A Better NHS

A flawed Bill with a hidden purpose

Publised in the Lancet today http://press.thelancet.com/nhsbillletter.pdf

The passage of England’s Health and Social Care Bill has been highly controversial and unusually prolonged owing to extraordinary public, professional, and parliamentary concern. On Feb 8, 2012, the Bill entered the House of Lords report stage. By this date, 301 amendments had been tabled to the Bill to be moved at report stage; of these, 165 (mainly government) amendments were tabled on Feb 1. This excess of amendments in itself raises serious issues about the processes to ensure the robustness of parliamentary scrutiny.

The UK Government has given several assurances to parliamentarians that it has taken heed of the concerns of the public, patients, peers, and medical and nursing professions, some of which are set out in a Comment (Feb 4, p 387).(1) It has tabled further amendments to allay concerns. On Feb 6, we published a briefing2 which covers crucial amendments relevant to the fundamental structural changes contained in the Bill, specifically the transfer of powers to clinical commissioning groups (CCGs) and other commissioners in place of the current delegation of powers to primary care trusts (PCTs). In it we show that:

(1) The amendment to Clause 1, which concerns the duties of the Secretary of State for Health, would not restore the duty to provide health services or to secure provision, which, in association with section 3 of the National Health Service (NHS) Act 2006, is the duty that underpins the current structure of the NHS.

(2) Amendments to Clause 4, which promotes autonomy over public health, would still require the Secretary of State to accept the principle of autonomy.

(3) Amendments to Clause 12, which concerns the new structures of the NHS, namely CCGs, would not require CCGs, operating on behalf of the Secretary of State, to make sure that comprehensive and equitable health care is available for everyone, nor to be responsible for all residents in single geographically defined areas that are contiguous, without being able to pick and choose patients.(2)

(4) Amendments to Clauses 24 and 25, which again concern the responsibilities of CCGs are aimed at universal coverage. However, as we show in our briefing,(2) these are oblique and messy, do not go very far, and do not address the problem of service and patient coverage at source.

(5) Amendments to Schedule 2, which concerns the basis of services, leave unchanged the legal basis for private companies and law and accounting firms to commission services instead of the Secretary of State.

The Government’s continued insistence on its structural changes and its failure to provide an adequate account of why they are necessary confirms concerns that the policy rationale has not been fully disclosed. The Government says that its changes are “vital”.(3) But this is only the case if the object is to create a system that permits alternative funding sources for services currently provided free as part of the NHS. These amendments do not affect the heart of the policy behind the Bill, which is to introduce a mixed financing system and to abolish the model of tax-financed universal health care on which the NHS is based.

The Bill and current amendments fail to safeguard the core principles of universal care and the duties of the Secretary of State to uphold those principles. The duty on the Secretary of State to provide or secure provision in accordance with the founding legislation of the 1946 Act must be restored if England is to have a national health service.

PR is a London-based public interest lawyer who has supported 38 Degrees on an unpaid basis. TT is a non-practising barrister and formerly Head of Legal Services, Vale of White Horse District Council. The other authors declare that they have no conflicts of interest.
*Allyson Pollock, David Price, Peter Roderick, Tim Treuherz
a.pollock@qmul.ac.uk

References

1 Pollock AM, Price D, Roderick P, et al How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England. Lancet 2012; 379: 387–89.
2 Pollock AM, Price D, Roderick P, Treuherz T. Briefing note 14. Clauses 1, 4, 12 and Schedule 2: the duty to provide, the hands-off clause, GP commissioning, and the red lines. http://www.allysonpollock.co.uk/administrator/components/com_article/attach/2012-02-06/20120206-Pollock_HouseOfLords_HSCB_Briefing14_C1_4_12_Sch2_06Feb12.pdf (accessed Feb 10, 2012).
3 House of Lords Constitution Committee. 22nd report, Health and Social Care Bill: follow-up. Appendix 2, correspondence: letter from Earl Howe, Parliamentary Under Secretary of State for Quality, Department of Health, 10 October 2011. http://www.publications.parliament.uk/pa/ld201012/ldselect/ldconst/240/24005.htm (accessed Feb 10, 2012).

Faced with hostility from such unlikely quarters as Conservative Home, ‘the unpopular and unnecessary NHS bill could cost the Conservative Party the next election, Cameron must kill it‘, The Mail on Sunday who exposed, ‘The firm that hijacked the NHS, The Spectator ‘Lansley’s health problems are beginning to look terminal’  and ‘Lansley’s battle should’ve never been fought’, not to mention ‘bonkers’ Baroness Warsi’s farcical defence of the health bill…

… it was no surprise that Lansley felt obliged to come to his own defence. He chose to do so from the subscription-only pages of the Health Service Journal (though you may be able to access it here) where he laid his defense down like an evangelical preacher speaking to the faithful. The self-satirising, “There is little we can learn from examining the past”, “There is nothing to fear from competition” and ” in any other sector, it is the thousands of individual decisions to adopt a new technology – from, say, cassettes to compact discs to mp3 players – which combine to sweep away less effective services” Really? … Healthcare is not like any other commodity.

… is only eclipsed by the evangelising tone of his sermon. The parable of how the tape-cassette became the MP3 player was even proselytised by Rentoul the faithful from the Independent.

Actually, this was further eclipsed, but fortunately non-HSJ subscribers are protected, by the astonishing number of anonymous comments that could find ‘nothing to disagree with’ or said, ‘he makes some very good points’. It is this non-thinking that would lead me, if I had less respect for my head or the wall, to hit one against the other.

There are many types of competition in the NHS with hundreds (perhaps thousands) of awards for quality, innovation and research. One reason why critics object to competition as envisaged in the bill is because it is specifically about competition between hospitals and providers for patients and competition between patients for doctors. Quality and innovation may, or may not have anything to do with what it takes to attract patients. The choices patients make about their care are very sophisticated and quality of care is just one of many considerations. The health bill has a severely limited view of patient choice and competition; it views them as market-levers. The problem with this is summarised by the Inverse Care Law which states,  The availability of good medical care tends to vary inversely with the need for the population served.  This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

Another reason I and other critics have been campaigning so hard and long against the health bill is that it lacks any evidence. When the bill was announced my immediate response was, ‘Extraordinary changes require extraordinary justification backed up by extraordinary evidence’ . As Paul Corrigan, ex-health advisor to Tony Blair has blogged to death, the government have failed to provide a convincing reason for overhauling the NHS. And Ian Greener today responded with eight myths about NHS reform.

If the NHS was a patient in need of treatment and Lansley was a doctor he would be from a lost generation who learned their communication skills from Sir Lancelott Spratt, for whom a reasonable question about the risks of major surgery (or, ‘do I really have nothing to fear from competition?) was answered with, “Don’t worry my good man you won’t understand our medical talk”

Lansley is true to his faith, he has learned little from the past.

Julian Tudor-Hart. SPEECH AT UNVEILING OF ANEURIN BEVAN BUST AT SCHOOL OF HEALTH SCIENCES, UNIVERSITY OF GLAMORGAN, APRIL 2007

Thank you very much indeed, Donna, for letting me speak at this great occasion. Your department, and this university, are going from strength to strength, and this development is an important part of this progress.

Nye Bevan is a great brand name.

So great, that people should think at least twice before they apply it to any new product.

First, they need to think whether they really want to be associated with a man Winston Churchill described as “as great a curse to his country in time of peace as he was a squalid nuisance in time of war”,[1] and who was for one year expelled from the Labour Party for consorting with Communists in defence of the Spanish Republic.

For people who live from their property and power rather than their work, Nye Bevan meant trouble.

Second, the Bevan brand implies principle.

It’s important to be clear what the central principle of Bevan’s NHS actually was; not just that the NHS should be free, but that health care would cease to be a traded commodity.

He accepted that many consultants would continue to trade privately in the spare time these dreadfully busy and overworked people somehow contrived always to have, but he was confident that once their main instruments of production – the hospitals, together with their staff and equipment – had been nationalised, private consultant practice would soon dwindle to insignificance.

Like everyone else in the Labour movement, but more deeply and tenaciously than anyone else, Bevan believed that neither health care nor education should be traded commodities, that their public provision should not be a business pursued for profit, and that a healthy and educated nation was a shared asset for all, not just the sum of competing personal gains.

This building, and this university, are triumphant material expressions of that belief.

Bevan believed in a free NHS, free in two senses: firstly that patients would no longer have to worry about whether they could afford care, and secondly that doctors would no longer have to worry about recovering fees from people who could scarcely pay their rents or mortgages.

If anyone here thinks those problems lie in some distant past, they need to be reminded that in USA, the wealthiest nation in the world with the most advanced medical technology, 18% of citizens have access only to emergency care, medical costs are the most frequent cause of bankruptcy, and both of these trends are rising.

For Nye Bevan, the principle of a free service, developing as a gift economy rather than as trade for profit, was central – so much so, that when Treasury secretary Hugh Gaitskell drove the first prescription charges through Attlee’s cabinet, Bevan resigned his Ministry and returned to the back benches, where he became a thorn in the flesh thereafter for every coward who flinched and traitor who sneered.

