A Better NHS

Thanks to Ron Singer for collating this.

Extraordinarily Lansley, Cameron and Burns all insisted that doctors supported the reforms today. Who’s been on the hallucinogens?

Doctors vote to axe Tory NHS reforms in embarrassing blow to Lansley
Daily Mail – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)
Doctors demanded the scrapping of NHS reforms yesterday in an embarrassing slapdown for Andrew Lansley. At an emergency meeting, the British Medical Association said the Health and Social Care Bill, currently going through Parliament, must be withdrawn. Also:-

Doctors urge the Government to abandon health reform bill
The Independent – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)
BMA chiefs demand Andrew Lansley scraps ‘dangerous’ reforms
Daily Mirror – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)

Healthy to fight plan
Daily Mirror – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)

BMA urge ministers to scrap ‘top down reforms
Telegraph – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)

Doctors call for a halt on NHS reform bill
Metro – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)

Ministers face fury of doctors over NHS reforms
Yorkshire Post – Wed 16 March 2011(BMA mention, quote Hamish Meldrum)

Plans to overhaul the NHS will harm patient care, says doctors
Evening Standard – Tue 15 March 20011 (BMA mention, quote Hamish Meldrum)

Doctors ‘want halt to NHS plans but reject opposition’
BBC News Online – Tue 15 March 2011 (BMA mention, quote Hamish Meldrum)

Doctors call on Government to scrap NHS reforms
C4 News Online – Tue 15 March 2011 (BMA mention, quote Hamish Meldrum)

BMA members call for Health Bill to be withdrawn
Hospital Dr – Wed 16 March 2011 (BMA mention, quote Hamish Meldrum, Andy Thornley, Jacky Davis)

National Health Service: Dogma, democracy and the doctors
The Guardian – Wed 16 March 2011 (BMA mention)

Doctors’ U-turn
The Sun – Wed 16 March 2011(BMA mention)

BMA rejects Health Sec ‘no confidence’ vote
Sky News Online – Tue 15 March 2011 (BMA mention)

The Times (Wed 16 March, p10) – has a piece on the SRM and reports that the BMA has demanded the Health Secretary scraps his plans for NHS reform.
(BMA mention and Hamish Meldrum quote)

The FT (Wed 16 March, p9) – has a piece on the SRM and also reports that the DH are disappointed that the BMA has hardened its opposition.

Experience shows that for-profit hospitals try to avoid the responsibility for comprehensive healthcare
Sir, Shirley Williams (Opinion, Feb 28) gives a perceptive analysis of the catastrophic effect that awaits health care if Andrew Lansley’s proposals become law. Those who wish to use market forces in the health service must realise that the regulation needed to ensure co-operation in a multi-unit competitive health service run for profit will be both very difficult and very expensive.
Experience shows that for-profit hospitals try to avoid the responsibility for comprehensive healthcare. Existing private hospitals in the UK regularly transfer patients requiring intensive care to NHS hospitals. Some private hospitals in the US have declined to provide services such as obstetrics, have tried to avoid accepting patients with complex problems and have exploited loopholes in necessarily complex regulations to maximise profits.
GP fundholding would be a very expensive and probably misguided experiment with destabilisation effects, and with costs that in the short term have to be taken out of patient care. Allowing commercial organisations to take over any of the hundreds of NHS hospitals or GP groups will be a privatisation that will dwarf that of the railways in scale and in regulatory problems.
The taxpayer will pay for the huge administrative costs and the company profits, as well as for the healthcare, while the general practice consortia and the hospitals will be primarily motivated by a requirement to concentrate on patients with illnesses where they can make the biggest profit.
For the Conservatives and the Liberal Democrats to form a coalition when the country’s finances were critical is understandable; for the MPs and peers of both parties to support a measure based on unproven theory that was not in either manifesto, and would introduce expensive and irreversible changes to the detriment of patient care, would be unforgiveable.
Professor Sir Dillwyn Williams
Cambridge
Sir, The handing over of control of local medical practices to GPs, who are not democratically accountable and have neither the time, inclination or the accounting experience to manage their practices properly without costly administrative help, is a crude step towards privatisation that will further distance NHS patients from the personal attention from their doctors that they have a right to expect.
I do not understand how David Cameron and Nick Clegg have allowed the Government they run to be hijacked by Mr Lansley in this way. His reforms are ideologically motivated and organisationally flawed. They should be opposed by all parties. The country has higher priorities at present.
Adrian Slade
London SW14

Sir, My colleague Shirley Williams echoes criticisms I made of the Government’s Health Bill during its recent second reading. For Ministers to believe that they can push through the biggest reorganisation at the same time as seeking the greatest efficiency gain in any health system in the world shows that they have allowed their ambitiousness to become megalomania.
The Government is leading our NHS into an avoidable high-speed train crash. Although the easy pickings from the wreckage will be gleefully picked up by the private sector, most informed observers are warning that the core of the NHS may be fatally wounded.
Andrew George, MP
Liberal Democrat member of the Health Select Committee

Pace and scale of Reforms

1.This meeting calls for the BMA to investigate the legality of the government’s action in implementing significant parts of the Health and Social Care bill ahead of its ratification by Parliament, and then to take any appropriate legal action.

That this meeting demands the BMA oppose the Health and Social Care bill in its entirety as the Coalition Government has no mandate to enact it.

2.This meeting believes the NHS provides a high quality, cost effective, equitable, accessible, popular service. The NHS is not broken. The government has no mandate to dismantle it and has provided no justification for the changes and no convincing evidence to support its claims. The governments proposals will work against integration of primary and secondary care, which is necessary to improve the quality, safety and efficiency of patient care.The proposals are being rushed through, untested and at enormous cost, destabilising existing management structures and putting the NHS at great risk.

That this meeting insists that the BMA must cease its policy of critical engagement and oppose the Health and Social Care Bill outright. The BMA must instead lead in the development and publication of evidence-based policies, which build upon and improve the service we already have.

The engagement of Patients

3.That this meeting instructs the BMA to inform the public, and the Coalition Government, that many GPs have signed up for pathfinder status, not because they support the Health and Social Care Bill, but through fear that the government will drive through the changes and ignore the results of any consultation.

Expansion of the market

4.This meeting believes expanding the role of the market and encouraging an ‘any willing provider’ policy is in our view the antithesis of continuity of care, integrated planning and collaboration between healthcare professionals to provide high quality patient care. These are non negotiable core values of our NHS. These values are undermined by expanding the market into healthcare provision and encouraging any willing provider.

That this meeting demands the BMA actively oppose the Health and Social Care Bill as a whole until the planned expansion of the market and offers to any willing provider are removed.

5.This meeting believes the Health and Social Care Bill will encourage a market based approach to healthcare that will worsen health inequalities, and put at a disadvantage the most vulnerable and unwell in society who are unable
to exercise true choice. This is contrary to the founding principles of the NHS to provide equitable healthcare according to need.

That this meeting demands the BMA oppose the Health
and Social Care Bill in its entirety.

Price Competition and competitive tendering

6.This meeting notes there is extensive evidence that price competition between private sector providers of health care does not provide good quality patient care. The Health and Social Care Bill plans to introduce both price competition and competitive tendering into the NHS. We believe the legislation as it stands will threaten the standard of patient care, undermine collaborative practice and the integrity of the NHS.

As our voices were not heard through consultation, that this meeting demands that the BMA actively oppose the Health and Social Care Bill as a whole until price competition and competitive tendering are removed from the legislation.

7.This meeting notes the NHS is funded by public money. Therefore the privacy laws around prices paid to private providers of medical care to the NHS should not apply. This is essential in order to ensure transparency for the tax payer and appropriate use of public monies.

That this meeting commits the BMA to lobby the government to add a clause to the Health and Social Care Bill removing financial secrecy agreements for any organisations who are providers within the NHS .

