Saturday 24 March 2012

Response to Lord Ashcroft's blog and poll on Conservative Home

Lord Ashcroft’s blog on ConservativeHome about doctors standing against coalition MPs at the next election is an interesting read. It relates to a letter I wrote to the Independent on Sunday, which was signed by 250 doctors. The fact that he has written about it and also performed a poll is a clear sign that the coalition Government are worried.

He concludes from his polling results that doctors standing against Conservative and Liberal Democrat MPs would result in boosting the Conservative party’s electoral fortunes. However, his article and conclusions are flawed in many respects as I discuss below.

His first key point is about GPs standing on a similar ticket in 1990. He says:
“In 1990, a group of GPs established the NHS Supporters Party, with the identical aim of standing 50 parliamentary candidates; the peak of its success was to achieve ninth place in the Mid-Staffordshire by-election of that year, with 102 votes.”

This refers to Kenneth Clarke’s Working for Patients reforms, which introduced the internal market into the NHS. The BMA launched a major campaign against the reforms, but they did this unilaterally. No other major professional group spoke out. This is very different to the current reforms, where virtually every healthcare professional group came out against the reforms as illustrated graphically here. This level of opposition raised so much concern that the bill was “paused” and more recently, 3 cabinet ministers urged Cameron to drop the bill. There were even No 10 briefings against Andrew Lansley saying he should be “taken out and shot”. Public demonstrations and opposition were also highlighted in the media with the June Hautot heckling episode being the most memorable and damaging. Thus, this is a different level all together. In addition, the GPs in 1990 did not have the weapons of social media that are available now, and the political climate is also very different. Another key point is that Lord Ashcroft’s poll shows that a NHS party would have 18% support. This would be enough to win seats, not merely finish 9th place in a by-election.

Lord Ashcroft also makes the assumption that our NHS party would stand candidates in marginals and would not get other parties to stand down. He clearly has no understanding of our strategy. In fact our party (which is in the process of being formed) is being advised by an expert in voting theory and the placement of candidates will be considered very carefully indeed. For example, the South West of the country would be an good place to target Liberal Democrats with significant majorities.

He also extrapolates his poll percentages to an overall electoral result, but if we only field 50 candidates, then we would not see a swing to the Conservatives in the way he describes. In addition, this is not just about taking seats. Even if we don’t take a single seat, we will raise publicity to make the NHS a toxic issue for the Tories and the Liberal Democrats at the next election. They are likely to lose votes even in constituencies we don’t contend. Our repeated message will focus on the undemocratic dismantling, denationalisation and privatisation of the NHS. We will focus on the key messages, which came from the professional associations that stated that the reforms will damage the NHS, fragment care, widen health inequalities, be detrimental to education and training and ultimately harm patient care.  
The phrase “No top down reorganisation” will reverberate around the corridors of Conservative Central Office.

So my own conclusion is that the coalition is rattled by the formation of this new group. We will not be frightened off by Lord Ashcroft’s mistaken claims that we will boost the chances of the Conservative Party being re-elected. We will plan carefully, avoid splitting votes, and try to take as many seats as we can. We don’t fear failure. In fact we are spurred on by the fact that we are in 3rd place in Lord Ashcroft’s poll before we have even registered with the electoral commission. We don’t even have a name yet, but one thing is certain, that name will contain at least three letters.... N H S

Friday 9 March 2012

Speech at TUC Save Our NHS Rally, Westminster Central Hall, 7th March

Because I’m bloody angry about this bill

As co-chair of the NHS Consultants' Association, I support Bevan’s idea and vision of an NHS which is comprehensive, equitable and free to all at the point of delivery and crucially an NHS that is publicly funded, provided, and accountable.

But this bill fundamentally undermines these principles because it is a denationalisation and privatisation bill that will dismantle the NHS with profound knock-on effects for the social fabric of our nation. It will bring back fear to the poorest and most vulnerable in our society.

The Government has systematically failed to make the case for its radical reforms at a time when the NHS is performing very well by international comparisons. The bill lacks an evidence base, is hopelessly flawed and is being introduced at a time when the NHS is facing the biggest financial crisis in its history.
According to Professor Patrick Dunleavy of the LSE, it has all the hallmarks of a “Policy Fiasco”

The bill is a top down reorganisation and it has no democratic mandate.
It will increase costs and bureaucracy, fragment care and reduce access to care, undermine professionalism and the doctor- patient relationship, the social contract and the public service ethos, and worsen healthcare inequalities and healthcare outcomes.