I find it amazing that so little media attention has been paid to the fact that our Wales Assembly government has found the courage and imagination this year to end all prescription charges for NHS prescribed medication, revoking precisely that step back to toward a priced rather than valued society, which Bevan refused to take.

Why the silence?

Perhaps, when every officially recognised expert in anything has almost forgotten where the Labour movement came from, when none dares to imagine any society other than the one we have, and all agree that the only way to end poverty is to make rich people richer still, they simply cannot believe their eyes; it must be a mistake, a transient folly that will soon give way to more urgent and common sense issues, like getting a supercasino for Swansea.

But no, this can’t be a mistake.

This defiance of all current notions of public service “reform” is too big to ignore much longer, even if it stays almost mute.

And it’s not the only one.

Wales long ago stopped going down the PFI road to ruinously expensive private investment in public services, with contracts hidden from public accountability by 30 years of commercial secrecy.

No corporate investor offering primary care in supermarkets has yet been invited to replace established family doctors, as they have in England.

No Welsh NHS hospital has been compelled to compete with its neighbouring hospitals for survival, nor have Welsh GPs and their patients been compelled to make consumer choices nobody ever asked for.

Offered every encouragement to slit our own throats, we have obstinately refused, despite every assurance that it can only do us good.

So watch this bust carefully, and respect its still explosive power.

Nye’s ghost is alive and well, even if he now operates silently, with that shrewd Welsh subtlety that can slip us through bad times.

He still has a mighty place not just in history, but in the world of social justice yet to come, and in this university he will be in safe hands.
[1] Hansard vol.416, col.2544

On the eve of the report stage of the Health and Social Care Bill

Still Fatally Flawed – the Proposed NHS for England

The great majority of the bodies that speak for the health professions are now calling into question the fundamentals of the Health and Social Care Bill. Ever since I published Fatally Flawed on my website1 on 30 March 2011, I have been waiting and hoping that most of the Royal Colleges would realize that the Health and Social Care Bill was quite unlike any other legislation on the NHS put forward for debate since 1946. The very size of the Bill and its complexity makes it unamendable.
As we come to Report Stage in the House of Lords it is crystal clear that despite the best efforts of all those concerned and despite the many amendments that will be passed, the fundamental structure will remain intact. The Chairman of the National Commissioning Board envisaged in the Bill, himself a distinguished academic and barrister, has described the Bill as “completely unintelligible”; one of the reasons that the complex inter- reaction of this legislation has taken time to come through to the health professions. Today the risks of going ahead with the Bill are now being professionally assessed by more and more of the Royal Colleges as being greater than the risks of stopping this Bill even in its last stages.

Of course there are exceptions and the Royal College of Surgeons has written to me clearly content for the Bill to continue. Yet that is not the view of all surgeons. The President of the Royal College of Ophthalmologists wrote to me only a week ago saying, “The Bill does have some positives at face value. It puts doctors and patients at the core of the NHS and benefits will accrue from this. There is some concern that this may not be translated into actual practice.”

There are other major concerns which need to be addressed if the reform bill is to make things better and not worse. Commissioning, as it is being inferred, will introduce unfair competition in which major teaching hospitals are likely to be disadvantaged. Willing providers are likely to bid for the ‘lucrative procedures’ leaving hospitals to deal with the complex procedures, which in turn are inadequately funded as per current tariffs. This particularly applies to ophthalmology where cataract surgery is being diverted to independent providers who do not provide training. In some centres there aren’t enough cataracts left to fulfil the training needs. The number of cataract operations performed by consultant ophthalmologists too is dropping leading to deskilling. Equally importantly, the income generated from the volume of cataract surgery is used to subsidise more complex procedures whilst still retaining a positive financial balance. Loss of this volume of cataract surgery will have significant negative knock on effects on other complex procedures disadvantaging patients.

Another potential serious consequence is the risk that emphasis will shift from providing holistic care to patients to ‘organ based care’. Different services will be commissioned from possibly the cheapest providers. This will mean that patients have to travel to one centre for one type of treatment and to another centre for another treatment affecting a different organ. In ophthalmology several patients have more than one condition affecting the eye for example diabetes and cataract and glaucoma, glaucoma and cataract, macular degeneration and cataract or glaucoma. If different conditions are commissioned from different providers the patients will have to move around. This will require very efficient communication between centres to avoid duplication of medication and other intervention. We feel that such insights can only be provided by the doctors who are at the coal face delivering health care. If policy decisions are made without such insight we will be putting patients at risk.

Currently there are two major thrusts from the government in relation to the NHS. One is to make a saving of 20 billion pounds and the other is the Health and Social Care Reform Bill. Unfortunately the two are being linked and PCTs and Trusts are using the reform initiative to push through changes that are purely driven by cost saving objectives. This has muddied the waters and brought disrepute to the proposed reforms. In ophthalmology this is reflected in arbitrary thresholds of visual acuity being set for cataract surgery. Thresholds for the first and second eye are different with a greater loss of vision being required before surgery can be considered for the second eye. The thresholds that are set have no scientific basis whatsoever and are purely determined by the number of cataract procedures that can be deferred to meet the savings targets. Moreover, the thresholds are variable across the country creating a post code lottery. The variable thresholds being set by different PCTs/Commissioners is further proof that these are based on financial rather than clinical needs. This is depriving many deserving patients from necessary surgery. Certain procedures such as lid warts and benign growths are being banned altogether without any alternative options being offered to patients.

If this is what the future of the NHS will look like then the Bill has serious problems. If this reflects the gap between the spirit of the Bill and its implementation then greater clarity is required in the form of explicit instructions to commissioning groups.

Of course, in terms of whipping Conservative and Liberal Democrat MPs and Peers, the Bill can be placed on the Statute Book. The House of Lords can only revise legislation and mainly negotiates amendments with the Government. The only person who can stop this legislation is the Prime Minister.
Yet if the Prime Minister went to the Cabinet, as he should, and asked for it to be withdrawn, the NHS would heave a collective sigh of relief and next day start to implement, under existing legislation, those aspects on which there is widespread agreement. Stephen Dorrell MP, himself a former Secretary of State for Health, pointed out that this could be done when this legislative monstrosity first started to emerge. A year has elapsed since the Bill was presented. We have already had an unprecedented Government induced legislative ‘pause’. This ensured an intensive debate and has served the useful purpose of delineating an agreed pattern of reform for the future under existing legislation.

Why should David Cameron listen and decide to shelve the legislation? In the summer when he ordered the ‘pause’ he was aware of public disquiet, reflected in opinion polls. He was entitled to hope that the Future Forum committee that he appointed would help to alleviate concerns. But the Future Forum was not a representative grouping and increasingly as the medical profession looked behind the White Paper and started to understand the dertails, concern mounted. Never before have the doctors, nurses, midwives, physiotherapists as the professional bodies concerned with professional standards, come together in such numbers to oppose legislation going ahead.
David Cameron is the first Prime Minister to face such a professional outcry. It is no good him pretending that this protest is linked to issues of pay and pensions because the BMA and the RCN want the Bill dropped. Both organizations have a dual function, trade union and professional ethics and standards. What is uniting the health professions is a risk assessment of the dangers of the Bill made in the context of evidence-based medicine.

David Cameron should remember the words he spoke about the NHS during the election. Most of those who work in the health service were aware of his own late son’s illness and felt that when he spoke about the NHS not having any more top down reorganizations, he carried the conviction of someone who had real experience of what the NHS represented in British life. When he talked of his ‘Big Society’, many envisaged the ethos of the NHS would be part of that. During the 2010 General Election the NHS was not, as in previous General Elections, anywhere near as big an issue between the parties. Voters believed not only that there would be no more top down reorganisations but the Conservatives had absorbed the strengths and realities of the NHS. There was nothing from the Liberal Democrats either to identify them with these reforms. It is also noteworthy that the most recent assessment by the OECD in praising the achievements of the NHS drew attention to the fact that this was despite the adverse consequences of numerous reorganizations. Why are we having the mother and father of all past NHS reorganisations?

Supporters of the Conservative/Liberal Democrat coalition groan when people point out they have no mandate for this legislation but that is the fact. They fought an election with no voter envisaging anything remotely like this Health and Social Care Bill. Furthermore, they have broken the conventions of legislation that while a Government after Second Reading in the House of Commons can implement some limited aspects of the legislation in advance of the Bill receiving Royal Assent, the democratic approval process must not be prejudiced. The conventions never envisaged the collapsing of so many existing structures and the attempt at wholesale implementation prior to Royal Assent. Yet some in and around the coalition now invoke, as an argument for not going ahead with the legislation, the prospect of chaos if the legislation is stopped. Not only do they exaggerate the likely effect of not going ahead but even to use such an argument is a constitutional outrage.

It is now incumbent on the Prime Minister to hear directly from representatives of those Royal Colleges that believe the Bill should not proceed and address their objections. It was after all the Prime Minister who stated that “put simply, competition is one way we can make things better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates. The Prime Minister needs to hear from the professions why this paper has been challenged repeatedly, not just on its conclusions but on its methodology, most recently in an article in the Lancet showed that there is no evidence that patient choice in the NHS saves lives.

