the-nhs-bill/

[2] There is a vast literature on neo-liberalism and the failures of the market in health care and the arguments are not new.  TINA was rejected from the beginning.  For an earlier example see : Ben Griffith (1999) Competition and Containment in Health Care NLR 1-236 July/Aug ’99.

[3] As an example see Hunter.D (2016) the Health Debate  Policy Press Bristol

[4] Seddon.J (2008) Systems Theory in the Public Sector).

Briefing Note produced by Leeds Keep Our NHS Public

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How we might we influence Local Authorities to oppose health cuts, closures and Sustainability and Transformation Plans and Accountable Care Organisations?

ALL councillors have a duty to oversee and scrutinise the work of Health Trusts and CCG’s. Some have representatives who have sit on health boards but ALL Local Authorities have a powerful and statutory role in overseeing any reconfiguration proposals through their Joint Scrutiny roles. They can exercise that power forcefully but must be made aware of their briefs.

Health Campaigns Together has produced an excellent broadsheet (Into the Red Zone) for councillors which can be found on the HCT website . It’s thorough and detailed but it summarises the cuts programme we all now face and how Local Authorities must face up to them.

As campaigners, our role is to initially educate and inform councillors about the imminent threat to the NHS and their local services. Never assume they know even if they tell you they do! Groups must find out who all their councillors are and make them aware of our existence.

Remember, they are there to represent us but also have very busy workloads so they will priorities issues. We must make them aware of the importance of health.

Identify those who sit on Health Scrutiny Committees and target them. Also identify every political group leader and make appointments to meet them, if required on a regular basis. Ultimately they can control what every councillor does. Foster good relations and pick out those who appear sympathetic.

Find out when councils meet and organise lobbies and address the full meetings. Get the press there and invite them to join the photo shoots. Councillors always have an eye on the next election! Invite councillors to any public meetings or events your group may organise (NHS Birthday is a good opportunity).

Most councillors have local surgeries, so pay them a visit and get them onside as much as possible.

The Health Scrutiny role however is key. They have statutory powers to veto local recommendations by CCG’s or Trusts (although ultimately the final say rests with the Secretary of State via the IRP process). Councils can refuse to endorse Sustainability and Transformation Plans and are the only statutory public body which can do so.

Some councils will happily refuse to endorse Sustainability and Transformation Plans (they are still a minority) but the government is offering sweeteners to get them to support Sustainability and Transformation Plans. And councils can take out legal action via judicial reviews either on their own or jointly with campaign groups so make them they have the resources, expertise and power to do so!

Intransigent councils can of course face electoral challenges from campaign groups standing under the single issue banner (e.g. ‘Save our NHS’ or even NHAP). This needs careful thought and preparation but it can help to change minds very quickly! And as always keep the press informed of everything we are doing re councillors as they don’t like adverse publicity.

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Accountable Care Organisations” are mentioned 18 times in the Cheshire & Merseyside Sustainability and  Transformation Plan with no details or background. Massive reorganisation plans are now surfacing in Warrington, St Helens, and West Cheshire. Management consultants PwC, who helped write the STP itself, are guiding developments.

Accountable Care is a concept from the US health insurance market. The idea there is that a group of healthcare firms take responsibility for providing care for a given population for a defined period under a contract with a commissioner, such as Medicare. ACOs use market-based mechanisms to lower costs whilst achieving pre-agreed quality outcomes. They ‘align incentives’ between providers and commissioners, sharing any savings between hospitals, doctors and the commissioning Medicare programme itself.

An earlier version is known as the Health Maintenance Organisation, run by the insurers themselves. It involved routine denial of patients’ access to medically necessary treatment, fighting claims, screening out the sick, paying exorbitant CEO salaries, and systemic fraud. Low rent medical care had considerable hidden costs in top-ups and deductibles.

Now, the ACOs have healthcare providers in the lead. But the same insurance firms are driving and developing the process. NHS England boss Simon Stevens’ former employer UnitedHealth already has contracts with more than 800 ACOs across the US, and has just launched a national accountable care organization, NexusACO, which will be available to employers in 15 US markets.

One form of ACO, mentioned in the STP, uses ‘capitated’ or ‘global’ fixed payments to providers for all or most of the care that their patients may require over a contract period, adjusted for severity of illness, and regardless of how many services are offered. Clearly, once the payment is in place, it is open to providers to offer only as much care as required by the contract.