Unsurprisingly there is near unanimous opposition to this bill from the major healthcare professional organisations. Even the LibDems own health policydoctors are calling for the bill to be withdrawn.

Professor Lyndsey Davies, President of the UK Faculty of Public Health said the bill:
“will damage the NHS and the health of people in England”

In the face of such massive opposition from the very people who are crucial to the success of any NHS reform, the idea that this bill is about to reach Royal Ascent and pass onto the statute book beggars belief.

It is a national scandal that MPs and Peers have failed to listen to healthcare professionals and withdraw this bill. The NHS is being disgracefully horse traded for political purposes.  A shameful example of putting the interests of party politics before patients and the public.

It is vital that the Libdems debate their Emergency motion to withdraw the bill.
So I will be channelling my anger into a 42 mile run from Middlesbrough to Gateshead to try and support the brave LibDems who actually care about the NHS and want to save it for the generations to come.
But let’s keep fighting and punish those LibDem MPs who support this bill, at the ballot box

Sunday 4 March 2012

Why the NHS reforms won't do what they say on the tin

Has the case for radical NHS reform been made?

A major reason given by the coalition Government to justify the need for radical reform of the NHS is that the demands and expectations of an aging population combined with technological advances in medical care, and a financial crisis, mean that the current model is not sustainable financially.
The Government also claim the NHS performs badly compared to other nations in terms productivity and efficiency, as well as clinical outcomes.

On the former claim, Professor John Appleby, chief economist from the King’s Fund wrote an interesting data briefing for the BMJ, Can we afford the NHS in future?  He noted Andrew Lansley’s comments to a Daily Telegraph article in June 2011:

“If things carry on unchanged, this would mean real terms health spending more than doubling to £230 billion (by 2030)......This is something we simply cannot afford.”

Appleby commented that this was a short step to an argument that the NHS must change (because unchanged equals unaffordable) and that the change it needs are the Secretary of State’s reforms i.e a version of the “politician’s syllogism”:
1. The NHS must change (otherwise it is unaffordable)
2. This (the reforms) is change
3. Therefore we must do this (the reforms).

Appleby went on to critique Lansley’s argument and concluded that “Spending on health will be a matter of choice, not affordability

Professor Ian Greener’s recent blog also laid waste to the Government’s case for change and is essential reading. He noted that the Government approach to policy making is known as a ‘garbage can’ approach in the academic literature ie a solution in search of a problem- not evidence-based policy, but ideologically-driven policy.

Thus the Government are starting from a very weak position if they think radical change to the system is needed.

So what about the reforms themselves? Do they offer a solution to the fulfilling the long term future healthcare needs of our population, or not?

In my opinion, you only have to scratch the surface to see that the proposed NHS reforms will make things worse not better and this is the case from a professional, organisational and economic perspective.

Professional perspectives and effects of the reforms
From a clinical viewpoint, all professional bodies have concerns that the reforms will damage the NHS, fragment care, reduce access to care, increase inequalities, and undermine medical professionalism and the doctor patient relationship. In fact these concerns have hardened more recently, and thus the majority of professional and representative bodies of healthcare professionals are now callinging for the bill to be withdrawn. It therefore really makes you wonder how on earth MPs and Peers can even consider passing this legislation in the face of such professional opposition. The following remarkable statements from clinical leaders only serve to emphasise this:

Professor Lyndsey Davies, President of the UK Faculty of Public Health (UKFPH):
“It is clear that the majority of our members now believe that the Health and Social Care Bill, if passed, will damage the NHS and the health of people in England

Dr Clare Gerada, Chair of the Royal College of GPs
“GPs don’t think the bill is going to create a patient led NHS, they don’t think it is going to increase autonomy, they don’t think it is going to improve patient care, and they don’t think it is going to improve healthcare inequalities”

Crucially, in terms of addressing the needs of an aging population, which is a key Government objective and a reason for reform, this statement from the British Geriatric Society calling for withdrawal of the bill (by it’s President Professor Finbarr C Martin) completely undermines the Government’s argument and credibility:
It has become clear that the proposed legislation is both deeply flawed in detail and deeply troubling in its possible consequences. Our position is informed from the perspective of our members' knowledge and commitment to the health and community services needed by older people. We are concerned that the Bill does not support the changes necessary to provide integrated, high quality consistent care for our ageing population and has a serious risk of undermining the progress made in recent years”

He also states:
“The BGS remains committed to work in partnership with all health and social care services to ensure our ageing population receives the best care possible. In our view the provisions in this Bill will be a step backwards in attempts to do this”

Thus from a clinical professional perspective, the Government’s reforms will fail to do what they say on the tin.