The Prime Minister also needs to hear the professional view asking for publication of the Department of Health’s Transition and Strategic Risk Registers concerning the Bill. The date of the Freedom of Information Tribunal hearing has been brought forward to the 5 and 6 March. At the very least the Government should concede that if the Tribunal uphold the Information Commissioner’s view that the Register should be published, they will not go through further appeal proceedings and allow the Register to be published before the Third Reading of the Bill in the House of Lords. It appears that the contents of one of the risk register is now leaking and there are claims that the chief warning in the report is that it looks as if: Lansley’s reforms will spark a surge in health care costs and that the NHS will become unaffordable as private profiteers siphon off money for their own benefit. The report specifically warns that GPs have no experience or skills to manage costs effectively. The profit element contained in Lansley’s reforms is the chief reason for the report citing these worries. This is the reason Lansley refuses to publish the report, because he has claimed that his bill will make costs in the NHS more affordable. This flaw in the bill if exposed would undermine his entire argument and it is the reason the report will not be published until the bill becomes law.
The Prime Minister should also be ready to listen to the concern of the profession on the latest evidence from Holland. The Dutch competition authority (the NMa) has had the effect of fragmenting service provision and impeding the provision of high quality care. We have learnt recently of a €7.7million fine levied on the Dutch GP association for a “bad case of anti- competitive behaviour which was the National Association’s efforts to ensure that all areas of the country were adequately provided with GP services.

It is an extraordinary development that a Bill that was heralded by the Government as primarily being about enabling and freeing GPs has ended up with the Royal College of General Practitioners calling for the Bill to be withdrawn. The Dutch Patients and Consumers Federation is now calling for the involvement of competition in healthcare to be urgently reviewed. Since the enforcement of competition in the Netherlands and in the UK will both come under the same EU regulations, the Government cannot go on saying they are not sure of what the EU competition law will do. Monitor will have to work in the same way as the NMa in the Netherlands. Also once again we have the Government refusing to publish relevant facts. In this case the legal opinion that was given to the last Labour Government in 2006 on the implications of EU competition law on health when Labour has said they are more than willing that it should be published. The most recent guidance of the Office of Fair Trading (Public Bodies and Competition Law) issued in December 2011 states that for both UK and EU competition law “non- compliance with competition law can have serious consequences.

Professional concerns about the impact of the EU law on the NHS are serious. They are entitled to know whether the Prime Minister stands behind the speech made to the NHS Confederation in 2005 by Andrew Lansley when David Cameron was not the leader about the party’s plans for the NHS. Lansley said, “Much of what I have described is like the EU’s developing framework for services of a general economic interest. I recognize this and I welcome it. The vital aspect of our relationship with Europe should be to encourage the EU to be concerned with promoting competitive markets.”
The Prime Minister should also be ready to explore with the professions the questions about the role of Monitor in the light of the recommendation of the Future Forum that competition in the NHS should be limited to competition on quality not on price. It appears that under the Bill the “Most Economically Advantageous Tender” (MEAT) arrangement is likely to be permitted to be used by the National Commissioning Board and the Clinical Commissioning Groups. But as so often with the Bill this detail on competitive tendering will emerge later through Regulations that we have yet to see and will be the case also on competitive tendering. Regulations are unlikely to be published even in draft before the Bill is planned to receive Royal Assent. The devil will be in the detail. Talk of a level playing field for tendering is misleading. Charities and not-for-profit organizations will not have the same financial and technical resources as private companies.

Earl Howe wrote to Peers on 22 December about the Regulations “requiring commissioners to justify their decisions in terms of benefits to patients and value for taxpayers money. The Regulations would reflect the existing Principles and Rules for Competition and Cooperation in the NHS”. But in fairness to the last Labour Government competition was not for universal application. There was no insistence that any willing provider had the right to tender for virtually every health provision contract in England.
The MEAT procedure involves combining both quality and price, with contracts chosen at the lowest price for some acceptable pre-declared level of quality. This is how most competition contracts, in effect, work. First the contractor has to deliver a service at an adequate standard and then the decision is influenced by price. In health the risk is that this becomes all too often a race to the bottom on quality of provision.

The Government is attaching far too much importance to a few studies whose conclusions and methodology have been professionally challenged. Only recently Earl Howe partially quoted Professor Smith in a 2009 Health Report to the OECD having commented that, “competition can take many different forms, and sharpening competitive forces is likely in general to be an important tool for most health systems”.” Yet Professor Smith suggests that for completeness and balance this quote ought to include his previous sentence too; “true market competition introduces a set of raw incentives that carries serious potential for adverse outcomes for many aspects of healthcare.”

Many in the health professions want to proceed with care and caution over the introduction of competition policies in healthcare. They are ready to see further experiments in competition but they want an objective evaluation and an evolutionary approach that was becoming the hallmark of the internal market in the NHS. The Prime Minister, however, needs to explain to the health professions directly why and on what evidence he is endorsing the abandonment of the internal market present since 1988 and instead introducing a full blown external market. In the process ensuring a rationed healthcare system popularly accepted as democratic and as fair will be replaced by rationing through QUANGOs and competitive tendering seen as unfair.

It is not just the health professions but a growing body of informed opinion who are not prepared to accept that healthcare can be likened to just another utility. The Bill envisages Monitor’s role modeled on the laws that have already been set up for utility regulators. It is the commercialization and marketisation of the NHS that runs through this Bill which calls into question the very existence of an NHS in England in 5-10 years time. It does not help that growing perception when the Government has appointed two non- executive directors to join the Chair/CEO of Monitor who are all former McKinsey senior managers and have specialized in privatization; the Chair/CEO has the very same background, suggesting that skills in privatisation are considered essential qualifications for a senior role in Monitor. Nor that in 2010 private equity investors in New York received a personal invitation to enter NHS provision from a former NHS Director of Commissioning through a presentation on profit opportunities arising in the UK healthcare sector, which stated “in future, the NHS will be a state insurance provider, not a state deliverer. In future any willing provider from the private sector will be able to sells goods and services to the system. The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years. GPs will have to aggregate purchasing power and there will be a bid opportunity for those companies that can facilitate this process.”

The Prime Minister would be well advised to have the Chancellor of the Exchequer accompany him in any discussions with the health professions. Treasury officials are beginning to speak openly, though admittedly in private, about their growing concerns over delivery of the £20bn efficiency savings by 2015. Those in the Treasury who have served in or know well the Department of Health are fully aware that an organization in turmoil undergoing massive reorganization does not usually provide efficiency savings. There is an even more important aspect – an organisation in which its most dedicated supporters feel alienated is even less likely to accept pay restraint and pension reform, other key government priorities.

Of course, halting the Health and Social Care Bill will be a political rebuff, a ‘U’ turn over which the Labour Party would be bound to crow for a while. But the Prime Minister showed over the Government’s forestry proposals that that sort of criticism lasts for a few days and is soon forgotten. The prize for foregoing the Health and Social Care Bill is potentially immense. A relieved workforce, a uniting of the health professions, an accompanying readiness to adopt a reform programme within existing legislation at a faster pace than ever before. These are major advantages worth far more than temporary political embarrassment. An NHS that is all working together can and will adopt a positive reform programme. There is no appetite within the health professions for the status quo. What they all want is coherent evidence- based reform.

I am very grateful to Dr Lucy Reynolds, Health Services Researcher, for bringing to my attention many new facts and information.

1 www.lorddavidowen.co.uk
2 Martin McKee, Does Anyone Understand the government’s plan for the NHS? BMJ 2012: 344:e399doi: 10.1136/bmj.e399 (published 17 January 2012)

3 Health at a Glance 2011. OECD Indicators 10.1787/health_glance-2011-en http://www.oecd– ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en

4 Cooper Z, Gibbons S, Jones S, McGuire A. Does hospital competition save lives? Evidence from the English NHS patient choice reforms (Working paper No 16/2010). London: LSE Health/The London School of Economics and Political Science, 2010. http://eprints.lse.ac.uk/28584/1/WP16.pdf (accessed Sept 29, 2011).
Cooper Z, Gibbons S, Jones S, McGuire A. Does hospital competition save lives? Evidence from the NHS patient choice reforms. Econ J 2011; 121:228-60

5 www.thelancet.com Vol 378 December 17/24/31, 2011

6 http://eoin-clarke.blogspot.com/2012/02/andrew-lansley-covers-up-nhs-report.html
7 Sheldon T, Is Competition Law Bad for Patients, BMJ 2011; 343:d4495 and 2012;344:e439
8 Sheldon T. Dutch GP association is fined €7.7m for anticompetitive behaviour. BMJ 2012;344:e439 http://www.bmj.com/content/344/bmj.e439?view=long&pmid=22250223

9 ACEVO Procurement and Commissioning P3 http://www.acevo.org.uk/document.doc?id=51

10 Apax Partners conference, Opportunities Post Global Healthcare Reforms, October 2010 http://www.powerbase.info/images/f/fe/Apax_Healthcare_conference_2010.pdf