Implications for the future of education

8.This meeting believes the education of the future NHS workforce is crucial to the ability to continue high quality care and to ensure high quality clinical governance. This health and Social Care Bill threatens the delivery of comprehensive integrated education to all members of the workforce. The ability to teach will be put in peril by a multiplicity of providers with little interest or incentive to provide education.

That this meeting demands the BMA oppose the Health and Social Care Bill as it will destroy the comprehensive national delivery of high quality education.

The principle of clinician led commissioning

9.This meeting believes that the purchaser-provider split in all its various incarnations over the last few decades has not improved the NHS. This meeting agrees with the Commons Health Select Committee which stated in March 2010 that commissioning in the NHS has been ’20 years of costly failure’. Further pursuit of this failed idea will further fragment the NHS and lead to a dangerous rift between primary and secondary care.

That this meeting demands the BMA must implacably oppose any legislation that does not remove the purchaser provider split from health care provision. (meeting would like the BMA to note that this is a very important motion)

The future of Public Health

10.This meeting has concerns that the lack of clarity and guidance to GP consortia regarding public health involvement in commissioning, including the development of Health and Well-being Boards, will lead to lack of integrated working between GP Commissioning Bodies and public health specialists in effective and imaginative strategic planning of healthcare for local populations.

That this meeting demands the BMA oppose the Health and Social Care Bill in its entirety until consultation and planning between Public Health
Specialists, Local Government, and patients have been undertaken and guidelines for integrating pubic health involvement in GP consortia commissioning are established.

11.This meeting believes that the governments plans to work with the commercial food and alcohol industries to improve healthy eating and drinking habits in the general population is akin to putting the criminal in charge of the justice system, and is an insult to the intelligence of the population.

That this meeting calls for complete separation between
public health and commercial food and alcohol interests, and that the BMA demands this

Examples  from two London BMA divisions for the Special Representative Meeting to be held on March 15th

1. This meeting has no confidence in the Secretary of State for Health, Mr Andrew Lansley.
2. This meeting opposes the provisions of the Health and Social Care Bill as they will be detrimental to the future of healthcare delivery in the England.
3. This meeting believes that the provisions of the Health and Social Care Bill are not in the best interests of patients, the public or the wider NHS.
4. This meeting believes that the Health and Social Care Bill will end the NHS as we currently understand it, as a publicly owned and provided service.
5. This meeting believes that the Health and Social Care Bill will result in the NHS becoming a franchise rather that a coordinated public health service.
6. This meeting believes that there is no evidence to support the contention that a market system will improve the quality of care in a nationally delivered heath service.
7. This meeting believes that the vast majority of evidence demonstrates that a market system is detrimental to the delivery of an equitable, cost-effective and quality driven health service.
8. This meeting believes that price competition drives down the quality of health care and insists that the BMA should rigorously oppose the introduction of such measures into the NHS
9. This meeting believes that the NHS should remain the preferred provider of healthcare services in the UK
10. This meeting believes that the policy of ‘any willing provider’ outlined in the Health and Social Care Bill will lead to the disintegration of the NHS
11. This meeting believes that the commissioning of healthcare must involve a partnership between GPs, Public Health physicians and hospital based Consultants, if it is to succeed.
12. This meeting believes that the Health and Social Care Bill reforms are potentially so detrimental to the care of our patients, that the BMA should consider industrial action to prevent their implementation.
13. This meeting believes that the Health and Social Care Bill is designed to disguise the wholesale privatisation of the NHS under a veneer of patient choice and clinically lead commissioning
14. This meeting opposes the separation of commissioning and the provision of Post Graduate Medical Education as it’s based on unproven political dogma, rather than any sound evidence.
15. This meeting believes GP commissioning consortia are being set up to become the ‘fall guys’ for Andrew Lansley.
16. This meeting believes that cooperation and integration between social and health care will be adversely effected by competition between healthcare providers
17. This meeting believes that and the creation of a market system and subsequent fragmentation of the NHS will create significant conflicts of interest and introduce huge opportunities for corrupt practices across the health service and calls on the BMA to expose this risk to the public purse.
18. This meeting believes that Public Health services should not be reformed whilst the NHS and Local Authorities are both undergoing severe service reductions.
19. This meeting believes that the purchaser provider split has been a disaster for the NHS ever since its introduction and calls on the BMA to continues to oppose it wherever possible.
20. This meeting believes that the Health and Social Care Bill is a disaster waiting to happen and urges the BMA to publicise to the general public, the degree and nature of this threat to the NHS,
21. This meeting believes that ‘local risk pooling’ with create health care ghettos and increase health inequalities.
22. This meeting accepts that the NHS must change to respond to difficulties caused by altered patient demographics, development and costs of medical technology etc but does not believe that the Health and Social Care Bill provides the correct solutions to these problems.
23. This meeting believes that standards of Post Graduate Medical Education can not be guaranteed where healthcare is delivered by ‘any willing provider’.
24. This meeting believes that GP commissioning consortia must hold all meetings in public and that their decisions must be made known to their local population.
25. This meeting believes that the total cost of the NHS redundancy payments, due to the abolition of Primary Care Trusts (PCTs) and Strategic Health authorities (SHAs), must be made public before the next general election.
26. This meeting believes that the government has no mandate for the introduction of the changes to the NHS outlined in the provisions of the Health and Social Care Bill.
27. This meeting believes that the government has no mandate for the introduction of the changes to the NHS outlined in the provisions of the Health and Social Care Bill and calls for a national referendum, to coincide with the referendum on electoral reform, to confirm that the general public support its provisions, before the Bill can be enacted.
28. This meeting believes that the speed of implementing the provisions of the Health and Social Care Bill will be potentially disastrous for the NHS.
29. This meeting believes that the BMA should poll its membership before the 2011 ARM, to consider the scope and scale of potential industrial action which might be required to oppose the implementation of the provisions of the Health and Social Care Bill.
30. This meeting believes the public should be informed about the level of qualification of anybody delivering their healthcare.
31. This meeting believes that GP commissioning consortia should purchase services based on their patients’ medical need and not on their wants, where the latter has no supportive evidence base.
32. This meeting believes that the BMA should withdraw from any further ‘critical engagement’ with the government concerning the Health and Social Care Bill and calls on the profession to actively oppose its introduction.
33. This meeting believes that the National Commissioning Board must be appointed through an open and transparent mechanism and that any relevant person specifications and job descriptions must be in the public domain.
34. This meeting believes that the National Commissioning Board must have significant clinical representation from a variety of health care professions, including community and hospital based physicians.
35. This meeting believes that there is no place for ‘commercial confidentiality’ in a publicly funded health service.
36. This meeting believes that the terms of all financial transactions between the NHS and external contractors over the value of £250,000 should be made public.
37. This meeting believes that all GP commissioning consortia should be required to hold their meeting in public and make their accounts available to public scrutiny
38. This meeting believes that all GP commissioning consortia should have at least 1 lay member and 1 hospital based consultant on their Boards.

Here is a letter I wrote about a patient who was discharged from hospital last year. I was quite upset, as you can tell. Names have been changed to protect confidentiality, but it’s otherwise exactly what I wrote:

Dear Consultant/ ward sister/ Hospital Chief Exec.

I visited Mr Bloggs at home today just a few hours after he was discharged from 2 weeks on Ward 3 under your care.  When he arrived home he looked as if he had spent 2 weeks sleeping on the floor of a hostel for alcoholic sailors rather than on the acute ward of an NHS hospital.  He had an enormous beard, he was absolutely filthy and he was disorientated.  If I had taken photographs of him and sent them to the national newspapers there would be no doubt that he would be on the front cover of all of the grubby tabloids and probably some of the more serious newspapers.  I simply cannot believe that this is happening on your watch to one of my patients.  His carer spent over 2 hours cleaning and shaving him when he got home and I went round to visit as soon as I could so I could help to make sense of the mess of his medications.

I would be grateful if you could give me your considered response and assurance that this won’t be happening again.