Organisational perspectives and effects of the reforms
One of the key arguments the Government has put forward to justify the reforms is to cut bureaucracy and save money. However, several respected commentators have highlighted the fact that the bill increases bureaucracy and complexity of the system and will increase costs.
Professor David Colquhoun has explained this well in his blog and produced some really useful diagrams to show the complexity of the new system compared to the previous system.
Roy Lilley has also explained how 3 layers of management have been replaced by 7 layers.

This is clearly a major reorganising and restructuring task and the Government estimates of these costs have been challenged by academics including Professor Kieren Walshe from the Manchester Business School and Professor Patrick Dunleavey from the LSE
Current estimates of the reorganisations are around £4 billion compared the Government figure of £1.3 billion.

Walshe states that “Little of the current architecture of the NHS will survive these changes unscathed.”
He then offers this advice to the Government:
“In brief, the government should learn three things from the history of NHS reorganisation:
1.Firstly, structural reorganisations don’t work.
2.“reorganisation adversely affects service performance
3. the transitional costs of large scale NHS reorganisations are huge”

Patrick Dunleavey states that the reforms have all the hallmarks of a “policy fiasco”.
Thus from an organisational perspective, the Government’s reforms fail to do what they say on the tin.

Market based systems and financial perspectives and effects of the reforms

For the NHS market to function there needs to be patient choice to drive competition between a plurality of Any Qualified Providers (AQP). Money then follows the patient through payment by results (PbR).
Stimulating competition and patient choice is one of the key aims of the bill. Andrew Lansley made what is now an infamous speech to the NHS confederation in 2005, where he stated that:
 The first guiding principle is this: maximise competition.... which is the primary objective”.

“Competition and choice are not just slogans. They are a policy whose time has come.”

He went on to describe how this would be achieved - by maximising the numbers of purchasers and providers in the system.
His method of increasing numbers of purchasers is by getting money closer to the patient (consumer) ie to GPs or patients themselves:
The statutory formula should make clear that choice should be exercised by patients, or as close to the patient as possible, thereby maximising the number of purchasers and enhancing the prospects of competition, innovation and responsiveness to patients”

This is why his reforms are placing £60 billion of the NHS budget in the hands of “GP led” Clinical Commissioning Groups and why the policy of patient held budgets is being expanded.

In terms of maximising the numbers of providers, this will be achieved through the Any Qualified Provider (AQP) policy, where private companies and third sector (non profit) organisations are encouraged to enter the new market.

This creation of excess capacity in the system is the only way for patient choice and the market to function, which is confirmed by Lansley himself:
“The reforms I describe are designed to stimulate a significant capacity response”

However, having excess capacity is inherently inefficient, especially in a single payer system where there is a finite amount of money. Also very worrying is the drive to promote citizen–consumerism in healthcare, where patients act like consumers in a marketplace and shop around for health services. This is a system that responds to wants rather than needs, and is a recipe for inflating healthcare expenditure and creating inefficiencies through overtreatment and undertreatment.  

So the slogan “No decision about me without me” is really about the idea of citizen- consumerism and increasing consumer power in the new healthcare market.
This clearly has highly significant cost implications for a single payer system.

If we now factor in the transaction costs of the market, it becomes apparent that it is highly unlikely that the single payer system can survive. This important paper in the BMJ, shows how the market has inflated costs in the US system. Moreover, in the UK, research from Karen Bloor of York University, which was cited by the Health Select Committee’s report on Commissioning in 2009, has estimated that administrative costs of the NHS following the introduction of the internal market reached about 15% of total NHS budget versus ~5% prior to the purchaser-provider split. The new market may reach higher percentages as the number of market transactions will increase and the need for private commissioning support through the Framework for External Support for Commissioning (FESC) is encouraged.

Thus from a financial perspective, the Government’s reforms will fail to do what they say on the tin.
In fact the reforms will.   Coupled with increased costs associated with the reforms, the system will break under the pressure.