Update 09.02.2012

Earl Howe letter about competition 22 December 2011 Contains rebuttal from Dr Lucy Reynolds

PRESS RELEASE February 3 2012: IMMEDIATE

Lansley challenged as alleged leak echoes concerns over Health Bill

New Journalists’ Briefing helps to “Unpick the Spin” on the Bill

 Campaigners are demanding Health Secretary Andrew Lansley confirm or deny the truth of an alleged leak from the document that his Department of Health has been suppressing in defiance of rulings by the Information Commissioner.A blog post, by a pro-Labour critic who claims to have knowledge of the document, reports that the issues raised by the ‘Risk Register’ compiled by DH officials more than a year ago include:· Warnings that Lansley’s controversial top-down reorganization of the NHS could “spark a surge in health care costs”· The possibility that the extra costs of bringing in more private sector could make the NHS “unaffordable”· The fear that GPs – who are to be nominally in charge of “commissioning” (purchasing) services worth upwards of £60 billion a year through “Clinical Commissioning Groups” – lack experience and skills in managing costs.These warnings of potential risks in the Bill echo criticisms raised ever since Lansley’s proposals were first put forward. But the Risk Register has been withheld from MPs and peers voting on each stage of the Bill, and from the so-called ‘Future Forum’ on the Bill, despite two rulings by the Information Commissioner – upholding Freedom of In formation Act requests from the Evening Standard and former shadow Health Secretary John Healey – and calling on the DH to release it.

A defiant Lansley has now dragged the process out further by appealing against the Commissioner’s ruling, with a Tribunal hearing now scheduled for next month, AFTER key votes in the House of Lords, which will turn its attention back to the Bill next week. Dr John Lister, Director of campaign group Health Emergency, said:

“If true, this leak confirms that Mr Lansley has been hiding serious warnings from MPs, even while he dismisses critics raising these very points. It is likely that this leak could now be followed by others – and I challenge Mr Lansley to stop wasting time and set the record straight: he must confirm or deny the substance of this leak, and publish the Risk Register without further delay.For twelve whole months he has denied MPs and peers information they needed to form a proper evaluation of the Bill. He has even admitted his fears that publication could swing opinion against his unpopular and controversial proposals. If this leak is false, what is he so determined to hide from us?”

The leak coincides with the publication (attached) of a new easy to read Briefing by campaigners ‘Unpicking the Spin’ of the government’s presentation of the Bill, and refuting claims that it would save money, give local control over health services, put GPs and clinicians in charge, empower patients or improve outcomes. Dr Lister said: “Time is running out for the media, the public and many of our politicians to wake up to the real focus of this apparently complex Bill: the creation of a competitive health care market that would be costly, divisive, bureaucratic and unfair. Above all, it’s a Bill to empower the private sector, not patients or clinicians. That’s why the Bill cannot be amended. It must be defeated or withdrawn.”

FURTHER DETAILS: the blog leak can be found at http://eoin-clarke.blogspot.com/2012/02/andrew-lansley-covers-up-nhs-report.html ·

The Briefing from Public Health for the NHS is attached here:Unpicking the spin Briefing, or available from john.lister@virgin.net ·

Dr JOHN LISTER can also be contacted on 07774 264112

NHS hospitals play a central role in our healthcare system. They use around three quarters of the £100bn NHS budget and understandably their performance comes under close public scrutiny. Hospital managers are under heavy pressure to meet financial targets, as well as those related to the standards of care. Hospitals that are in regular deficit are often referred to as ‘failing’, even if they are performing well in terms of the clinical care that they are delivering.
On top of the long-term pressure to meet financial targets, there is now a drive for the NHS to make £20bn of efficiency savings and for all NHS hospitals to become foundation trusts by 2014.

Part of the current government’s solution is to give commercial companies the chance to take over the entire operational management of NHS hospitals that have persistent financial problems. The first of these schemes has been signed with Circle; the company will now be managing the debt-ridden Hinchingbrooke Hospital from February 2012. It is very likely that this is just the first of many agreements that will be signed with private companies to outsource the entire management of NHS hospitals in line with the government’s commitment towards increasing both competition and the role of the private sector within the NHS. The deal with Circle can be viewed as a test run for a business model which might then be applied to run other struggling hospitals in the hope that it
will alleviate debt and reduce costs. The major concern of any ‘business model’ applied to an NHS hospital by Circle or any other commercial organisation is that in order to reduce costs the first target will be a reduction in services.
In this report we examine the prospects for the scheme expanding and look at which companies are interested in taking up this business opportunity. The deal with Circle attracted a high level of media coverage, with its Chief Executive more than willing to outline the company’s business ethos, but many of the other
providers that might be interested in NHS hospitals are not often in the public eye. This report looks at the structure, investors and business history of all the major players in the UK’s private hospital business, and from these identies causes for public concern about how the companies’ business approach might impact upon the NHS.
We also examine the evidence to support the idea that the private sector offers a solution for the problems of the worst performing hospitals. Finally we include an analysis of the government’s plan within the Health and Social Care bill, to lift the cap on the income that NHS hospitals can generate from private patients. This is already creating interest amongst commercial providers in running private patient units on NHS sites and could be an additional impetus for companies to want to run NHS hospital services.

Link to full report from the NHS Support Federation

NHS support federation PDF download

The NHS Reforms- Lansley’s wonderful plan, by Clostridium difficile

Good day!  May I introduce myself?  I am a Clostridium difficile, and I live in soil and in intestines.  I like to set up home inside hospitals, as there I can spread to new people, especially when there’s a lot of antibiotics used.

I’m really looking forward to the NHS reforms. After six years of being hammered by disease control measures run by primary care trusts, it looks as though good times are coming for me, because the PCTs are being dismantled.

PCTs were amongst the NHS bodies required to have Directors of Infection Prevention and Control (the terrifying Dipcies): nurses, directors of quality, directors or consultants in public health. Their joint infection prevention and control committees attacked us on all fronts. They stopped us moving through nursing homes to hospitals to GP surgeries and round again. They imposed nursing, community pharmacy, and health protection measures. They cut the rich supply of antibiotics that were killing our competitors and giving us space to thrive. They stopped the prescribing of loperamide against diarrhoea which stopped us being flushed out of those lovely warm guts, and instead we could breed and breed. They encouraged spotless wards and clean hands so we couldn’t spread so easily.  In some parts of the country ruthless senior management and medical staff championed hand washing, good antibiotic prescribing and “serious untoward incident” exercises, which really hit me and my family. They double tested. In Sandwell, my kill rate fell by half and my hit rate by even more. It was a massacre.

All those measures will be going under the new arrangements. Thankfully this government has no respect for high quality medical advice –our national enemy Tzar Duerden has already gone, and the government listens only to the economists and the big investors. No-one at national level takes nosocomial infection seriously, and even those in the front line who want to don’t have the expertise or troops on the ground to control us. Financial competition between hospitals will mean that nursing staff productivity will be expected to go up, regulation will decrease, and cleaning will be done as fast and as cheaply as humanly possible. Andrew Lansley is our greatest friend ever! He’s even better than Mrs Thatcher who started the outsourcing of hospital cleaning and helped MRSA to spread in the hospitals.

The new public health provisions don’t include Dipcy roles. The individual Directors of PH that I used to fear will now assure (sic) a system but will have to battle local authorities and Public Health England for any weapons to keep fighting me. Some military strategists have called it ‘responsibility without power’; I say they’ll be up shit creek without a paddle. And that’s fantastic – shit creek is my home ground.

And not only will we run riot, but the free marketeers will even safeguard our privacy through commercial confidentiality: there’s no sign that private hospitals will be required to report hospital-acquired infections, and they won’t voluntarily do it, because that would put patients off and reduce their income.  Maybe those hospitals won’t even trouble to collect information to monitor our growth and spread, because doing that costs money, and they are allowed to conduct their business as they see fit under Clause 4 so as to meet their profit goals.  All the NHS hospitals are to be converted to Foundation Trusts, which also don’t have to report any data at all, and those too will be constantly pushed to save money.

Even under the present system, I have crept into Foundation Trusts. I have escaped detection in those FTs who took a ‘business decision’ not to do two stage testing because they thought they would be more likely to miss their financial targets if they spent money on robust infection control. Some have resisted the pressure to operate the double test against us because they don’t want to know we’re there!  Afraid their masters will punish them for finding us!  Their outsourced cleaning contractors haven’t helped them much either, with their everlasting wrangling over how much time their cleaners will do on what.  Blood stains congealing on the lino in this day and age….

The CCGs won’t know enough about us to understand how to find us let alone fight us, and they will try to push what hospitals charge them downward so as to stretch their shrinking referral budgets.  So if hospitals can’t charge for this through patient referrals, and all central budgets have been abolished in the reform, where are hospitals supposed to get money from to fight us?  We can see from marketisation of healthcare systems such as China’s that prevention measures cease because the market doesn’t fund them: ill people pay for their own care, but no-one wants to pay for prevention measures.