Mr Bloggs, has metastatic cancer and is quite easily disoriented. He is quiet, gentle and uncomplaining, like many elderly people.

I’ll quote from the letter of response:

Mr Bloggs medical and nursing notes are comprehensive and note that he was assisted with personal needs. … a heavy beard is not recalled … he was regularly monitored and well attended to … he did not voice any concerns … he engaged well with staff and there were no reports via staff of dissatisfaction. I appreciate patients do not always feel comfortable raising concerns but usually there are indicators that staff will pick up on.

Mr Bloggs social worker … has also confirmed that Mr Bloggs did not raise any concerns about his care on the ward.

I am sorry that there is such concern about Mr Bloggs care. I appreciate that this may be an unsatisfactory response from me and I certainly do not wish to be, or appear, defensive.

There are a few important points I think come from this.

1. Many elderly patients, like Mr Bloggs, do not complain, or ask for things they need. The have to be looked after, they need doctors and nurses to advocate for them and to be pro-active about their care rather than waiting to be asked for help. The political project to convert patients who need looking after into consumers who can advocate for themselves needs greater criticism.

2. Shocking as this may seem, it is possible for people to be neglected while everybody is following procedures and for nobody to notice. Box-ticking medicine and nursing cannot ensure personal care.

3. Patient choice (part of the project to convert patients into consumers) is not likely to improve the situation, Mr Bloggs and others like him, will keep going back to the same hospital and being neglected. There are no shortages of patients like Mr Bloggs. As a local GP I want my local hospitals to improve the quality of care, it simply isn’t practical for many of my patients to go to another hospital next time they are critically ill. See this post for an example of patient choice worsening inequalities.

4. In my practice, every complaint is subject to a ‘critical and untoward incident analysis’ with a plan drawn up to try avoid something similar happening in future.  Hospitals need to respond to complaints in a way that demonstrates action is being taken to prevent the same problem happening again and they need to be assessed, as we are, to ensure that action is taken.

5, Hospitals must, urgently improve the personal  care of patients. The neglect of the elderly quite rightly horrifies us. It is inexcusable. But if we want better personal care, we need more nurses (or more care assistants) and we have to pay for them. This is impossible whilst the government are trying to achieve the cheapest universal healthcare in Europe by making £20bn cuts and spending £3bn on a massive re-disorganisation.

6. My patients complain about hospital care quite a bit. Only rarely is it necessary for me to complain on their behalf.

See also

BMJ blog by Allison Spurier. Caring for Older People

Patient abuse, a Bad Case of Mangement Blowback. Badmed.

The news this week that you may have to phone a call centre to make an appointment with your GP needs a little more explanation than it’s so far received.

At my practice we have nearly 11000 patients, 9 doctors and 6 receptionists. We offer about 600-700 appointments a week not including about the same number of phone calls from doctors to patients for advice.

Approximately 30% of our practice population changes every year, which is typical for an urban practice. Our most vulnerable patients, the elderly, illiterate, learning disabled and mentally ill tend to be less mobile than the younger professionals.

Early last week a new patient came in to make an appointment, she wanted to be seen the following afternoon at around 5pm. When the receptionists told her that there were no appointments then, she started screaming at them, “I’m a professional! I pay my taxes! Don’t you people know how busy I am!”

Our receptionists have a high threshold for abuse. They are shouted at and sworn at on the phone and face to face several times a day. Occasionally they are spat at and patients throw things at them. We look after patients who are excluded from normal society, including about 100 registered heroin addicts, at least as many alcoholics, wife-beaters and child abusers. Many of our patients never go out, except to come to the surgery because they are crippled by anxiety, paranoia and inability to cope with normal social interactions. The movie Mary and Max offers a wonderful sensitive insight into the life of someone who suffers problems like many of our patients.

Because we have a very low staff turnover, our receptionists know what to do when Brian starts banging his fists on the desk, when Shirley collapses drunk on the floor in the middle of reception, when Joyce starts undressing and when Sandra rings up screaming that the devil has stolen her tea bags again. They know that when Sidney who has schizophrenia and serious complications from his diabetes comes in looking anxious that they can call one of the doctors or nurses to review him opportunistically because he rarely ever comes in for an appointment. They know that when Fatima calls to say she has chest pain she doesn’t need an urgent appointment, but when Arthur says he feels breathless he needs urgent medical attention.

When young professionals scream at the receptionists it upsets us all because they are there to help. It offends and upsets us because we know how vulnerable our other patients are and how hard it is for them to get anything. It upsets us because we know that when the angry professional sees the doctor they won’t treat the doctor like the receptionists. It upsets us and it is offensive because healthcare should be distributed according to clinical need, not according to how much tax people pay. It offends our other patients who cannot work and don’t pay tax. It offends patients with mental illnesses that I am seeing every week because their Employment Support Allowance (ESA) has been cut after a 10-20 minute assessment that is hopelessly inadequate at judging the functional disability of their illness, and consequently their lives are filled with endless paperwork, appointments and anxiety-inducing beaurocracy trying to appeal or cope without the money. They are also busy.

Another patient, dismayed at the difficulty getting an appointment with her GP at another practice and at what she thought was unprofessional behaviour, said, “Give me a headset monkey any day.”

I’ll leave aside the reference to someone in a (likely Indian) call centre being a ‘monkey’, it’s offensive, but it’s off subject. Unprofessional behaviour needs to be brought to the attention of the practice manager, and though it’s also off-subject, I strongly support the National Association for Patient Participation Groups as a way for patients, doctors and receptionists to work together to improve the service in GP surgeries.

The underlying problem with the angry professional is one of social inequality. She cannot cope with a system that tries to treat everyone equally at the same time as prioritising the most vulnerable. As I cycled past a surgery in Kensington yesterday I wondered if a patient there would shout out loud in the waiting room, “I pay my taxes!”  or would it loose its effect in a room full of tax-payers?

The point I am emphasising here is that GP receptionists have to face the most challenging people, under the most stressful circumstances every day. They are part of the team that looks after our patients and their insights are vital.

They cannot and should not be replaced with call centres.

The answer to the questions that remained after yesterday’s post

Q.Why are private companies queueing up to ‘help’ with GP commissioning and why are some GPs so enthusiastic?

A. Because of the profits

From Alice Miles, New Statesman 07.02.2011

To quote the bill: “The board may, after the end of a financial year, make a payment to a commissioning consortium if, in the light of an assessment carried out under Section 14Z1, it considers that the consortium has performed well during that year . . . A commissioning consortium may distribute any payments received by it under this section among its members in such proportions as it considers appropriate.” These payments will be made every year. There’s no need to wait and see whether this system will damage care down the line. There is a clear financial incentive to do exactly as Lansley directs.

Q. How will they make money?

A. By rationing care. As Shane Gordon, chief executive of the North East Essex GP Commissioning Group pointed out in his DH blog,

unfettered choice = cost pressures ++

Or as two senior policy advisers said last week on twitter,

cannot see gpccs shaping markets, they will be buying off the shelf. Patient choice + awp [any willing provider] = no commissioning

In other words, patient choice is too expensive. We can either have patient choice and any willing provider or GP commissioning. But not both. And with £20bn cuts to make, choice will have to go. We can commission some services such as A&E and other emergency/ unplanned (acute) care. But this alone will not make the £20bn savings demanded by Lansley. To save money commissioning will have to severely restrict patient choice and/or reduce the amount of money paid to the providers.

They can do this in different ways.

Redbridge PCT has limited GPs to just 4 referrals a week. So if you’re in need of a specialist and a GP has used their quota, you have to wait and see if they have less referrals the following week, or wait for your GP to appeal.

My PCT, City and Hackney has bought out a long list of ‘de-commissioned’ services. As a result, one woman who had a gastric bypass operation 3 years ago has been refused funding for surgery to remove the excess skin that is hanging off her now that she weighs 12 stone less than she used to. When she had the original surgery she was told that the excess skin removal was part of the service. Not any more.