The specified care needs may not be comprehensive, and the defined patients may not be the geographical population. Indeed, as the Cheshire & Merseyside plan states “Greater focus could be paid on ensuring primary care is at the centre of care models and ACOs are built on GP registered lists.”

Two models promoted by the Five Year Forward View come straight out of the ACO playbook: the Multispecialty Community Provider, and the Primary and Acute Care System. The MCP, based on primary care in localities and prevention, aims to reduce avoidable hospital admissions. The Cheshire & Merseyside STP states explicitly “In parts of the system there is some ambition to build the ACOs around multispecialty community providers.”

All ACO plans simply accept the massive NHS funding cuts. They assume that pooling NHS and local authority resources, and expanding new models of care in the community, will justify cutting hospital budgets. The National Audit Office and the Nuffield Trust have recently demolished those assumptions. Warrington ACO

Warrington has agreed to pool CCG and local authority health and social care budgets, and are “determined to move away from a national tariff-based payment system to a defined capitated budget.”

The ACO Board will be established by 1 April 2017 with an independent chair and will comprise:

  • Warrington Borough Council (Commissioning)
  • Warrington Borough Council (Provision)
  • NHS Warrington Clinical Commissioning Group
  • Warrington and Halton Hospitals NHS Foundation Trust
  • Bridgewater Community Health NHS Foundation Trust
  • Five Boroughs Partnership NHS Foundation Trust
  • Warrington GP representatives

Board tasks will include designing plans for:

  • Shared accountability and risk share
  • Pooled/aligned budget arrangements.
  • Contractual (and funding) flexibility through agreed contractual arrangements that bind the ACO.
  • Arrangements for commissioning/contracting from the ACO to the health and care market.
  • An appropriate vehicle for delivery.

Options for the ACO structure include Corporate Joint Venture and (full) Merger, to be determined through an options appraisal workshop.

St Helens is setting up an “Accountable Care Management System” to involve the CCG, health providers and St Helens Council. It is set to go live in April 2018 and intends to transfer these services from Day 1: Adult Social Services, Children’s Social Services (excluding Youth Justice), Public Health, Community health services, Adult Care Services (excluding maternity), Primary Care, Mental Health Services, Community Safety Services, Community fire safety, Mental health street triage, Victim support services, Probation services, Ambulance. Other services may be added later, and the only permanent exclusions are Youth Justice, Community fire protection, and Road safety.

St Helens is now asking itself: Will the ACMS compete for tenders as a collective? Will the ACMS itself issue tenders and procure services from others?

West Cheshire CCG is planning to establish an ACO, whose parties include:

  • NHS West Cheshire Clinical Commissioning Group
  • The Countess of Chester NHS Foundation Trust
  • Cheshire and Wirral NHS Foundation Trust
  • Cheshire East and Chester Council
  • The three West Cheshire primary care localities of Ellesmere Port & Neston, Chester City and Rural

It will “take a distinct approach to segmenting our GP registered population by risk, around which our plans are based”. It will issue a Memorandum of Understanding between providers, who “have been challenged to advise how they can release a material portion of their existing resources to enable this transformation”. It will also issue a “prospectus”.

Liverpool Community Health is being broken up and handed to other providers. The biggest single contract is planned as an MCP with Bridgewater Community Health in partnership with the Liverpool GP Federation and Liverpool City Council, whose bid came in £4.6m below the value of the services it would provide. Cuts in back office staff are anticipated. In November, Rosie Cooper MP asked Bridgewater to confirm or deny plans to set-up a joint venture, pooling all budgets to provide all community health and social care from a single company. I don’t know if she got an answer.

Currently, the plan is on hold as the Care Quality Commission report on Bridgewater, finally released on 6 February, identified serious clinical failures. Liverpool CCG made clear that locality working and partnership with LCC and the GP Federation was their reason for backing the plan, unfazed by the CQC report.

Bridgewater is part of the Warrington and St Helens plans.

If it does proceed, the Liverpool MCP may later emerge as all or part of a fully fledged Accountable Care Organisation. The obvious question is, accountable to whom?

Evidence?

The NHS is supposed to deliver evidence-based medicine, clinicians are educated on that basis, and new treatments are only licensed after passing rigorous trials and cost-benefit analysis. What’s the point to medical school or nurse training if evidence is tossed overboard?

The St Helens plan purports to list evidence for each of their plans. None of it is referenced. For example “Stand alone telephonic case management has been estimated to reduce admissions by 5%.” Says who? The Nuffield Trust (pp85-6) says there is mixed evidence on case management. Research at the University of Manchester published in 2015 is entitled “Effectiveness of Case Management for ‘At Risk’ Patients in Primary Care: A Systematic Review and Meta-Analysis”. From the abstract:

“This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs.”