The marketised NHS will encourage more antibiotic use, because that’s what the consumers (formerly known as patients) want. So not only our pathogen competitors will be killed off but also the normal gut flora that keep us out, at least those that can’t come up with some kind of antibiotic resistance.  And from those that have or can develop this resistance, we Clostridia can often acquire the resistance genes, so that protects us from being killed off by antibiotics ourselves.

Public health surveillance will be moved into local authorities, and Public Health England will be so remote from where I and my offspring live.  I expect to run riot in nursing homes once again because the local authorities won’t have the troops to fight me.

I just can’t thank Mr Lansley enough for his brilliant reform.

Translators note:   Clostridium difficile, aka C.diff, is a bacterium which lives in the guts of about 3% of the population.  Generally harmless, if allowed to get out of hand it can cause severe diarrhoea, and a fulminating enterocolitis leading to death.  It has been subject of English government health policy because of its place as a healthcare-associated infection spread by poor hygiene, excessive antibiotic prescribing and use of antidiarrhoeal medications. Until now C. diff has been silent on the reforms, but now speaks through the medium of Dr John Middleton, Director of Public Health Sandwell and  Dr  Lucy Reynolds ,Public health military strategist at  London School of Hygiene.  C diff holds the honour of being Andrew Lansley’s greatest fan (outside the City of London, of course). 

Lansley’s problem hasn’t only been a failure of communication. It has been a failure of justification and a lack of evidence.

Right after the white paper was announced I wrote, ‘extraordinary changes require extraordinary justification backed up by extraordinary evidence’
The Health White Paper, Equity and Excellence, was remarkable for its lack of references and so several months after it came out, the government produced some post-hoc justification in the form of a piece of PR on the No. 10 website: PM article on the Health and Social Care Bill. It was swiftly decimated by (most famously) Professor John Appleby (chief economist at the King’s Fund) and Ben Goldacre (Badscience blogger and columnist). The comprehensive deconstruction has been compiled by Richardblogger.
After the White Paper came the Health and Social Care bill. Again the government failed to add references or justification. So this time they ‘paused’ and produced another piece of PR called Working together for a Stronger NHS.
Ben Goldacre’s response was to say what most of us were thinking, ‘I’d expect this from UKIP or the Daily Mail, not a government leaflet’.

Update 23.2.2012. Last week the government produced another PR document in the form of 19 fact sheets. Another blogger, Chris Mason has made the forceful point that none of them are linked to any evidence!

Chris has also had an email exchange with the department of health in search of evidence about cancer deaths and the costs of new medicines. They were unable to provide references.

Moving on from fanciful claims about healthcare outcomes.

Will the health bill streamline NHS management?

Here are 2 interesting links for the benefit of readers who do not follow twitter.

The first is an organogram of NHS structures from the Financial Times last year showing the difference before and after the bill.

The second is a blog from Paul Corrigan  (previously health policy advisor to Tony Blair 2005-7) published today, in which a GP explains to his constituency MP where responsibility for local health services will lie after the bill.

The answer to the question, “will the Health Bill streamline NHS management?”, is an emphatic, “no”

Not one of the other justifications for NHS reform including: putting doctors in charge, empowering patients, improving health outcomes, the ageing population and containing costs, stand up to scrutiny.

The press, with very few exceptions, have accepted the justifications without bothering to investigate them. If Lansley says we need to reform the NHS because of an ageing population is it so self-evidently true that they don’t check it out, or is there another reason? (Ageing adds about 0.5%-1% to healthcare costs per year)

If Lansley says that GPs are the best people to take on NHS commissioning, do they ask, “I wonder what that involves? Are they trained to do that? Is it like treating patients or running a surgery?” (It’s a mixture of legal-contracts, public-health needs assessment and complex administration, nothing like runnning a surgery) Do they wonder about the 40% of NHS services including local services like health-visitors and primary care that will be commissioned centrally? Or do they question the intention that “The NHS sector, which provides the majority of commissioning support now, needs to make the transition from statutory function to freestanding enterprise” (i.e. it will be privatised and run by international insurance companies, not your friendly local GP)?

The medical profession, being a mixed bunch, have fallen into a small, but politically ambitious camp of reform enthusiasts, and a far larger group of evidence-based practitioners who have seen the justifications as the snake-oil pedalling it is.

See also:

Why the NHS reforms won’t do what they say on the tin. Bevan’s Run

What is the problem the NHS bill is supposed to solve? Ian Greener

How the NHS measures up to other health systems. Open access link BMJ 22.02.2012 Guardian.

Measuring NHS performance using amenable mortality. Interpret with Care JRSM

The consequences of abandoning the Health and Social Care Bill. BMJ

Changes to the NHS have created an ‘unholy mess’ BBC

Cameron’s NHS Myths

Is the NHS Commissioning Board really being set up to liberate CCGs? NHS Alliance

“The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK,” said Mark Pearson, head of health at the OECD.
When it was put to Pearson, a respected economist, that the NHS faces its biggest upheaval in 60 years with the coalition’s health bill, he said: “The NHS is so central to the political process that every politician has to promise to improve the NHS. But there’s no big reform that will improve it. Better to let it bed down and tinker rather than wondering about more or less competition. It is less the type of system that counts, but rather how it is managed.”
Full story at: http://www.guardian.co.uk/politics/2011/nov/23/health-bill-nhs-oecd-report

Excellent presentation by public health consultant David McCoy.

Dear Better NHS readers,

 Hackney Keep Our NHS Public have been working to secure a demo outside Parliament to register public opposition to the Bill.

We now have permission for this! Please help us by attending and promoting this weekday demo – which continues until 8.30 p.m. The sooner we start promoting the demo the better. We have heard that others may soon announce plans to demonstrate and we hope that is the case and will support them.

The details of which are on the flyer attached.

It is widely predicted that the 8th of February will be the day the Bill moves to the Report stage and we could not arrange anything any sooner. This is a formal demo for which we have Metropolitan Police Approval.

Where: Wed 8th Feb. Old Palace Yard Westminster SW1P. Opposite The Lords

When: 2.30 – 8.30 p.m. Bring banners and placards and everyone you know!

Andrew McCabe HackneyKONP.org E Mail us: HackneyKONP8thFebDemo@gmail.com mailto:HackneyKONP8thFebDemo@gmail.com

The rumours in the press and social media that significant concessions
have been made by the government ( Earl Howe )  to the Colleges on the
Bill, not least around Clause 1 duty to provide are false. A real concession would be a return to the 2006 wording, and they remain 100% obstinate about not doing that and not explaining why they won’t.

Please read this briefing which shows the founding duty on the Secretary of State (NHSAct 2006 ) has not been restored and no significant concessions have
been made.

http://www.allysonpollock.co.uk/administrator/components/com_article/attach/2012-01-17/Pollock_HouseOfLords_HSCB_Briefing12_HoweLetter_17Jan12.pdf

Our focus for public health should now be be on the key Clauses which
underpin  the Red Lines set out in the Lancet article (below) and
restoring the fundamental duties of the sec of state.

http://www.allysonpollock.co.uk/administrator/components/com_article/attach/2012-01-24/Lancet_2012_Pollock_HealthAndSocialCareBill2011.pdf

Believe nothing until it is on the face of the Bill,(and checked by
independent lawyers) the same goes for reassurances about CCGs Clause
(12)and geographical areas and autonomy Clause 4.

David Cameron 27.01.2011:

This month, we published the Health and Social Care Bill, which sets out our plans to modernise the NHS … as with any big change, some myths have crept in and people are understandably nervous about what it will mean for them. So I want to address some of these concerns …Myth number one is that no change is needed at all. I disagree. Despite the best efforts of staff, the NHS does not consistently deliver the patient-centred, responsive care we all want to see. Too often, the decisions of frontline doctors and nurses are over-ridden by a top-down system which doesn’t allow professionals the freedom they need. This is the reason that, despite spending the European average on health, some of the outcomes are poor in comparison. For example, someone in this country is twice as likely to die from a heart attack as someone in France …

Guardian/British Medical Journal 27.01.2012:

The number of people dying from a heart attack has halved in the last decade, with falling rates of smoking, greater use of statins to lower cholesterol, and better NHS care thought to be behind the fall.

Fewer people in England are suffering a heart attack, and fewer of those who do are dying as a result, according to research by Oxford University reported in Thursday’s British Medical Journal.

They used official NHS data on hospital admissions and mortality to study 840,175 men and women who between them had 861,134 heart attacks between 2002 and 2010.

Overall, mortality rates among men fell by 50% and among women by 53%.

Link to the BMJ article

See also:

Does poor health justify NHS reform? Prof John Appleby Kings Fund

Heart attack deaths halved in the last decade. BBC

Britian’s record on cancer, who’s right? Straight statistics

Update 04-3.03.2012

Government confirms the Health Bill will privatise patient representation. Lord Toby Harris.

HealthWatch; is it being set up to fail? National Voices

On radio 4 this morning the inimitable Simon Burns, Andrew Lansley’s right hand man, said that the coalition’s health bill would “slash bureaucracy, put doctors in charge and give patients more power”.