Another way to save money is for commissioners to refuse to register high cost patients. As extraordinary as this sounds this was a warning from Clare Gerada, head of the Royal College of GPs this week. The NHS has an enormous risk pool, meaning that the costs of one patient within the entire NHS are negligible, but the risk pool is being divided up into several hundred consortia so that a few very expensive patients could have a significant impact on the budget for a single consortia. For example if a few people need very expensive intensive care or cancer drugs they could seriously reduce the amount of money left for other patients (and the commissioner’s profits)

Another way is to only allow referrals to the cheapest providers. Since providers can compete to provide the cheapest service, this will be possible. But everyone agrees that competition on price in healthcare is dangerous because it leads to a deterioration in quality.

“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Health Service Journal

All of these potential solutions will restrict choice so patients will have very little say in their referral. GPs will have to select from a short list of value-for-money providers and quality will suffer.

The transformation of the NHS from a public service into series of businesses and the conversion of patients and healthcare into commodities is dangerous and foolish ideology.

This is part 2. See also 10 things wrong with GP commissioning.

In a letter to GPs in September Andrew Lansley defined commissioning:

Many of you recognise that you take commissioning decisions already on a daily basis – when advising a patient whether to self-care, managing a patient directly, prescribing a medicine, or when referring a patient to a specialist for further investigation and treatment.The purpose of the proposed reforms is to give you and your colleagues in general practice – as people who see patients every day and understand their needs – the responsibility to shape sevices to deliver high quality care that your patients expect and deserve.

[The reforms] are about giving you the overall responsiblity for the design of services which meet your patients’ needs and to respond quickly when failures  in services arise.

1. Lansley clearly doesn’t understand commissioning. Commissioning is based on a purchaser-provider split. It is when GP purchasers pay specialist providers to do things for their patients, such as major operations, heart scans, chemotherapy, psychotherapy, intensive care stays etc. All the things we cannot do ourselves. The things we can do ourselves, advice, reassurance, prescribing etc. are not commissioning, whatever Mr Lansley says, unless he expects me to set up a contract with myself so that having diagnosed you with eustachian tube dysfunction I can then give you some advice and reassurance.

There remains a tricky, false distinction between what GPs do in their surgeries, e.g. minor surgery, blood tests, physiotherapy and what hospitals do. Therein lies the potential for conflict of interest if as a GP (purchaser) I commission myself to do work usually done by a hospital (provider)

2. We already shape services, we have been doing for years. In City and Hackney we have worked out Care Pathways so that GPs and our local hospital specialists work effectively together and our patients can be sure that up to date clinical guidelines are followed and the appropriate investigations are ordered in the right place at the right time. So patients referred for infertility treatment are investigated before referral so that hospital appointments are not wasted repeating tests that could have been arranged by the GP.

Care-pathways like this can save money by minimising hospital appointments and can improve quality of care by disseminating guidelines and sharing expertise between GPs and their hospital colleagues. We don’t need a £3bn NHS reorganisation to do this.

3. GPs are already handing the ‘responsiblity to shape services’ to international health insurance corporations.

I am signed up with my colleagues to become a commissioning pathfinder consortium. This is not because I approve of commissioning, but because I believe I must be responsible. Our local GPs almost unanimously oppose commissioning as proposed in the health bill, but we fear that if we refuse,  a private company will be given the job instead. In fact last month it was reported in Pulse:

NHS London has awarded a contract to the KPMG Partnership for Commissioning to support the development of pathfinders across the capital.

The partnership, claimed to be the first of its kind, sees KPMG teaming up with UnitedHealth UK, the National Association of Primary Care, Healthskills, NHS Primary Care Commissioning and legal firm Morgan Cole.

A move that outraged many london GPs who were not consulted, and most of whom are unaware of lawsuits regarding fraud by KPMG and UnitedHealth in the US. A pathfinder consortia in west london called the Great West Consortium has already employed UnitedHealth to to their commissioning for them.

A commissioning enthusiast, Shane Gordon, GP in Colchester and chief executive of the North East Essex GP Commissioning Group said this about private sector interest in his pathfinder consortium on his new DH blog:

“We’ve been inundated with offers of ‘help’ and training from every quarter. The difficult bit will be choosing which ones will really add value.”

Private companies are queueing up to get involved in commissioning. There are shareholder profits to be made here. That’s money that won’t be going on chemotherapy or joint replacements.

4. There is a conflict between patient choice and commissioned care pathways. In my original post, 10 things wrong with GP commissioning, I couldn’t figure out how patients could have choice unless we commissioned several versions of each service. Now I know. When I refer you to a specialist you can choose who you see from a list on a computer program called Choose and Book. On the website it says the one of the benefits of Choose and Book is that:

You can choose any hospital in England funded by the NHS (this includes NHS hospitals and some independent hospitals)

The providers that appear on Choose and Book are determined centally by the DH, not by your GP commissioner. You are allowed to choose ‘any willing provider’. This could (if a Patient’s Rights Directive goes through) include providers from all over Europe.

A patient came to see me having checked the NHS Choices website and discovered that the Royal London Hospital for Integrated Medicine was on Choose and Book for fertility treatement. She was amazed at the range of options that included Harley St clinics … on the NHS! But she wanted homeopathy, so she chose the Integrated Medicine hospital. So we have spent enormous amouts of time and energy designing a care pathway and it has disappeared amongst hundreds of ‘willing providers’.

GP commissioners will be controlling providers like we control the supermarkets. See this blog from Anna Dixon of the Kings Fund, Providers need to get their act together while commissioners look the other way and this report from the BMA News: “A GP leader has said foundation trusts could become so powerful that they undermine new consortia”

5. Monitor is a central agency to ensure competitiveness. It means that the ENT service we have designed with a local ENT surgeon and a GP with a special interest in ENT who see patients together in a local GP surgery may not be eligible because it costs more for the initial referral than other ENT services even though we have very high satisfaction rates and very low rates of follow up. This saves money in the long run and is more convenient for patients. You can see what services are provided and guidelines for GPs here.

With thousands of services already on Choose and Book, GP commissioning will be better described as GP de-commissioning. With £20bn of cuts, far more services like A&E and maternity departments will be closed, or de-commissioned like these than commissioned.

In a Redbridge PCT GPs have been told that they are only allowed to make 4 referrals a week. Draconian measures like this may be replicated by GP commissioners in order to save money.

6. Private providers will be able to ‘cherry pick’ elective services that are easy to replicate and will the be able to register centrally with the NHS Commissioning Board, bypassing the commissioning consortia. Private providers may be paid 14% more than NHS providers in order to make a ‘level playing field‘ for competitiveness. This means that existing hospitals will be in serious danger of not being able to offer services cheaply enough to survive and may go bust.

7. GP commissioning cannot drive up quality or drive down costs if it is driven by patient choice. When I refer patients, the vast majority just want the closest provider. But this may not be so simple in future. Where I work in East London there is a lot of choice, for example there are 100 dermatology choices within 30 miles of my surgery. The criteria which determine where providers appear on Choose and Book is determined by the DH and are distance from the surgery and waiting time. Other details are only available on the NHS choices website and include nothing to help judge clinical quality.

Of the 51 patients I referred out of 807 appointments I made in the last 3 months of 2010 none were interested in provider choice. In almost every case they had to go through a time-wasting, complicated process called choose and book, and in almost every case they chose the local service.

The government are expecting quality and cost improvements to come from patients and GPs being sufficiently picky about their secondary care providers, that the providers are forced to compete on price and quality, driving prices down and quality up. But it cannot happen with GP commissioning.

8. Patients’ will not be empowered. In the Guardian today Lansley stated, “But beyond institutional accountability, genuine patient choice will bring a dramatic level of direct accountability to NHS providers.” This is not the case as Andy Cowper’s perpetualy insightful policy blog explains. The plan to put patients at the heart of the NHS lacks any substance.

In summary.