Future perspectives and effects of the reforms on creating a mixed funding system

The new market system will increase healthcare expenditure and force the NHS into financial meltdown. This will be catalysed by the McKinsey £20 billion QIPP efficiency drive, which amounts to a 4% per year efficiency saving until 2015. This scale of savings has not been attempted in any healthcare system in the world and it will lead to the demise of the single payer system, which Derek Wanless concluded was the most cost efficient way to fund the NHS. This then opens the door to a mixed funding system with increasing use of private insurance, user fees and top up payments.
And this is where we come to the heart of it - the reforms will makes this transition happen in the following ways:

• Firstly, Clinical commissioning groups will increasingly becoming rationing bodies, driving up waiting lists and reducing the number of NHS core services. Thus there will be an increasing demand for healthcare insurance as waiting lists go up. The QIPP efficiency measures will act as a catalyst to this process;
• Secondly, Foundation Trusts can borrow money from the City to invest. They will have to repay this by treating more NHS patients and more private patients. This will be aided by the raising the cap on private patients’ income for FTs to 49%. However, financial pressures will drive foundation Trusts into further debt burdens forcing closures, mergers and private management takeovers. This is already happening. In fact, this whole process is crucial to stimulating the private healthcare insurance and private provider industry.
• Thirdly, there will be a new insurance market set up for top ups and co-payments; and
• Fourthly, in the next Parliament, it is likely that more direct patient charges will be introduced.
A failure of the NHS to provide a comprehensive service and the move towards opening up a mixed funding system requires the Secretary of State to abdicate his/her duties and powers to provide a comprehensive healthcare service to the nation’s population. This effectively denationalises the NHS and explains why the Government will not back down on Clause 1 and related clauses, which have been hotly debated in the Lords. They need to abolish these clauses to abolish the NHS and create the mixed funding systems. The work of Peter Roderick, Allyson Pollock and others is an essential read to understand this in more detail. I therefore strongly recommend the Duty to Provide website.
English citizens will increasingly have to consider taking out healthcare insurance policies as financial pressures cause the NHS to fail. Healthcare rationing by CCGs, Rising waiting lists, and reduction in NHS core services will fuel the insurance industry’s engine. This clearly has the most adverse effect on the most vulnerable in society because of the Inverse Care Law .
Finally, opening up the NHS to EU competition law will dramatically increase the amount of capital available to bring into our health service, but ultimately this capital will flow back to the investors at a profit, which will be at the expense of the UK citizens as taxpayers and in the form of private healthcare insurance premiums and out of pocket healthcare expenditure.

Conclusion: The politics and false economy of the reforms
The Government’s reasons for radical reform of the NHS are flawed, lacking in evidence, and driven by ideology. Their solutions will actually create more problems by increasing healthcare costs and bankrupting the NHS, leading to a mixed funding system of healthcare, with increasing marketisation and privatisation. Of course, increasing privatisation is a key supply side economic policy of the Government, which they are applying right across the public sector. New Labour were doing similar things, but not in such a drastic manner. I have discussed the politics of this neoliberal approach in another blog. The basic premise is that privatisation of public services will reduce the tax burden on corporations, reduce inflation and stimulate economic growth. However, the drive towards privatisation and a mixed funding system will increase economic and healthcare inequalities, which are both known to damage economic growth, which in turn impacts heavily upon the social determinants of health, causing a viscous circle of greater inequality. This is in direct contradiction to Clause 3 – the new duty of the Secretary of State for Health to reduce health inequalities.
The reforms will be economically damaging for a number of reasons. Citizens will have less money in their pockets as they have to pay for increasing proportions of their healthcare costs. Thus they will have less money to spend in their local economies. In addition, private companies will reduce terms and conditions for health workers who will have less money to spend in their local economies. These companies will also siphon off taxpayers money into their profit margins, the meteoric pay packets of their CEOs, and offshore tax havens. This will all be damaging the UK economy and thus NHS privatisation is a false economy.
We are about to lose our greatest institution, which is a highly performing and popular healthcare system. The NHS not only delivers on access, equity and fairness, but also acts to redistribute wealth around the country and stimulate local economies through the multiplier effect, helping local private businesses to grow and help stimulate the overall economy. Let’s not lose it to an ideologically driven coalition government, who have absolutely no democratic mandate to dismantle it.