Just as I have never met a doctor who thinks they will be in charge, nor a manager who thinks there will be less bureaucracy, I am yet to meet a patient who thinks the Bill will give them more power, still less one who can explain how. Part of the problem is that the government has muddled ‘patient choice’ with ‘patient power’. Just because having more power usually gives you more choice it does not follow that more choice is empowering.

I’ve tried to answer this question myself, because I think that patient empowerment is an essential part of good care and I’d like to see if it is possible.

Below is the complex way in which the bill enables this.

At the lowest level patients join their GP practice patient-participation group (PPG) (not all practices have them, but all should)

A representative from the practice PPG joins the Local Involvement Network (LINKs) though you may join LINKs without being on a PPG

LINKS are being abolished by April 2013 and replaced with Local HealthWatch. The problem with LHW is that it is part of the Care Quality Commission (CQC). According to the government’s own Health committee, “the CQC was established without sufficiently clear and realistic definition of its priorities and objectives. The timescales and resource implications of the functions of the CQC were not properly analysed, and the registration process itself was not properly tested and proven before it was rolled out” Health Policy Insight

The Health and Social Care Bill 2011 currently establishes health and wellbeing boards as committees in local authorities. The proposed health and wellbeing board membership includes:

• at least one councillor from the local authority
• the director of adult social services
• the director of children’s services
• the director of public health
• a representative of the local HealthWatch
• a representative of each relevant clinical commissioning group
• other persons or representatives the local authority or health and wellbeing board thinks appropriate.

The director of public health will be the principal advisor on health and well-being to elected members and officials in the local authority.

From April 2013, Local Authorities and CCGs, together with local HealthWatch, will be required to prepare the Joint Strategic Needs Assessment through the Health and Wellbeing Board. This will require groups to undertake a comprehensive analysis of the local needs of their population.

So patients can, if they are lucky/ pushy/ talented/ connected or a combination of all these things, get representation on a local authority Health and Wellbeing Board by April 2013.

This doesn’t sound like empowerment to me. And given the state of the CQC and the Bill it might very well not happen.

In the meantime I would like to encourage you all to join your GP practice patient participation group. If there is not one already, ask them to set one up, or even volunteer to set one up for them. Then whatever happens you’ll have a foot in the door.

And do ask your GP a few of these questions while you’re at it:

1. What is your opinion of the Health Bill? Do you support the BMA, the RCGP, the RCN and the Royal College of midwives in their opposition? If not why not?

2. How do you think the Health bill will affect your practice and your patients?

3. The government say that you are going to be in charge of the NHS budget instead of bureaucrats. This sounds good, but what does it really mean?

4. The government say that the health bill will give patients more power. How will it do that?

5. Do you have a patient participation group that I could join?

6. How do patients contribute to the local GP commissioning group?

See also: Big Society Volunteering NHS Vault

Patient & Public Involvement Response by Brian Fisher, GP

The initial design offered absolutely nothing to communities and individuals. Through argument and lobbying, these are now the additional responsibilities and expectations on CCGs. It does not add up to any kind of democratic arrangement, but it does offer opportunities for participatory democracy.

In addition, through a range of mechanisms, the LA has far more say.

CCGs have duties to promote patient involvement in all their functions. This is stronger than the previous obligation which was to “have regard to the need to” promote patient involvement. Clinical commissioning groups will have to involve the public in

• planning all commissioning arrangements,
• developing and considering all proposals for changes in commissioning arrangements
• all decisions affecting the operation of commissioning arrangements.

The previous plans had the same provisions, but they applied only to “significant changes”. They now apply to all changes and arrangements.

CCGs’ commissioning plans will need to be the result of ongoing joint work with Health and Wellbeing Boards.  Clinical commissioning groups must involve Health and Wellbeing Boards in preparing or revising their plans and, in particular, to share drafts with the Board and consult it on whether the drafts take proper account of the Joint Health and Wellbeing Strategy.

HWBs can make any objection to the NHS Commissioning Board if they feel that commissioning plans do not match the agreed strategy.

CCGs have duties to promote shared decision-making: patient involvement in decisions about their own individual health and social care.

The governing body must meet in public (except where it would not be in the public interest to do so). Membership of the governing body must include at least two lay members, together with one registered nurse and one doctor with secondary care experience. One lay member must have a responsibility for promoting PPI.

Transparency. There will be increasing expectation to publish health data in the public domain.

Independent scrutiny remains Authorisation requires:

• that CCGs will not only listen but respond to the recommendations of local communities.
• That CCGs do proactive work in their communities, for instance community development

HealthWatch is quite a mess at the moment. It may pull through to become a force for good.

Update 22.2.12

Lansley condemned over Health Watch Guardian

Public involvement blog. Big beast sells out public involvment Involvement sell out gathers pace

DH letter about Local Health Watch Jan 2012

Flagship Health Watch policy to be watered down by amendments HSJ 27.2.12

This is little more than a selection of newspaper headlines, but it reveals the extent to which the Public Heath profession has been usurped by the junk food industry in the diet-related disease strategy for this country.

1. “The Department of Health is putting the fast food companies McDonald’s and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg’s, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”

http://www.guardian.co.uk/politics/2010/nov/12/mcdonalds-pepsico-help-health-policy

2. “The secretariat for the Public Health Commission that day was, as usual, provided by Unilever and its marketing team.

It must have felt like a new dawn for the food and drinks industries. After more than four years of determined and co-ordinated lobbying, they were about to achieve the corporate PR agency dream: being invited to write the policy themselves. And, if the Conservatives won the election, in Lansley they would have a health secretary who understood them.

He not only subscribed to the libertarian view that public health should be more a matter of personal responsibility than government action; he bought in to the whole pro-business PR view of the world. (At that time, Lansley was a paid director of the marketing agency Profero, whose clients have included Pepsi, Mars, Pizza Hut and Diageo‘s Guinness. He gave up the directorship at the end of 2009.)”

“Diageo, in fact, had closer links with the Lib Dems than the Conservatives – its corporate relations director, Ian Wright, was one of three people who paid donations directly into Nick Clegg’s personal bank account to fund a researcher – but that would come in useful later once the election results were known.”

http://www.guardian.co.uk/politics/2010/nov/12/government-health-deal-business

3. Register of Members’ Interests

http://www.publications.parliament.uk/pa/cm/cmregmem/100927/100927.pdf

LANSLEY, Andrew (South Cambridgeshire)
Remunerated directorships

Profero (non-executive); digital marketing agency. Address: Centro 3, 19 Mandela Street, London, NW1 0DU. Work includes attending board meetings and advising on strategy and vision for the company. (Resigned 31 December 2009.)

31 July 2009, received payment of £1073.32. Hours: 8hrs. (Registered 21 September 2009)
28 August 2009, received payment of £1073.32. Hours: 7hrs. (Registered 21 September 2009)
30 September 2009, received payment of £1073.32. Hours: 8hrs. (Registered 1 October 2009)
30 October 2009, received payment of £1073.32. Hours: 6.5hrs. (Registered 18 December 2009)
30 November 2009, received payment of £1073.32. Hours: 8hrs. (Registered 18 December 2009)
31 December 2009, received payment of £1073.32. Hours: 6.5 hrs. (Registered 1 February 2010)

4. Freud Communications is a premium PR service whose clients—among them Mars, Nike (NKE), Pizza Hut (YUM), and Diageo (DEO) —pay above-market rates, says Rogers of PRWeek. Where a typical consumer PR firm in London might charge £100,000 a year, Freud commands £250,000 to £500,000, according to Rogers. “If you’re a company with a problem, he can call on his informal network of advisers and friends, CEOs, and politicians,” says Rogers.

In 1996, PepsiCo (PEP) was rolling out newly blue soda cans. To publicize the event, Freud enlisted Air France to paint the Concorde blue and the Daily Mirror to publish on blue newspaper for a day. Freud then arranged for a bevy of celebrities, including supermodel Claudia Schiffer, to pose with the blue products. The successful campaign had all the key ingredients of Freudian PR: celebrity endorsement, brand dollars, and newspaper collusion.

http://www.businessweek.com/printer/magazine/matthew-freud-will-see-you-now-09012011.html

5. The Department of Health announced that from January, its entire public relations work on public health would be handled by Matthew Freud‘s communication agency, which lists several fast and snack food producers among its clients.

Other Freud clients include Pepsi, KFC, Walkers Crisps and the premium drinks company, Diageo.

http://www.guardian.co.uk/media/2011/dec/20/matthew-freud-contract-department-health

PRESS RELEASE: January 12, 2012 IMMEDIATE
Public Health community calls on Royal Colleges to oppose Health Bill
 
An influential group of public health experts has sent an urgent plea to all the medical, nursing and allied health professional Royal Colleges and Faculties urging them to oppose the government’s unpopular Health and Social Care Bill.
 
The letter calls on the Presidents and Board members of all the Royal Colleges and Faculties to “unequivocally, vigorously and publicly oppose the Bill while there is still time”.
 
It follows results from the biggest national survey of GPs so far by the Royal College of General Practitioners, in which a massive 98% of GP respondents wanted the colleges to stand together and call for the Bill to be dropped.
 