GP Commissioning is being taken up because most GPs believe that we have to be responsible for our patients, and the alternative is that we will loose what little autonomy we still have because private corporations will be given the job instead.

At the heart of GP commissioning is the purchaser-provider split which is more accurately called the GP-Hospital specialist split. Safe, effective and efficient care needs GP-Hospital teamwork, not a split.

Quality health care depends on quality training, teamwork and regulation. Not competition.

There will be far more de-comissioning and closures than commissioning.

GP Commissioning will be a disaster for patients, GPs and the NHS.

Update 20.1.2012

GPC warns CCGs could face ‘bureaucratic nightmare’ on tendering. GP news online

Update 29.1.2012

GP commissioning. What lies behind the hard sell? Martin Mckee & Lucy Reynolds GP commissioning JRSM

From Slavoj Zizek, Berlusconi in Tehran London Review of Books:

Kung Fu Panda, the 2008 cartoon hit, provides the basic co-ordinates for understanding the ideological situation I have been describing. The fat panda dreams of becoming a kung fu warrior. He is chosen by blind chance (beneath which lurks the hand of destiny, of course), to be the hero to save his city, and succeeds. But the film’s pseudo-Oriental spiritualism is constantly undermined by a cynical humour. The surprise is that this continuous making-fun-of-itself makes it no less spiritual: the film ultimately takes the butt of its endless jokes seriously. A well-known anecdote about Niels Bohr illustrates the same idea. Surprised at seeing a horseshoe above the door of Bohr’s country house, a visiting scientist said he didn’t believe that horseshoes kept evil spirits out of the house, to which Bohr answered: ‘Neither do I; I have it there because I was told that it works just as well if one doesn’t believe in it!’ This is how ideology functions today: nobody takes democracy or justice seriously, we are all aware that they are corrupt, but we practise them anyway because we assume they work even if we don’t believe in them. Berlusconi is our own Kung Fu Panda. As the Marx Brothers might have put it, ‘this man may look like a corrupt idiot and act like a corrupt idiot, but don’t let that deceive you – he is a corrupt idiot.’

The British Medical Journal depicted the Health and Social Care bill with a picture of Frankenstein’s monster on the front cover with ‘Bill’ on his forehead. They called the reforms “mad” and defended the use of the word,

We needed a word to communicate the sense of the government’s proposed reforms as being “mentally disordered or deranged; insane; resulting from or caused by madness; extremely and recklessly foolish” – the Chambers dictionary definition of the word “mad.” We were trying to be accurate, not clever.

Andy Cowper writes the Health Policy Insight blog has probably contributed more analysis to, and has more detailed knowledge of the NHS reforms than any other individual. His posts are full of scathing, mockery, and mild-expletive-laden-ire.

Scourge of homeopaths and the Daily Mail, Ben Goldacre’s response to Lansley’s presentation of medical statistics was titled ‘Andrew Lansley and his imaginary evidence’ but he made sure, as always to avoid politics,

I’m not in favour of, or against, anything here: all health service administrative models bore me equally.

There is an inherent danger here of not seeing the wood for the trees. In his excellent essay, Dehumanized: When math and science rule the class, Mark Slouka quotes Dennis Overbye,

Nobody was ever sent to prison for espousing the wrong value for the Hubble constant.

The arguments that really matter to people are moral, not scientific. They are about justice, equality, rights and wrongs. A close reading is better than a brief glance and good science as a foundation is self-evidently better than bad science, but we have to be able to extrapolate from facts about facts to implications for people and policy.

The government’s recent attempt to justify the reforms on the basis of health outcomes are a post-hoc distraction: in July last year I wrote, “Extraordinary changes require extraordinary justification backed up by extraordinary evidence” There was no extraordinary justification or evidence in the white paper. The references provided would have embarrassed a first year undergraduate.

As the Lancet reported in October, the justification is clear:

“The White Paper’s proposals are ideological with little evidential foundation. They represent a decisive step towards privatisation that risks undermining the fundamental equity and efficiency objectives of the NHS. Rather than “liberating the NHS”, these proposals seem to be an exercise in liberating the NHS’s £100 billion budget to commercial enterprises” Lancet Oct 6th 2010

We need nerds. I am very grateful for people like Andy and Ben who pick over documents of extraordinary size and complexity to explain the detail to those of us who are fully occupied with our work and families.

There are a handful of people looking at the bigger picture and one of the best is Richardblooger who writes the excellent evidence-to-policy blog,  Conservative Policies Dissected.

But we all need to go beyond the trees and look at the woods to see that the pronouncements on the NHS from politicians of all parties are absurd, and whilst we mock, they hide like Berlusconi behind a façade of buffoonery while the savage process of dismantling the NHS goes on.

Guest post with permission By Clive Peedell, consultant oncologist and co-chair of NHSCA –  First published on HospitalDr blog 3rd February 2011 11:03 am

The poll tax was famous for bringing down Margaret Thatcher and causing profound long term damage to the reputation of the Conservative Party. It is notable that one of the key players at the time was Oliver Letwin, who in 1986, recommended the poll tax to the Prime Minister after being asked to evaluate its likely impact.

Oliver Letwin is currently Minister of State for Policy and has had a significant influence on Conservative Party health policy. He was recently rated Number 2 out of the top 100 most influential people in the NHS by the HSJ.

According to Nick Seddon of the think tank Reform, Letwin “has been a key driving force behind encouraging greater plurality of provision – from the private and third sectors – and the development of new ownership models”.

He was also recently asked to review Lansley’s reforms and gave a solid thumbs up to plough on. This was in no way surprising, because his own ideology is so similar to Lansley. In 1988, Letwin wrote a paper about the NHS reform for the Centre for Policy Studies called Britain’s Biggest Enterprise. This paper offers a fascinating insight into his thinking and contains many of the current policy proposals.

In his conclusion, he stated: “One could begin with the establishment of the NHS as an independent trust, with increased joint ventures between the private sector; move on next to the use of credits to meet standard charges set by a central NHS funding administration for independently managed hospitals; and only at the last stage create a national insurance scheme separate from the tax system”.

It is therefore no surprise that he was once famously quoted as saying that “the NHS will not exist” within five years of a Tory election victory and there would be “no limits” to NHS privatisation in an interview with The Times.

His 1988 paper could easily be seen as a prototype of the current Health Bill and is a classic example of modern conservatism’s solutions for the public sector i.e. using markets and the private sector to replace any profitable state functions, whilst leaving unprofitable services well alone. The evidence base for these policies is totally lacking, hence the constant references to Lansley’s reforms as being ideologically driven. The editors of the BMJ have gone as far as calling them “mad”.

David Cameron has now placed his full weight and reputation behind the proposals and he therefore cannot “be for turning”. This is an enormous political risk. This is particularly ironic, because by exempting the NHS from the worst of his government’s spending cuts, the level of public suspicion was subsiding that the Tories would dismantle Britain’s best-loved institution. In fact, the NHS was a non issue in the pre-election debates.

Now, the public, the media and the professions have started to cotton on to what the Tories are up to. Whether the Bill passes or falls, this could be Cameron’s very own ‘poll tax’ issue and once again the fingerprints of Oliver Letwin will be there.

My satirical post yesterday was out of frustration because the Prime Minister and Secretary of State have such a breezy contempt for evidence.

When SoS Lansley came to visit my surgery yesterday with Nick Robinson from the BBC, the interesting discussions were stopped by Nick Robinson for being too ‘technical’. But evidence is technical. Political propaganda on the other hand is deceptively simple. So when Dr Deborah Colvin challenged SoS Lansley’s assertions that the UK health outcomes are way behind Europe and she quoted Porfessor John Appleby’s highly critical analysis of the data published in the BMJ, Lansley quite literally, with a sweeping gesture, dismissed her concerns and Nick Robinson steered the conversation back to sound-bite stuff.