St Helens says “Social prescribing has saved Newcastle West CCG an estimated £2 – £7 million”. This is actually the Ways to Wellness programme which started in 2015 and runs for 7 years. It hasn’t been evaluated yet. Nuffield describes it as a “large scale trial”. The actual savings it will achieve are, at this stage, only projected.

Warrington says “Evidence shows that proactive planning using risk stratification is a key tool to improving outcomes”. Again, no reference for that. The Nuffield review found risk stratification tools still struggle to identify ‘at risk’ individuals at the point before they deteriorate.

A virtual ward is a model of home-based multidisciplinary care based on the idea of a hospital ward. Intended to avoid emergency admission or readmission, patients are typically identified using a risk stratification tool. As Nuffield reported, an evaluation of three NHS virtual wards targeting patients at risk of admission found no reduction in emergency hospital admissions in the six months after admission to the ward, but it did find a decrease in elective admissions and outpatient attendances. There was no reduction in overall hospital costs.

Private sector

The private sector are directly involved in formulating the ACO plans. Notorious management consultants PwC, formerly PriceWaterhouseCooper, were paid £300k for their work on the Cheshire & Merseyside STP. They were advisors on 17 other STPs. They are involved in plans for ACOs in Tameside, Wigan, Manchester City, Oldham, Cheshire, St Helens, Hounslow and Richmond, Northumbria, Mid-Nottinghamshire, and Croydon. The Northumbria plan, intended as the first ACO in the UK, has been postponed indefinitely as the CCG is £41m in deficit.

West Cheshire CCG appointed PwC to undertake an initial ‘due diligence’ phase. The consultancy also convened three workshops for the parties to the ACO.

In St Helens, the Project Management Office is “supported and challenged by PwC”. PwC has input into the proposals for Governance, IT, Business Intelligence, Communications and Engagement. A Workstream stakeholder reference group has Specialist /practitioner input from three people, two of whom are PwC staff.

The private sector can also be involved in the Governance structures themselves. In St Helens, the leadership is currently with a People’s Board, including the Council and NHS providers, but also the Community Rehabilitation Company and Helena Partnerships. Helena are a housing management group which took over former council housing. The CRC is a privatised probation service, 75% owned by Interserve, a facilities management company with PFI and other health service contracts.

The private sector is also funding new models of care. The Newcastle Ways to Wellness programme is an outcomes-based contract funded through a Social Investment Bond which includes £1.65m from Bridges Social Sector Funds. Bridges Fund Management describes itself as “Capital that makes a difference”.

The End Game

The implications for wages, terms and conditions of NHS staff when employers merge across care sectors under PwC guidance, with local structures which will threaten national agreements, are immediate. Looking further ahead, no private company is big enough to buy the whole NHS. But once the STP plans are implemented and ACOs are established across England, health transnationals will see discrete local systems with budgets of £1bn or less, with structures compatible with the US health insurance market. They could be bought and sold.

Theresa May is adamant that the NHS will remain free at the point of use. Even if that’s true, a big if, she does not mean a comprehensive, universal service, with decisions on treatment made according to clinical need, publicly provided, publicly accountable, funded out of general taxation. That’s what we’re fighting for.

 

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Don’t Slash, Trash and Privatise our NHS!

A Briefing prepared by campaigners from NE London STP area – November 2016

STPs are driven by a combination of NHS underfunding, new budget cuts, and the Government’s determination to shift the NHS from a clinically-driven service towards US-style models that fit more readily with private insurance-based and corporate-managed healthcare. These changes will have a devastating impact on the NHS and on services and healthcare for local people.

The population of NE London is set to increase by 18% over the next 15 years but there are no plans to increase services – only to ‘reduce demand’ for healthcare. Most of the published STPs – including NE London’s – contain little or no detail of proposals for specific service, funding or sites. Instead they are replete with vacuous intentions for happier populations keeping themselves healthier and out of hospital.

‘Everyone will submit an STP because they have to, but it means there is a lot of blue sky thinking, and then a lot of lies in the system about the financial position, benefits that will be delivered – it is just a construct, not a reality.’ Julia Simon, until Sept 2016, Head  of NHSE Commissioning Policy Unit.