The growing level of opposition across a wide range of health professionals reflects a deeply felt concern that the very integrity and equity of the NHS in England is under threat. The proposed changes will create a much more fragmented, market-driven health service, with competition replacing cooperation, with disputes over accountability and liability, with huge variation in what is commissioned and provided, and with the risk of increasing inequalities in health and access to healthcare.
 
Professor Alan Maryon-Davis, one of the signatories and a former President of the Faculty of Public Health, said:

“The complexities and consequences of this sprawling Bill are being gradually understood by more and more health professionals – and they don’t like what they’re seeing. Most of the Royal Colleges and Faculties have so far sought to engage constructively with the government to gain various concessions. But there has been no change in the Bill’s fundamental thrust – to turn the NHS into a giant marketplace, putting profits and productivity before people. Hence our plea to the Colleges and Faculties to act decisively before it’s too late”
 

Professor Allyson Pollock, another signatory, who is an expert on NHS policy said:

“There is a wealth of research pointing to the fact that the Bill will widen inequalities, threaten patient safety, corrupt the practice of medicine and lead to a huge waste of public money on administration and unwarranted profiteering”.
 

This letter to the Royal Colleges follows one sent this week by Lord Owen, arguing that that in light of the government’s refusal to publish the formal risk assessment of the Bill, the Colleges should argue that it would be riskier to proceed with the Bill than to stop it.
 
Dr Jacky Davis, a member of the BMA Council said:

“Given the level of disruption caused by the Bill, coupled with all the concerns and warnings that have been produced by heath policy experts, and given the huge challenge of having to make unprecedented efficiency savings, purely on the basis of prudent risk management, it is clear that this Bill should be withdrawn. It would be safer to stabilise the health system first; and then allow a full and proper debate about the need for any legislation at all”.
 

NOTE to Editors: Copies of the detailed briefings sent to the Royal Colleges can be found at: http://www.healthprofessionals4nhs.co.uk/

PRESS RELEASE:

Wednesday January 11 2012: IMMEDIATE RELEASE

Lord Owen steps in on Health Bill after Commons “misled”

What’s Lansley got to hide?  

Former Health Secretary Lord Owen has stepped up the fight to force Andrew Lansley to release a potentially damning “Risk Register” compiled by Department of Health officials, assessing the controversial Health and Social Care Bill, which Lansley has withheld from MPs and peers since this time last year.

Lord Owen, who tabled a motion on the Risk Register last month in the Lords, has now written personally to the Presidents of the medical Royal Colleges warning that the dangers of proceeding are far greater than those of stopping the Bill now. Ministers have been encouraging the DoH to implement aspects of the Bill even before parliament decides, to make it seem a “done deal”.

Publication of the Register was first requested under the Freedom of Information Act last February: but Mr Lansley has flouted the law and defied two instructions from the Information Commissioner to release the document. According to the Evening Standard:

“Mr Lansley’s officials had argued that releasing the Risk Register, when the Standard put in its FOI request in February with debate raging over the NHS changes, would have “jeopardised the success of the policy”.

Almost a year later the Register still has not been released. The matter goes before a tribunal on January 16, but in the meantime the Risk Register has been consciously kept under wraps for the entire duration of the Commons stages of the Bill, leaving MPs to vote time and again in ignorance of the findings. And it has also been withheld from the Lords during its debates, despite further attempts to force its release.

This secrecy confirms suspicions of opponents of the Bill that the document reveals some of the many weaknesses in Mr Lansley’s proposals for greater private sector involvement and competition in the NHS, and for the Secretary of State no longer to be accountable to Parliament for a fragmented NHS run nationally by an unelected Commissioning Board, and locally by private sector management consultants, who will be steering the “Clinical Commissioning Groups”.

The danger is that the risks identified in the register, and many proposals in the Bill itself, could escape any scrutiny in parliament, with the pitfalls of the Bill exposed and felt by patients and the public only after the Bill becomes law.

Campaigner Dr John Lister, a health policy expert at Coventry University, said:

“What has he got to hide? Mr Lansley has cynically attempted to mislead MPs – most of whom have no idea what the Bill says, but have voted on party whips – by withholding this document. He is now trying to do the same with the House of Lords.

“Lansley’s plan is not just lacking any supporting evidence: it is being pushed through with damning evidence suppressed.  This is taking a massive risk with patient care.

“If our own Parliament won’t uphold the law on Freedom of Information, or demand the full facts, it speaks volumes on our flimsy democracy.”

FURTHER DETAILS: Dr John Lister 07774 264112, john.lister@virgin.net

Bevan’s Run

Campaigners fighting on to try to prevent Lansley’s Bill reaching the statute book include hospital consultant and BMA Council member Clive Peedell who is staging “Bevan’s Run” from South Wales to London His route started at Bevan’s birthplace in Cardiff yesterday (January 10), passing through David Cameron’s Witney constituency on Friday January 13, and ends in a bedpan race down Whitehall on the 15th.  There will be rallies at each staging post: why not join Clive and colleagues for your nearest rally, or even for the run? http://bevansrun.blogspot.com/p/details-of-run-with-maps.html

Clive Peedell cliveypeedell@hotmail.com

PRESS BRIEFING: Health & Social Care Bill

Tuesday January 10 2012: IMMEDIATE RELEASE

Lansley’s NHS market could wind up like social care

While David Cameron and ministers talk misleadingly about “integration” of services for older people, the real danger is that the shambolic state of elderly care could be replicated across the whole of the NHS if Andrew Lansley’s controversial Health and Social Care Bill is rubber-stamped by the House of Lords.The Bill would fragment and “dis-integrate” the NHS: but the disintegration of social care has been taking place over the last 20 years. And the threat is that NHS care which is now free at point of use could be “integrated” with the failed social care system, which levies extensive means-tested charges – killing off the NHS as we know it.

Recent reports by Age UK and the King’s Fund on the crisis in elderly care have shown that 800,000 frail older people today are lacking services they need, rising to 1 million by 2015, while the Local Government Association recently warned ministers that the system of high-cost social care is “not fit for purpose”. BBC reports have exposed a growing problem of “bed blocking” and now hospitals are under pressure to discharge elderly patients despite the inadequate arrangements to care for them thereafter.

This competitive market in social care was created 20 years ago in sweeping “reforms” initiated by Margaret Thatcher. Until 1993, NHS hospitals were responsible for much long-term care, delivered free to all at point of use, funded from taxation, while those needing nursing home care had their fees covered by social security.

Now, with most NHS specialist elderly care beds having closed, and social care delegated to local government social services, patients are left dependent on costly, largely privatised domiciliary care, and privately-run residential care and nursing homes ” – while many more frail older people are excluded from any support by arbitrary “eligibility criteria” operated by cash-strapped councils facing 28% cuts over 3 years, and by local Primary Care Trusts. Elderly care is under-funded, fragmented, uneven, unequal and unsatisfactory, with responsibility split between local health and council commissioners, while 80% of domiciliary care is now privatised, and many care homes are run for private profit.

In this “market” vulnerable people are forced to “choose” between a multiplicity of low quality providers, who cherry-pick certain services and ignore others, leaving gaps in care. Pay and conditions for staff are notoriously poor, contributing to a demoralised, perfunctory service and the neglect of vulnerable people.

Competition has not brought improvements but has added new problems: elderly care is marked by poor contract management, sloppy and/or partisan commissioning, loose standard-setting, inadequate inspections, and rising charges as the remnants of public provision are replaced by a burgeoning private sector. And while the profits remain in private hands, any failure by private providers – such as the private equity firm that bankrupted the Southern Cross nursing home chain – lands back on the public sector, which has to step in and rescue the victims. The social care system is already becoming little more than a bare-bones service for the less well-off, with massive local variation and widening health inequalities. A similar fate is likely to befall the NHS if the current changes are implemented.

Mr Lansley’s plans for the fragmentation of the NHS involve disbanding its existing organisational structures, and rather than replacing them, turning over service coordination to the market’s “invisible hand”. The plans are devoted to opening up much greater involvement of private companies to deliver services paid for by the taxpayer; they include denationalising NHS hospitals as fast as can be managed. This threatens to fundamentally change, undermine and destabilise the health service.

The new system would be as poorly regulated, as patchy and incomplete, and as much of a postcode lottery as social care. It would allow private medical corporations or “any qualified provider” to scoop up profits – but dump all of the complex and costly cases onto publicly funded hospitals, for as long as such organisations exist. It would even allow local Clinical Commissioning Groups to designate some services as outside the NHS, making them subject to fees and charges for the first time since 1948.

London GP Jonathon Tomlinson said:

“If you want to know what a market in health care would look like, just look at elderly care – or dentistry, where charges are rampant, the private sector rules the roost, and many people cannot find an NHS dentist. Now GPs see many patients with dental problems. The NHS leads the world in fair access to care: Lansley’s Bill would undermine that.”

Lancashire GP and BMA Council member Dr David Wrigley adds:

“Our NHS was making real progress before Andrew Lansley’s Bill, and recognised as one of the best in the world: the danger is that it could become as unfair and chaotic as care of the elderly.”