Doctors spend their lives explaining medical problems in language patients understand. They are trained for a long time to do this and have to be sure that their information is accurate and clearly understood. It is the basis of informed consent. Politicians on the other hand have no duty to explain political problems to the same standards. Deception, over simplification (or the opposite), propaganda and rhetoric are the tools of their communication trade.

There have been excellent straightforward criticisms of the “myths and facts” put out by Cameron, published in the Times, and also available on the Number 10 website.

One of the best is from highly respected NHS commentator Roy Lilley: His blog article (that I have copied below) is available here.

For starters he [Cameron] chastises the NHS for poor outcomes.  We are “behind the best in Europe”.  Readers will know John Appleby from the King’s Fund, gave that a good kicking over the weekend.  It is not true

The PM says he wants to improve patent choice.  As the great unwashed, like you and me, are obliged to register with one practice only, we will only be able to benefit from the care-pathways, treatments and locations that our practice’s Consortia have agreed.  We have no input into that process and there is no legal requirement for the Consortia to make a place for a patient at the top table.  So that argument bombs.

Next, he tells us the GPs are gagging for it.  One hundred and forty one pathfinder consortia are hopping and skipping along the yellow brick road towards the blue horizon of a perfect future.  Er, apparently not.  We publish, today, the outcome of the Royal College of General Practitioners’ survey of GP’s views on the reforms.  It is the biggest survey, so far. If you are reading this in the DH or Downing Street, sit down and pour a strong cup of coffee.

GPs are about two to one (sometimes three to one) against it and don’t believe it will improve anything.  (More coverage in the Guardian).  So why are GPs joining up?  Pathfinders are GPs quickly getting into comfy groups with their mates before someone else dictates who they have to play with.  In some parts of the country they are trying to buttress collapsing PCTs.  In nearly all cases GPs are not trying to run pathfinders, they are creating PCT-lite, hiring other people to do it for them.

The RCGP survey could not have been more accurately delivered by Guy Gibson.  It is a Dam Buster.

The PM moved on to his next target; he tells us we have to cut the costs of bureaucracy.  Let’s look at the facts.  [Administration] costs in the NHS are about 5%.  In the US healthcare system they are about +25%.  In industry in general the percentage of management is about 16%.  In the NHS it is 13%.  There were 152 PCTs, now we are likely to have 200+ overlapping Consortia, meaning more management, not less.  All this is from a really interesting one-pager from Leeds University Business School.  Another prang for Downing Street.

Two final points in his letter; pharma prices are going up and there are more older people who will need treatment.  Neither of which the NHS can do much about.

In yesterday’s lobby briefing the PMs spokesperson admitted he is running to catch-up.

I can’t find any bomb-proof reasons to blow-up the NHS.  MPs have voted for the Bill at the second reading.  I guess they just don’t realise; NHS outcomes are in line, or as good as the rest of the world, or on a trajectory to better them.  Management costs are well within industry norms and could easily be reduced without destabilising the service.  There will be no improvements in choice as practices are bound to Consortia who are doing nothing more that PCTs used to do and there is already plenty of room to involve the private sector if the DH’s  FAQs on AWP are to be believed.

More important; they should look at the RCGP survey.  The Prime Minister has made much of having GP support.  It appears that is not the case and LaLa is running out of reasons.  Perhaps you should write to your MP and put them straight?

Thank you Roy.  roy.lilley@nhsmanagers.net

There is another excellent response to the same myths from Andy Cowper of Health Policy Insight with evidence (and swearing) here. Well said Mr Cowper.

And here is a response from the Times by Richard Horton, editor of the Lancet:

No, Mr Cameron, you are peddling myths about NHS reform. If the Government truly wants to reduce inefficiency, it should abandon the mantra of competition and market forces
Sir, David Cameron (Opinion, Jan 31) insists that “only by modernising [the NHS] can we achieve the world-class care that we all want to see”. But his five myths are dangerous untruths.
First, health professionals know the NHS needs to change. We understand that some health outcomes fall short of what we should all expect. What we are asking for is the evidence that Andrew Lansley’s reforms provide the right changes to address these shortcomings. The truth is, there is no evidence, not a shred. What we do know from GP fundholding in the 1990s is that the promised benefits to healthcare never materialised. There is no reason to believe that benefits will accrue this time around.
Second, this is a revolution, not an evolution. For the first time in the history of the NHS, private non-NHS providers are preparing to take over large sections of NHS care. For example, in its presentation to investors last year, Tribal Group, a private provider of commissioning services to the NHS, listed “Commissioning for GP consortia”, “clinical support services”, and “patient management services” as key “growth priorities” in the UK.
Third, doctors are being forced to do something many don’t wish to do. The Lansley reforms are not optional. They are being implemented right across the NHS. Mr Cameron’s revolution is coercive, not collaborative.
Fourth, this is privatisation by the back door. Tribal’s strategy, along with other private providers, is to respond to “major changes in structure of UK health markets” by focusing its “health business on emerging service delivery opportunities”. What is this, if not privatisation?
And finally, Mr Cameron suggests that patient care will not suffer. I hope he is right. But hope is the only evidence we have. It is not satisfactory to base the future health of our nation on such an ill-informed and ideological plan.
Dr Richard Horton
Editor, The Lancet

Well said Richard.

And finally an excellent overview of the evidence from another blogger, RedEaredRabbit: Facts Evasion

Prime minister David Cameron in a statement today said that the case for NHS reform could be seen by cutting through an aubergine.

He said that medical professionals, the BMA and other health unions, policy experts and patients who doubted the case for reform should go out immediately and cut through an aubergine. “The patterns made by the seeds clearly spell out the need for a complete overhaul and privatisation of the National Health Service” he said, looking very pleased with himself.

He said the case was more urgent than ever because his aubergine was beginning to go brown and wrinkly which made it a bit more difficult to read.

In a separate report, Secretary of State for Health Andrew Lansley  pointed out on his regular BBC radio 4 show ‘Before and after the Archers’, that the case for change was spelled out very clearly in his tea leaves. Questioned about the evidence base for his reforms he explained that Professors from the King’s Fund and other so-called experts didn’t know anything about tea leaves and were in fact communist reactionaries who should be ignored.

In a ingenious attempt to clarify the government’s case for change to a bewildered public, highly respected policy experts Andy Cowper of Health Policy Insight and Alastair McLellan of the Health Service Journal interpretated the reforms by singing acapellas of top hits by 1980’s miserablist band The Smiths.

In a poll of Hackney patients by Dr Tomlinson, 9/10 believed in tea-leaves and none had heard of Captain Beefheart.

An NHS accountant who has worked in the NHS for the last 20 years raised an interesting point at a meeting this week.

He explained why GP commissioning consortia (GPCC) which are replacing Primary Care Trusts (PCTs) are supposed to provide care for 500,000 patients. I had been wondering what good it could possibly do to combine 3 local PCTs, City and Hackney (200,000 patients) with Newham and Tower Hamlets with such diverse and complex populations to make one huge GPCC. I’ve been complaining for a while that this will make it very hard for GPs to work together and there will be far less local accountability and responsiveness to patient needs.

But the accountant told me that for most of the 20 years he had been working in the NHS it was common knowledge (among NHS accountants) that the ideal hospital catchment area was approximately … 500,000 patients. With an estimated population of 8 million, that makes … 16 hospitals.