Public Involvement in the NHS

Public Involvement in the NHS

How STPs will affect the NHS

An HSJ poll of leaders of England’s 209 Clinical Commissioning Groups has revealed the extent of “service changes likely or planned” over the next 18 monthsi:

  • 52% would be closing or downgrading community hospitals – in NE London, we will not be getting the additional hospitals we need to service the massive population growth predicted over the next 15 years (a rise of 270,000 – the size of Brighton & Hove – in the Barts Health boroughs alone) and 18% population growth across the NEL area as a whole.

  • 46% were planning an overall reduction in in-patient beds – the STP includes reducing Barts Health emergency bed days by 21,053 by 2017-18, to save up to £6.6m over the next five years – on top of the loss of 550 additional beds that would normally be required for the expanding population in the Barts area alone.

  • 44% intend to centralise elective services. NEL STP promises ‘a joint vision for surgical hub model across NEL’.

  • 31% would be closing or downgrading A and E – St George’s A&E looks set to close and, despite population growth which would be expected to add an additional 92,000 attendances over the next 10 years, the Barts Health area plans to hold A&E attendance down at current levels

  • 30% intend to close an urgent care centre or similar provision

  • 23% are planning an overall reduction in acute services staff

  • 23% intend to stop in-patient paediatrics in one or more hospitals

  • 21% would be reducing consultant-led maternity provision 

Funding

  • £22bn cuts to be imposed through 44 STPs across England by 2020-21: £578m across NEL. In the Barts Health area alone, despite population growth, the plan is to cut between £104-165m over five years
  • No growth in services despite sharply rising costs, growing population numbers and rising health needs – means a devastating decline in what’s available to individuals. These are CUTS, masked by deliberately ambiguous and vacuous language designed to mislead and manipulate the public.

% GDP spent on health (new definitions)

$ per head on healthcare

France

11.1

4,367

Germany

11.0

5,119

The Netherlands

10.9

5,277

Norway

9.3

6,081

Sweden

11.2

5,065

Switzerland

11.4

6,787

United Kingdom

9.9

3,971

Average (excl. UK)

10.7

5,264

  • UK spending on healthcare is significantly below the average of major European economiesii. If the UK were to increase its spend to 10.7% of GDP, this would equate to an extra £15bn pa.

Lack of evidence to support NHS England’s Five Year Forward View (5-YFV) ‘new models’

  • The NHS has a proud track record of evidence-based practise. This is all but abandoned in the 5-YFV.
  • The ‘new models of care’ are cost-driven. We campaigners don’t oppose changes to services – but changes need to be driven by combination of clinical need & requirement for good patient access. Service changes need to be rigorously assessed against these criteria.
  • STP changes are being imposed with no such assessment, and lack of valid, peer-reviewed research evidence-base. Anecdotes claiming success are routinely substituted for valid evidence that also takes account of a wider picture. Examples include:
    • decisions to focus services on specific outcomes often take no account of the impact on patients with multiple conditions who may lose co-ordinated care.
    • Arguments about the need to centralize highly complex specialized care are misused to justify closure of units offering excellent care for routine conditions. Often no account has been taken of increased risks of extended blue-light journeys to A&E or difficulties for patients and visitors facing of longer journeys.

The New Models of Care for the NHS mean:

  • Fewer sites for NHS services – people will have to travel further for healthcare.  We can’t assume a reduction in locations is acceptable without full analysis of travel implications for local patients and visitors – especially the impact on elderly or disabled relatives, families with children and people with limited English.
  • Specialist hubs: some specialist focus is needed for complex and rare conditions – but not for routine health issues where local services and accessibility / travel are more important. Local clinicians could access specialist advice if needed via good NHS networks.
  • Selling off the NHS family silver/estate. A one-off boost for treasury finance, with few or no guarantees for local funding. When it’s gone -much of it handed over to private housing – it’s gone forever – The London Chest Hospital land has already gone that way and there are plans to sell land at Whipps Cross Hospital too.
  • No new capital money – so rely on PF2  – Many of the new models of care require different, potentially larger premises than currently available. We fear a repeat of disastrous consequences of PFI. Barts Health NHS Trust is already paying more than £2.5m a week in unitary charges for its PFI hospital buildings.
  • Reliance on enhanced self care, Skype apps and unproven technology to avoid hospital admission and clinical care amounts to magical thinking! And relies heavily on unpaid family carers (mainly women). The NE London plan includes a 10% shift away from GP attendances in the Barts Health boroughs – despite the high levels of deprivation and language difficulties in east London.
  • A major shift of services away from hospitals and back towards primary care – Overstretched GPs will be expected to take on additional outpatient work.
  • The most vulnerable and socially excluded patients and families & women will be hardest hit. NE London includes some of the most deprived wards in the country.
  • Restructuring of the NHS involves less clinical, more corporate management. Ripe for privatisation. An FOI request to the drafters of Transforming Services Together found they had spent £3.5m on 20 corporate consultants, while the STP drafters had spent £800k on consultants in a matter of months.
  • Data-sharing. We are very concerned about proposals to share confidential medical data across a range of health and social care providers, leading to major potential for confidentiality breaches.