Mr Lansley has the support of only a tiny minority of GPs and doctors for his Bill, which was not put before the electorate last year. His plans have been actively opposed by health workers and criticised by a wide range of think tanks and pressure groups for patients. Now a succession of feel-good government “initiatives” and announcements are being used as red herrings to divert the media and public while this retrogressive legislation is forced through the House of Lords.

That’s why David Cameron is now suddenly declaring himself an expert on nursing rotas and prattling about improved standards even while thousands of nursing jobs and support staff are axed, wards closed and services rationed.

Campaigners will be fighting on to try to prevent Lansley’s Bill reaching the statute book, including hospital consultant and BMA Council member Clive Peedell who is staging “Bevan’s Run” from South Wales to London His route starts at Bevan’s birthplace in Cardiff today (January 10), passes through David Cameron’s Witney constituency on Friday the 13th, and ends in a bedpan race down Whitehall on the 15th. There will be rallies at each staging post: why not join Clive and colleagues for your nearest rally, or even for the run? http://bevansrun.blogspot.com/p/details-of-run-with-maps.html

FURTHER DETAILS:

Dr David McCoy d.mccoy@ucl.ac.uk

Dr David Wrigley dgwrigley@doctors.org.uk

Dr Jonathan Tomlinson echothx@gmail.com

Clive Peedell cliveypeedell@hotmail.com

Dr John Lister 07774 264112, john.lister@virgin.net

1. How does Earl Howe explain the comments he made at the Laing & Buisson Independent Healthcare Forum on 7 September (during the 3rd Reading) in which he informed the audience of private sector providers that there were big opportunities for them to make money by taking patients away from the NHS?
http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/12663018/big-opportunities-for-private-sector-in-health-bill-says-minister

2. What safeguards are to be put in place to prevent private equity companies from taking a stake in NHS ex-employee buyout “social enterprises”, gearing them up [raising loans against them and extracting the principal, a standard asset-stripping manoeuvre], extracting the cash and dumping the remains once no more income stream can be extracted?  i.e. the Southern Cross story?

3. There are sections of the Bill which pertain to property transfers (134, 299, 300 and Schedule 23), but none of them mention the value at which land and buildings may be transferred under their provisions.  What safeguards are in place to prevent NHS land and buildings being transferred at undervalue?  Can Earl Howe guarantee that these transfers will not take place for a nominal sum?  The Bill contains no provisions for public scrutiny of such transactions involving the Secretary of State and “qualifying companies”.  How will public oversight be arranged for this?

4. Several of the US companies which are hoping to come in to the NHS as either providers or commissioners have been in trouble for defrauding the US government.  What safeguards will be put in place to stop them applying the same low business standards to their dealings with patients, GPs and the UK government?

5. One large company which has been lobbying for access to the post-reform NHS is a South African company [Netcare, parent of General Healthcare Group] which was found guilty of removing the kidneys of minors and selling them. What “fit and proper person” tests are to be applied for the new entrants to our state-funded health system? Will the general public be allowed to lodge protests against particular providers who seem to have demonstrated themselves not to be fit and proper persons to be involved in running services for the NHS?  The Mirror alleges that GHG is under consideration for contracts to run transplant services in the UK: http://www.mirror.co.uk/news/politics/2011/09/06/organ-selling-firm-in-nhs-talks-115875-23399313/

6. Once NHS hospitals are required to make their money through selling services, they will have to balance their books or go out of business.  Is it planned for those burdened by expensive PFI deals to be left to sink or swim, or is the government planning to force the taxpayer to take over all of the PFI deals so that such hospitals have a chance of survival in the new market-place?  What efforts have been made so far to repudiate these deals and stop the PFI lenders and providers from continuing to fleece the taxpayer?

7. The Care Quality Commission has been running regulation on the basis of self-certification and has a track record of believing those assessments rather than inspecting in person; the Winterbourne View case demonstrated that self-assessments by profit-making, private-equity-funded suppliers are not to be trusted.  For the last year the CQC has recruited no-one with any medical qualifications for any of its management or inspection roles.  The reason appears to be systematic under-funding and management which fails to protest about the fact that it has insufficient funding to do the job properly. The Bill puts the responsibility for technical inspection on to the underfunded and underskilled CQC and mandates no extra funding. Can Lord Howe please elaborate on how the system will be changing to safeguard patients properly? For instance, how will the figure for an adequate amount of CQC funding be arrived at?  What is the planned frequency of facility inspections by medical doctors?

8. What safeguards are to be put in place to stop GPs denying patients treatment under the NHS (and retaining the money saved, as would be permitted by the Bill) then offering to give private treatment for the same complaint (as also permitted by the Bill). None are at present included in the Bill.

9. What proportion of the referrals budget is expected to be spent on commissioning overheads and profits (of contractors to which the commissioning tasks are outsourced)?  Is it reasonable to expect this to be in the 20%-40% range as applies to similar arrangements in the USA?  What do your projections show for the amount of the budget given to GP consortia which will be consumed by the outsourcing of commissioning costs?

10. The Bill (s13) allows privatisation of secure psychiatric services; s35 allows the Secretary of State to nominate whoever he likes to approve people to section individuals thought to be a danger to themselves or to other people. The Bill states that the SoSH may or may not arrange compensation for this task.  Clearly there is potential for abuse in this combination of changes.  There has been a recent related abuse in the USA: http://www.nytimes.com/2009/02/13/us/13judge.html?pagewanted=all but in that case the scheme required bribery of judges and the sentences were for months only.  In the NHS case abuse would not require any illegality, merely the possession of the right to lock people up and to be paid for doing so (under a contract) and the ability to approve people to section others (who as well as approval need the minimum qualifications specified under the Mental Health Act 1986); and the deprivation of liberty involved could be long-term or permanent. This seems to be a duty which should not be taken out of state supervision. What safeguards are to be put in place to protect the general public from being involuntarily admitted to profit-making secure mental hospitals which are paid by the number of inmates held?

11. What safeguards are in place to prevent inmates of secure psychiatric facilities privatised under s13 from being pacified with drugs which have serious permanent side-effects, or with ECT, in order to enable lower levels of staffing to be maintained and more profits made?

By Dr Lucy Reynolds.

Other articles by Dr Lucy Reynolds:

Provisions for competition in the Health Bill. Martin McKee’s blog 07.11.2011

Liberating the NHS: Source and direction of the Lansley reform 29.08.2011

Two issues with competition in healthcare BMJ 25.07.2011

For-profit companies will strip NHS assets BMJ 15.06.2011

Issues MPs and the media have missed in Lansley’s bill BMJ 24.05.2011

Apologies for the lack of original material. A new post on the theme of the sceptical healthcare consumer will be up soon. Meanwhile here are some of the more original, important, informative articles from the last 2-3 weeks:

Seven former presidents of the Faculty of Public Health accuse the Prime Minister of ploughing ahead with an “unprecedented marketisation” of services, which poses a “major threat” to the integrity of the NHS.In a letter to Mr Cameron, the group warns:

“The Bill is likely to produce a ‘patchwork quilt’ health system that will vary hugely across the country, failing to meet the diverse needs of the population and undermining the health of vulnerable, minority groups.” Independent Jan 1st.

Christmas is a time to count our blessings, reflecting how they came to be. For people living in England this reflection is more relevant than ever, as the coalition government paves the way for the demise of the welfare state. This statement will be seen by many as reckless scaremongering. The welfare state, not only in Britain but also throughout western Europe, has proved extremely resilient.1 How could any government bring about such a fundamental change? The assault on universalism: how to destroy the welfare state. Martin Mckee et al. BMJ 20.12.2011

… we are seeing the return to the Thatcher doctrine that people should expect to pay for private care, either out of pocket or through insurance, and that those of us who could not afford private care would, like the queues of patients waiting for their MRI scan in that 80s hospital, be second in line to the private patients. Memories of Paul, NHS Vault 29.12.2011

Bevan’s run: January 10-15th, 2012. 160 miles in 6 days from Aneurin Bevan’s Statue in Cardiff to the Department of Health, Richmond House, Whitehall, London. To protest against the Health and Social Care Bill and NHS privatisation. Calling at Witney (David Cameron’s constituency). On day 6 (Sunday 15^th Jan): High Wycombe to London (Richmond House, Whitehall). We aim to get to Richmond House at about 2-3pm. We will publish route soon, but anyone that wants to join in could meet us in Uxbridge. (Details of meeting point to follow). We will post Bevan’s Postcard to Department of Health. There will be speeches.

Market Failure in Healthcare Part 1: Market Failure in Theory The theory of market failure in healthcare was first described by Professor Kenneth Arrow in 1963 in his seminal paper,“Uncertainty and the welfare economics of medical care“.

“Indeed, the case I have made and experience elsewhere leads us to conclude that if we were to go down the road of introducing markets wholesale into British health care we would be paying a very heavy price in efficiency and equity and be unable to deliver a Britain of opportunity and security for all”

“The very same reasoning which leads us to the case for the public funding of health care on efficiency as well as equity grounds also leads us to the case for public provision of healthcare”. Gordon Brown, SMF speech 2003 Clive Peedell, Bevan’s run