According to the Darzi plan for healthcare in London: (summarised by Anna Athow in 2009)

London’s 33 DGHs (District General Hospitals) would be reduced to 8 to 16 acute major hospitals. The plan says “ The days of the district general hospital seeking to provide all services to high standard are over”. Many London DGHs would lose maternity and paediatrics. There would be fewer A&E departments and more urgent care centres. ( Lord Darzi interview with Guardian 11.7.07)

“Local hospitals” could have an A&E unit admitting acute medical admissions but without emergency surgery, 24 hour diagnostics or intensive care on site. The plan proposes that emergency doctors could resuscitate, intubate and ventilate patients requiring emergency surgery and transport them to an acute major hospital for their operation. ( p 65 150 Acute Clinical Care From Cradle to Grave. P 13 Report of the acute clinical care working group)

The NHS changes, costing an estimated £3bn, are the biggest and the most expensive in the 60-year history of the NHS. At the same time the NHS has to save £5bn every year for the next 4 years, something no health service in any country, anywhere, ever has managed. See this excellent explanation by Richardblogger of why this will be impossible without closing hospitals (or changing their minds about the cuts). The Department of Health has estimated that GP surgeries will, on average, have to save £2500 a day. Despite the fact that we have spent less on healthcare than almost any European country for the last 30 years, the government thinks we spend too much. These savings will only be possible if hospitals close and thousands of NHS staff lose their jobs.

In order to avoid responsibility they are giving most of the NHS budget to GPs and are forcing them pay private companies to do the work the NHS has done for years, but at a bargain prices. The coalition has set up an enforcement agency called Monitor to make sure the GPs accept the cheapest bids. When services close, GPs will be blamed for mismanaging the budget, even though they were trained to look after patients.

I am prepared to stick my neck out and suggest that perhaps we do have too many hospitals. We might even have twice the number of hospitals we need. The accountants might be right and healthcare might be safer and more effectively delivered from fewer hospitals. But surely if you’re going to make changes of that magnitude, they have to be carefully planned. One senior policy adviser tweeted to me last week, ‘planning is a dirty word’. So instead of planned, coordinated closures we have a quasi-market in which hospitals will close because they’re insolvent due to poor financial management or because they cannot survive in a market where prices are undercut and services cherry-picked by private providers. Hospitals will have to follow the money instead of  being planned according to clinical need.

If politicians think hospitals have to close, they should have the courage to say so, and take responsibility for it.

A government that delegates this responsibility to the market has no right to govern.

As the founder of the NHS, Aneurin Bevan said:

“The NHS will last as long as there are folk left with the faith to fight for it”

To preserve an NHS where patients, not profits come first:

• send your views to info.whitepaper@bma.org.uk
• join Keep Our NHS Public
• find out more from the NHS Support Federation

Letter from Lansley A, to Healey J 19.01.2011

Dear John,

As you know, the Health and Social Care Bill represents evolution, not revolution for the NHS. As the Chief Architect of Change, I am extremely proud of this bill, but I know that I owe your predecessors this small note of acknowledgment for their hard work over the last 30 years, paving the way for an NHS we can all be proud of,

Yours sincerely,

Secretary of State for Health, Andrew Lansley

Labours gift was to set up the NHS ready for Lansley’s Health and Social Care Bill by preparing an internal market, payment by results, the purchaser-provider split and foundation trusts. It did this (amongst other ways) by establishing a commercial directorate at the department of health, staffed almost entirely by representatives of the private health sector.

The following is from a campaign card I wrote in 2009 with Professor Harry Keen CBE MD FRCP (author of this letter to the Financial Times)

Click here to see the original campaign card

Public opposition to NHS privatisation is perfectly expressed by the inspiring words of the Election Manifesto that brought the Labour Government to power in 1997:

Our fundamental purpose is simple but hugely important: to restore the NHS as a public service working cooperatively for patients not a commercial business driven by competition.

The great progress and promise of our NHS is being undermined by progressive patchwork privatisation. This damaging process of privatisation has:

1. Converted the NHS into a market, driving NHS Hospitals and GPs into competition with each other instead of working together to care for patients.

2. Compelled the NHS to ‘contract out’ clinical work to private companies, some working in Independent (Private) Sector Treatment Centres, costing more cash and working less well than NHS clinics can.

3. Forced Primary Care Trusts (PCTs) to allow private health corporations to take over GP surgeries. Companies interested first and foremost in making a financial profit from treating the sick can now replace your local doctors.

4. Obliged hospitals and local health bodies to invite private companies to take over key NHS services. No longer just car parking, cooking and cleaning, they must invite private bids for core clinical services like bone and brain scans, physiotherapy, psychology and even surgical centres and local GP surgeries.

5. Appointed private sector companies into key NHS decisionmaking seats. Here they directly influence the spending of vast sums of public money to commission NHS services, some from private sector companies. This creates huge potential for favoured deals and conflicts of interest. A Competition and
Cooperation Panel acts as enforcer, making sure NHS managers don’t resist these privatisation drives.

________________________________________________________

Healey’s recent speech to the King’s fund was disingenuous at best. I wrote to my MP Meg Hillier and Health ministers Alan Johnson and Andy Burnham in 2009 and 2010 warning of the dangers of coverting a public service into a free market and their replies were patronising waffle, reassuring me me that there was absolutely no chance of the NHS being privatised under New Labour.

With the exception of the Greens, all the political parties have been committed to handing the NHS over to the private sector.

Only a committment to Labours 1997 pledge will represent serious opposition to this bill. But even if that is promised, can we believe them? Faced with neoliberal hegemony will any party commit to the re-establishment of socialised healthcare?

It is up to us as patients, professionals and citizens to save the NHS, we are fighting for more than health care. Democracy is at stake.

The Plot against the NHS

By Colin Leys and Stewart Player
Colin Leys is an emeritus professor at Queen’s University Canada and an honorary professor at Goldsmiths College London. His most recent books are The Rise and Fall of Development Theory, Market-Driven Politics, and Total Capitalism. He has been studying and writing about the NHS since the late 1990s. Stewart Player is a public policy analyst with extensive experience of studying the NHS. He is the co-author with Colin Leys of Confuse and Conceal: The NHS and Independent Treatment Centres, and author or co-author of numerous articles on the NHS.
with CARTOONS BY Julian Tudor-Hart

Do the coalition government’s plans for the NHS really mean a big change of policy?  Or do they just bring into the open what New Labour was already doing?

This book shows what has really been going on:

The plot: how a small ‘policy community’ inside and outside the Dept. of Health have schemed for ten years to replace the NHS with a US-style healthcare market – without telling parliament or the public.

The template: how the close links established after 2000 between the Department of Health and the US health maintenance organisation Kaiser Permanente led to the American market model becoming the lode-star of government policy

The players: the insiders of the policy community – the corporate heavies, the mercenaries (management consultants), the think-tankers and the freelancers (some academics and doctors), and the ‘revolving door’ that lets private company representatives into jobs in the Department of Health, and ex-ministers and officials into lucrative positions in private health companies

The interests served: the private health industry and its drive to take over from NHS hospitals and GPs – the companies involved, their lobby, their businesses, their fortunes – and in some cases, their crimes

How it has been done: key elements in the strategy – the provision of openings for the private sector at every stage of ‘reform’; so-called ‘pilot’ schemes that are never evaluated but promptly ‘rolled out’ across the country; buying off or denigrating critics; divide and rule in the NHS workforce; constant spin

The victims – us: the shape of the emerging healthcare market and how it is already driving costs up, and the availability and quality of care down, as revealed in real-life accounts by NHS patients and doctors; with high-quality care increasingly having to be paid for – by those who can afford it.

Market: General, Undergraduate and Post-graduate; Student Reading List; Library
Keywords:  Health policy, Health economics, Politics, NHS, Privatisation, UK.  Bic: MBN,KCQ, JP, JPP, 1DBK

216×138 mm; 128pp, 4 TABLES  EU publication  14.4.2011

Pbk    ISBN 978 0 85036 679 2     GB Pounds 12.95
——-

THE MERLIN PRESS LTD. [Editorial +44 [0]20 8533 5800]
Order books from www.merlinpress.co.uk<http://www.merlinpress.co.uk/>
6 Crane Street Chambers, Crane Street, Pontypool NP4 6ND, Wales  Tel 01495 764 100

Letter to Ron Singer, Medical Practitioners Union

Italics are my own for emphasis.