Downgrading professional staffing

  • Development of new roles such as Physician Assistant/ Associate (PA) (just 2-years’ training) are part of a general move to reduce costs while de-professionalising (dumbing down) the NHS and heightening management control – the plan for the Barts Health boroughs includes recruiting 85 PAs over the next 10 years, to replace an expected shortfall of 195 GPs
  • These changes have a poor evidence base, often reporting ‘acceptability’ rather than outcomes. Evidence for success is often anecdotal and much of the ‘research’ would not meet professional standards or peer-review requirements.
  • Proposals to engage PAs rather than experienced (yet cheaper) nurses have been justified by ‘too many professional limits’ placed by professional bodies on nurses!

  • There is no mandatory registration for PAs, raising major concerns about regulation.

  • There is robust (and unsurprising) evidence that PAs are less effective than doctors at diagnosis

  • BMA warnings that PAs are not a substitute for fully trained doctors are likely to be ignored

  • Concerns that PAs will not recognize important signs that a fully trained doctor would spot

  • Pressure to grant PAs independent prescribing powers will lead to enhanced risk to patient safety and increased risk that PAs will be used to substitute for, rather than support, doctors.

  • Concerns that GP receptionists may in future be triaging patients and directing them to PAs who will miss more subtle indications

  • Concerns that patients directed to PAs are more likely to be elderly, vulnerable, speakers with poor English etc – while articulate middle class patients will be able to get GP appointments

  • Similar concerns apply to other proposed new roles, substituting minimally trained staff for professional clinicians, nurses, pharmacy and professions allied to medicine throughout the NHS.

  • As the Nuffield Trust puts it: ‘……. In the future, care will be supplied predominantly by nonmedical staff, with patients playing a much more active role in their own care. Medical staff will act as master diagnosticians and clinical decision-makers’.iii

Implications for community care services

  • Local Councils have already presided over 30% cuts in adult social care, with over 400,000 fewer people receiving social care services since 2010, and those in receipt getting fewer hoursiv. We have not heard councils explaining these cuts and protesting loudly and very publicly about them.
  • Local councils have outsourced the future of the social care sector to large financialised businesses which want to be paid more for doing the same (with no questions asked about their accounting and finance decisions). These businesses manoeuvre politically to reduce risk and avoid consequences, while threatening to hand back vulnerable residents when they go bustv.
  • We are concerned that Councils will preside over a similar demise of our NHS.
  • Fewer hospital beds, and early discharge mean more pressure on GPs, primary care and community care services. The changes will mean repeated tightening of eligibility criteria and more people excluded.
  • Social care staff increasingly required to take on tasks previously done by NHS professional staff. Safety risks and extra burden on family carers – predominantly women – and vulnerable patients have not been evaluated.
  • There is a myth that providing more and better care for frail older people in the community, increasing integration between health and social care services and pooling health and social care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.”vi

A better future for the NHS: the risks and The NHS Bill

  • Our health service is being re-modelled in a way that will be ripe for wholesale privatization and insurance-based care, leaving a low quality rump NHS for those who cannot afford private insurance.
  • We are very concerned that this is the Government’s plan for future healthcare.
  • At least £4.5bn per year is wasted on simply managing the NHS market, and more on private profit
  • Procurement Rules mean that any marketized service is prey to international healthcare corporates.
  • There IS an alternative to this wholesale devastation. We want out Councils to support the NHS Billvii that will reinstate a publicly funded, publicly provided, accountable NHS. This Labour private members’ Bill, drafted by Professor Allyson Pollock and barrister Peter Roderick, is supported by Labour, the Greens and the SNP, and will receive a second reading in Parliament on 24th February 2017.

What we want from CCGs and councils

We understand and accept that CCGs and Councils are required to manage sharply diminishing resources – but we ALSO expect our political representatives, together with other councils, to explain and shout from the rooftops to protest the devastating impact of these cuts and service changes to local people, and campaign forcefully for the NHS Bill.

The NHS will last as long as there are folk left with the faith to fight for it. Aneurin Bevan, 1948

vii www.nhsbill2015.org/

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The NHS Consultants’ Association changed its name last year to make it clear that all doctors, not just consultants, were welcome to join.

They campaign for the restoration of the NHS as a publicly funded, publicly provided and publicly accountable service. This means the abandonment in England of the market based policies of the last 20 years, primarily by abolishing their key feature, the artificial separation into “purchaser” and “provider” as has already been achieved in the rest of the UK.

Their objectives are to:

  • Restore the NHS as a publicly funded, publicly provided and publicly accountable service
  • Secure fair access to health services based on needs not wants.
  • Promote professional and public involvement in evidence based planning of health care services.
  • Highlight current problems and controversies faced by the NHS and suggest solutions to them.
  • Help consultants to engage with policy making and management

The SHA works closely with DFNHS, and we have many joint members.

More details on their updated website.

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“the NHS is under threat of being carved up and sold off”

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 Why I Love the NHS

by Carl Walker

All royalties from the sale of this book will go to the NHS Support Federation

Publishing 27 February 2015 • Paperback • £9.99 • ISBN: 978-0-7198-1443-3

To request a review copy, or for all other publicity enquiries contact Sarah Plows: publicity@halebooks.com 020 7251 6551 ● www.halebooks.com

‘One of the things that has been missing during the debate over the NHS is something that speaks to the experiences of normal folk and reminds people just what an amazing thing a public national health service really is. Like so many British people, I have used the NHS for a number of reasons throughout my life – some serious, others less so – but where would I be now without it? I honestly don’t know.’

This book represents the real-life stories of all of us who are routinely and often unnoticeably held together by the people who work in the NHS. These are the people who patch up, sew back together, irradiate, advise, scan, plaster, console, repair, inject and support us, before delivering us back home to carry on our lives.

A sharply observed collection of sometimes outrageous, often excruciating but always entertaining accounts of different interactions with one of Britain’s greatest treasures.

Carl Walker is a principal lecturer in psychology at the University of Brighton and has fifteen years’ experience researching and publishing academic work on human behaviour. He is uniquely qualified to write this book on account of having embarrassed himself more times in a medical setting than any other human being alive.

‘Nothing about the savaging of the NHS makes me laugh. Until this book. Carl Walker mounts a timely defence of our National Health Service that just happens to be laugh out loud funny. Ideal for fans of ‘not dying’ everywhere.’ – Rufus Hound, Comedian

‘A thoroughly enjoyable antidote to much of the nonsense peddled about the NHS these days….lively, sharp, informative.’ – Oliver Huitson, Co-Editor, openDemocracy

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Lord Ashcroft has conducted some interesting research into the views of the public on the NHS.  It’s a substantial piece of work with a poll of over 20,000 people and day-long discussions with 80 members of the public.

He found discussing the practicalities of the future of the health service was hard because the subject is laden with emotion: one of the participants  described the NHS as “the soul of Britain”. Talking about potential reforms, even when aimed at ensuring the sustainability of the service in the long term, felt to many like an affront and made  them defensive.  Public understanding of the NHS is poor.  Most participants did not realise that NHS spending had doubled in real terms under the last government; greatly overestimated the proportion of NHS staff who were managers or administrators, and the cost to the NHS of “health tourism”; and were surprised to learn that around nine in ten prescriptions were free, or that most GPs were self-employed.

He found that people could be divided into 5 segments:

  • ‘Concerned Status Quo’ (28%): They see little justification for large-scale reforms. They are the least likely to support proposals like the use of more private providers, consolidating services into bigger units, introducing charges or holding down staff pay as a means of easing financial pressure, and the most positive about increasing funding by borrowing more, reducing the deficit more slowly or cutting other areas of government spending. Younger, poorer, likely to vote Labour.
  • ‘Armchair Realists’ (24%) recognise that the NHS faces big challenges and say reform is needed, but are very sceptical about many of the potential avenues for change.  Well off, educated, likely to vote Conservative not UKIP.
  • ‘Cautious Reformers’ (19%) more positive than most about recent reforms and more comfortable with the use of  private providers, more likely than average to support linking treatment priority with lifestyle. Older, White, homeowners. Likely to vote Conservative or UKIP.
  • ‘Founding Idealists’ (17%) Less worried than other groups about bureaucratic waste, or lack of funding. Generally negative about recent reforms and oppose the use of private providers.  Young. Mostly Labour voters, but many won’t vote at all
  • ‘Entitlement Protection’ (12%)  Rate too many people using the NHS who have not paid into it as the biggest long term issue facing the service. More likely than average to think that people who  smoke, drink or eat too much should receive lower priority. Not highly educated. Poorer. Likely to vote UKIP or Conservative.