Dear Dr Singer

The Health and Social Care Bill was presented to Parliament on Wednesday 19 January. It sets out the legislation required to implement the Government’s plans for major NHS reform, as outlined in its earlier White Paper ‘Equity and Excellence: Liberating the NHS’ released in July 2010. The scope and complexity of the Bill is immense and will have a significant impact on the future of NHS services as well as for the NHS workforce and public health.
We will be examining the Bill in great detail and be lobbying very hard to amend the most potentially damaging aspects of this legislation. We will continue to resist the introduction of enforced competition and the use of competitive pricing (the ability for one provider to undercut another), the enforcement of foundation trust status on hospitals, and the failure to provide for the co-ordination of education and training and workforce planningat a national level. Ploughing ahead with these changes as they stand, at such speed, and when NHS staff and experts have so many concerns, is an enormous risk and will incur considerable costs at a time of huge financial pressure. BMA’s response to the NHS reform health bill Whilst we support greater involvement of clinicians in planning and shaping NHS services, any benefits that clinically-led commissioning can bring are threatened by other parts of the Bill. We are particularly concerned about aspects of the Bill that would force commissioners of care to tender contracts to any willing provider, including commercial companies. Foundation Trust regulator Monitor will become the NHS economic regulator and will be given a legal duty to promote competition. This means it has the power to undermine decisions that commissioners have made to place contracts with the providers that they think offer the best and most appropriate services if, for example, a commercial organisation thinks it has not had exactly the same opportunities to compete. This has real potential to destabilise local health economies and fragment patient care. As a minimum, this could have the effect of removing funding from hospitals which may then have to reduce the services they can offer, as larger commercial companies are likely to chase the most profitable contracts, using their size to undercut on price. Allowing providers to be able to offer services to commissioners at less than the published mandatory tariff price, thus introducing price competition could be, evidence suggests, detrimental to the quality of care, especially if consortia have to make savings in order to stay within budget. Successful commissioning will involve GPs working closely with colleagues, including in hospitals and public health, to develop and implement the integrated care pathways that provide seamless care for patients and could potentially improve the NHS by making the service more efficient. However, enforcing competition between providers, as proposed in the Bill, will make it harder for GPs and hospital doctors to collaborate or for different providers to work together efficiently and for the benefit of patients GPC support and guidance. Recognising the necessity to start to put arrangements in place, many GPs and their practices are making good and constructive progress in working with others to set up their shadow consortia. The GPC has been issuing guidance papers to help GPs do so. Our pragmatic support for a concept we share, is not the same as support for all the changes the government wants to make, with some of which we disagree profoundly. It remains important for GPs to feel empowered to develop their consortia organically at a reasonable rate appropriate to them and to local circumstances. A major concern is that some are feeling pressured into surging ahead with consortium development because of the premature collapse of some PCTs which is causing serious local organisational difficulty.
GPs experiencing such problems should contact the BMA and their LMC for advice and support. Size of consortia will be an all important factor in their ability to function effectively. Our most recent guidance on this, The form and structure of GP-led commissioning consortia, advises that consortia should cover a population of between 100,000 and 750,000. However, in view of all the practical considerations, particularly in relation to the management of consortia and the most efficient use of scarce NHS resources, we recommend that consortia should be covering populations towards the upper end of the parameters previously advised, ie populations in excess of 500,000. This does not preclude the appropriate development of strong locality or sub-group arrangements within the larger consortium to ensure real and meaningful clinical engagement with all doctors. Consortia need to be big enough to be able to meet their core management functions internally, without becoming reliant on external providers for such functions or having external providers imposed on them, which could over time become the dominant party. Instead of going elsewhere for support, as we have stressed from the outset, consortia need to work with the best NHS managers, as their expertise and experience are invaluable and should not be lost to the NHS.

As the Bill provides us with more detail, the General Practitioners Committee will be issuing GPs with the further guidance they need on commissioning and clinically-led consortia to provide support and help them deal with the implementation of changes they are facing at local level. We urge you to consider how you can involve all GPs (sessional and principal), hospital and public health colleagues, nurses and other primary care professionals, and of course your patients, as well as engaging with PCT managers, to shape this uncertain NHS into a safer future. A toolkit is being put together for members who wish to support the BMA in lobbying on aspects of the Bill. It will include practical guidance on how to lobby an MP and put your messages across. This will be available on the BMA?s website from Monday 24 January at: www.bma.org.uk/nhsreformlobbying The BMA has also commissioned Ipsos MORI to survey members to ensure that our lobbying strategy reflects members’ concerns. You can also give us your views and feedback any local information to us by completing our online feedback form  on the BMAs website or emailing us at  info.healthbill@bma.org.uk

Thank you for all the feedback we have received so far, which is invaluable to us and will help to ensure that we are representing all of our members as best as we can.

Yours sincerely Laurence Buckman
Chairman General Practitioners Committee

See also Dr Lansley’s monster. BMJ editorial

and Shock therapy for the NHS, Independent

Extraordinary change requires extraordinary justification backed up by extraordinary evidence.

There has been, or very soon will be, extraordinary change, but there hasn’t been justification or evidence. There has been a lot of rhetoric and hot air, with repeated claims that ‘everybody accepts that the NHS has to change… is bloated… hasn’t improved in spite of all the extra money… is woefully inefficient…’ etc. Without a shred of supporting evidence.

Not only has there been a desperate lack of evidence to support the claim that the NHS was broke and needed Lansley to fix it, there is an even less excusable lack of evidence to support his proposed changes (opening the NHS up to any willing provider, GP commissioning etc.) many of which were well under-way before the bill came to Parliament on Wednesday.

What needs changing in the NHS and could it have been achieved without converting a public service into a market?

I  can agree with the Lansley on 3 things,

• Increased clinical involvement with managing and planning services is necessary
• Many hospital services can be provided more efficiently, effectively and safely in the community
• The NHS needs to be more responsive to patient needs

The risks are

• that medical professionals will spend more time in meetings and less with patients, undermining efficiency gains
• Hospitals will have to find ways of remaining financially viable once services are provided in the community, or they will have to downsize, close or merge with other hospitals.
• There will have to be greater patient participation at every level, more open and democratic processes, and better accountability at every level.

These changes could be achieved without converting the NHS into a market.

Clinical involvement is welcome, but it needs to be multi disciplinary, involving specialists as well as generalists. There is no reason to exclude hospital specialists, nurses and community services all of whom have important perspectives on the provision of care. This could have been achieved by altering the PCT structure. The GP-purchaser, hospital- provider split is costly and obstructive -the financial incentives obscure clinical decision making.

Clinical services do need to move out of hospitals to save money, improve access and safety, but this must be done in ways that does not force the financial collapse of the remaining hospital services. It has to be done in ways that ensure that essential services are protected and that health care is provided according to clinical need. Converting the NHS to a market risks private providers cherry picking the most profitable services, undercutting the local hospital and causing financial ruin and collapse of complex/ high risk services. One effect of converting the NHS into a market is that the government can wash it’s hands of responsibility once hospitals close, saying GPs chose to commission services elsewhere and so it was up to them. The alternative, careful planned closure would be politically very unpopular, however careful. Unplanned closures, due to the whim of markets will cause total chaos.

Greater responsiveness to patients can be achieved at a practice level by funding the creation of Patient Participation Groups (PPGs) and ensuring every practice has one. Representatives could then form PCT wide PPGs which could have representatives on the PCT board and on the Health Scrutiny Committees. Our local PCT is being demolished to make way for a commissioning consortia that includes 3 PCTs so it will be far more remote from patients. There is nothing in the white paper to reassure patients that they will be better represented.

I think that change is due, and what is more agree with the government about three important areas in which it should happen. These changes could be achieved without privatisation which is unnecessary, unaffordable and harmful.

BMJ editorial: Lansley’s Monster

Independent: Shock therapy for the NHS

From Spinwatch where there is more about Lansley’s private healthcare industry backers including 2020Health and Reform

Some clues as to how the NHS was converted from a public service to a free market. A 15min look at international health corps lobbying the UK department of health.