79% of those polled said they had used NHS services in the last six months:  70%  had visited their GP; 29% outpatient care;14% had
visited A&E.   74% of those who had experienced day surgery, inpatient care or A&E would recommend the service they had received to their friends and family.

When asked how good or bad they thought NHS services were in the country as a whole, the proportion awarding a good score fell to 30%. This was higher in Scotland (61%) than in England (56%) or Wales (53%).

There was almost equal agreement that “the NHS is one of the greatest health services in the world” (74%) and that “the NHS is very much under strain. Waiting times for elective care are going up, the four-hour A&E target is deteriorating and hospitals’ ability to get patients through properly is being affected (75%). It was notable that 80% of those aged 55  and over agreed that the NHS is one of the greatest health services in the world, compared with 64%  18 to 24 year-olds.  69% agreed with Andy Burnham (though without knowing he had said it) that the NHS “is heading for the rocks and we urgently need a plan to turn things around”, but only 45% agreed with Unite the Union that “David Cameron is wrecking our NHS” and 30% agreed with Dr Dai Samuel, Chair of the BMA Welsh Junior Doctors Committee who said “Looking at how bad the health service is, I would  not want to be a patient”. The lowest levels of agreement, however, were for statements suggesting the NHS had never been  better. Only 22% agreed that “the NHS has more doctors and more nurses than ever before” or that “fewer people than ever are waiting long periods for their operations” –both extracts from Jeremy Hunt’s Conservative Conference speech in October 2014, though respondents were not told this.

How big a problem do you think each of the following is for the NHS today?

(0 = not a problem at all, 10 = a very big problem indeed)

  • Too much being spent on management and bureaucracy: 8.21
  • Patients being denied drugs or treatments that could help them, because of cost: 7.60
  • Shortages of doctors, nurses and other clinical staff: 7.48
  • Variation in standards of care and treatment between different hospitals and areas of the country: 7.45
  • Hospital closures and other cuts: 7.40
  • Waiting times between diagnosis and treatment: 7.15
  • Low pay for NHS staff: 7.05
  • Trouble getting GP or other appointments at a convenient time: 6.87
  • Standards of cleanliness of hospitals: 6.45
  • Patients not being informed or involved in decisions about their own treatment: 6.26
  • The quality of nursing care provided in the NHS hospitals: 6.00

How much do you trust the following to tell you the truth about how the NHS is performing?

(0 = not at all, 10 = completely)

  • Your own personal experience: 8.10
  • Friends or relatives who work in the NHS: 7.64
  • Family and friends who have recently used the NHS services: 7.50
  • Your GP: 6.84
  • Organisations like the Royal College of Surgeons or the Royal Collage of Nursing: 6.76
  • Local TV or radio news: 5.52
  • National TV or radio news: 5.39
  • Local newspapers: 5.35
  • Unions like UNISON and Unite: 5.21
  • National newspapers: 4.85
  • Your local MP: 4.71
  • Andy Burnham, the Labour Shadow Health Secretary: 4.55
  • David Cameron: 4.09
  • Jeremy Hunt, the Conservative Health Secretary: 4.01

The full report – well worth reading – is here.

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The Health Service Journal organised a poll of 2000 voters across England in June.

They found that 70% of those questioned agreed that the principle of healthcare free at the time of delivery was under threat.  Of course no politician has actually proposed such a thing, but the idea is repeatedly raised by people within the NHS. And a large majority agreed with the statement that “The NHS is under threat from private healthcare companies”.  But half of them agreed that “If care is free it doesn’t matter if it’s publicly or privately run”, so it’s not very clear exactly how they though the NHS was threatened.  But 97% believed the NHS was worth fighting for, and 92% that it was integral to maintaining social equality.

It was closure of Accident and Emergency departments which most worried people 75%, while only 50% were worried about the possibility of introducing some charges and around 55% worrying about restrictions on medication or treatment.  The idea of moving services out of hospitals into the community was popular. 79% of young people were enthusiastic using smartphones to monitor their health. Older people, unsurprisingly, were less enthusiastic.  Younger people, though showing lower levels of support for the basic principles of the NHS, said they were more likely to change their vote based on NHS policy. This might be because they were generally more likely to change their vote than older people.

NHS Polling

90% agreed that NHS funding should rise as the economy improves. As usual most people felt the Labour Party understood the NHS and most thought the Conservative Party threatened it, but this advantage was much less when asked about running the service efficiently.  HSJ plans to repeat its survey quarterly until the General Election.

Two weeks ago Ipsos MORI did a survey for the British Medical Association of 1970 people across Great Britain. The BMA were no doubt pleased to find  66% are in favour of doctors having a greater say in how the NHS is run, and that 73% believe policies about the NHS from political parties are designed to win votes, not to do what is best for the NHS. They might have been disappointed to find that only 21% wanted to see less involvement by NHS managers in running the NHS.  However 64% agreed that “The NHS should manage itself, without the involvement of politicians, as it understands how best to provide healthcare.”

56% were satisfied with the running of the NHS.

Ipsos MORI Social Research Institute did a  Tracker Survey of Public Perceptions of the NHS for the Department of Health between Spring 2000 and Spring 2012. They seem to have abandoned it now, perhaps because they found a fall in agreement that “the government has the right policies for the NHS since December 2009 (from 28% to 22%)  continuing a steady decline since 37% was recorded in December 2009. 45% then disagreed that the government had the right policies.

There was a marked North/South gradient in responses to the question “Overall, how satisfied or dissatisfied are you with the running of the National Health Service nowadays?” 72% were satisfied in the North East, but only 61% in the South East.  There were similar gradients in social class.  72% of those in social classes D and E were satisfied compared to 64% of those in social classes A and B.  But the most significant feature was the marked reduction in satisfaction among those who were not actually users of the service – presumably because of the bad publicity generated by the campaign against the Health and Social Care Act.

NHS Satisfaction 2003-12 59% thought the reforms would make services worse for patients. 70% blaming both closures and privatisation.

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I went  to see an interesting play, This May Hurt a Bit, about the NHS in Bolton three weeks ago and thoroughly enjoyed it.  It is mostly about the politics of the NHS in England. I especially enjoyed the appearances of Nye Bevan, Winston Churchill and the Grim Reaper.  It’s on at the St James Theatre in London from 14 May – 21 June 2014

The producers, Out of Joint,  have kindly sent me a copy of the script.  There are 26 characters.  They produce it with a cast of 8, doubling up.  The set isn’t complicated.  It would be perfectly possible for amateurs to produce.

The play starts with Nye Bevan’s speech on the appointed day and moves quickly forward to 2011 where David Cameron is looking through the Health and Social Care Bill, which he confesses not to have read, and being briefed by Sir Humphrey.  From there we go to hospital where a surgeon is examining Nicholas’s prostrate gland, and then to outpatients.  The hospital is clearly struggling and Cassandra, a woman all too reminiscent of many NHS campaigners I have met, bursts out of the audience talking about the trade treaty which will enable US companies to take over our public services.

In the next scene a 65 year old confused lady turns out to be the NHS, hooked up to a life support machine, who explains the difficult relationships she has had with a series of Prime Ministers.

Stephanie Cole

Stephanie Cole

Nicholas’s sister turns out to be married to an American surgeon, called Hank, who is an advocate of commercial medicine, but his mother Iris  (played by the wonderful Stephanie Cole) is a powerful, if surprisingly foul mouthed, advocate for the NHS.  The family dinner party is interrupted from the audience by the interventions of Winston Churchill, and Bevan.  Their political argument is then interrupted by a lesson on the Private Finance Initiative.

Subsequently Iris has a fall which causes her to lose her memory and believe herself to be in the 1970s. Transient Global Amnesia, it’s described as, which to my surprise is a genuine diagnosis. The visiting paramedics have more words of political wisdom about the futility of changing structures.  So does the lady from the weather centre, who tells us about hospital closures.  The hospital ward is pretty chaotic. So is the Board of Directors.  But Iris continues to defend the NHS against Hank, who wants to send her to a private hospital.

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It was back in 2004, that the then Conservative shadow chancellor, Oliver Letwin, astonished his audience (of businessmen in Dorset) was reported as saying that within five years of a Conservative election victory “the NHS will not exist anymore.   Well look what happened – they’ve only been back in for 4 years and the NHS is already on its knees.  He may not have got the timescale quite right, but if the Tories get back in next year, the NHS that we have known for 65 years – the envy of the world, the greatest British achievement of the post war years, will disappear into a morass of private insurance, multinational run, cash rationed, postcode lottery chaos. 

NHS for people not for profit

The documentary film, One Thousand Thank Yous, shows what can happen though, if local groups fight back.  We don’t have to take it!  Please pledge.

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