RIP NHS?

Andrew Lansley, British politician and Shadow ...

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A truly national health service as conceived in the post-war years has been tottering on the brink for a number of years.  As the previous Labour government sowed, so the Liberal Democrats and the Conservatives will reap today as the NHS and Social Care Bill reaches its last stages in the House of Commons  and the Conservative Party  institute their idealised version on a market-led health service which will deliver profits into the hands of investment companies and will place efficiency above effectiveness in treatment delivery methods.

Yes, I feel bitter, very bitter. I don’t see the Labour Party hauling us out of the mess that the both the Liberal Democrats and the Conservative Parties have conspired to leave us with because the Labour Party in their previous guise very much laid the groundwork for this to be done.

I find it hard to believe the audacity and the incompetence of our political elite as they push through a hugely unpopular bill tonight but then, as I pause, I wonder if it is truly incompetence as they are ‘getting away with it’.

We have been confused by details and have been tricked into believing a ‘consultation’ process has taken place. It has taken place very much on the government’s own terms and the listening that has been done has been very selective.

I try not to have a blanket opposition to the ‘private sector’ and ‘profit-making’ in the health and social care sectors but I’ve been burnt by experience. There are some companies that may well be able to improve some aspects of service delivery and I completely accept we all need to move away from the blind public/private being good/bad depending on where you stand on the political spectrum. That’s quite hard for me to ‘get my head around’ as I feel instinctively that profit should not be made from ill-health but equally the government’s obsession with public being bad is equally short-sighted and damaging.

What really sticks is the way that Cameron has blatantly misled the country in the quest for votes. ‘No top down reorganisation of the NHS’ he said, lying openly to the nation and yet we have to accept the mishmash garbage that he is now leading through Parliament as the Health and Social Care Bill and it moves towards it’s Third Reading in the House of Commons today.

I feel angry at the way that language has been turned and stolen from us.

‘Choice’  has become a catch-word but as I have discovered through the ill-spirited and contemptuous way that ‘individual budgets’ have been delivered in social care – choice mostly a luxury of the ‘worried well’ or the more affluent middle classes – in whose ranks sit all those MPs who vote on these changes today.

Choice means very little if you are not in a group that can cost a company money rather than increase their profits.

We have been hoodwinked into believing that ‘choice’ will genuinely exist when these private companies rip up our public services to deliver profit to their shareholders? I think we should ask whose ‘choices’ is it that the government and the health companies that support then, they will be?

Let me turn to the social care sector again because that’s an area I am familiar with. I am very familiar in the ways that privatisation has worked or rather, not worked and the way that ‘choice’ has been promoted – falsely – as the achievable outcome for all end users.

The pushing of the public sector from social care delivery has decreased ‘choice’ in many instances. In the areas I’m familiar with, local authorities have been pushed out as providers of residential and home care services to be replaced by companies such as Southern Cross (RIP), Bupa, Care UK (always worth repeating that they donated to fund Andrew Lansley’s private office)  and homes have closed, block contracts have been signed to provide care at the cheapest costs which increases profits for the private companies of course and limits choice for individuals who need these services.

Anyone who claims that the roll out of personal budgets has or will change this and has increased ‘choice’ I will point to those who have capacity issues – those without family or friends to support them – those who are more marginalised have far fewer choice than the ‘mainstream’ who are able to engage in the process and that suits the government and the propaganda machine just fine.

That is what I fear for with the Health Bill (I am not sure why it’s even called the Health and Social Care Bill as Social Care is so obviously a troublesome ‘aside’ for the government).

Choice may well be nice for making decisions about which hospital is most convenient for a scan but what is being done to assist, support and advocate for those who are not able to make choices?

We are all in this together? Really? I doubt it.

As for me, I’m off to the vigil outside the Houses of Parliament tonight with my local Unison branch.

The TUC have also organised an ‘online vigil’ to oppose the passage of this Act.

And then.. to the Lords. But I will take careful note of the voting as it happens tonight. And I won’t forget.

Selling the NHS – The Beginning

The National Health Service Norfolk and Norwic...

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Yesterday, while most of the media, fixated self-referentially on the Murdoch hearings and Cameron was flying back into the country,  Lansley began to dismantle the National Health Service.

As The Guardian reports

In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for “competition on quality not price”. If successful, the “any qualified provider” policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and “home chemotherapy”.

So we are led to believe that being open for ‘competition on quality not price’ will act to pat us on the head, reassure us, and direct us back to the ‘big media story’.

It worries me and it worries me for a number of reasons. Lansley’s words are couched in the words of ‘choice’ but I wonder exactly whose ‘choice’ it will be to make these commissioning decisions for which, no doubt, large amounts of money will change hands and profit-making publicly listed and private companies will be able to partake.

I admit to a bias having been exposed and having experience in the adult care sector which was subject to a similar rollout of competition which was supposed to increase choice and quality.

I’ve written many times about the end result and how it is one that has inherently favoured larger providers and companies that have been able to deliver on economies of scale rather than the poetic vision of small scale providers delivering local services. Those small scale providers were quickly priced out of the market and I fear this will happen again.

But wait, I hear, ‘quality not price’ Lansley says.. to which I reply, ‘nonsense’.

Why? Because there will probably be minimum standards of ‘quality’ that a service has to reach and beyond those, it will be a price competition. That’s what is supposed to happen in care – but who checks the standards? who will check the standards? How can we have confidence in a well-resourced and well-delivered service when regulators are so weak.

I do not want any private company to make a profit on my potential need for services for my back pain, my hearing or a child’s wheelchair.

Of course, making the publicly delivered service is clearly both too expensive and veering against the government doctrine of handing the healthcare to private companies.

I am sure the first few providers will intersperse local voluntary organisations with large multinational corporations in their delivery methods. Again, I point to the adult social care sector. We started along the path with the NHS and Community Care Act (1990) having a lot of local providers together with a few Southern Crosses and Care UKs. The local providers were eventually priced out.

Of course in the case of podiatry and hearing services as well as primary care psychological therapies, we can see these as almost discreet services. The ones that will potentially be easy to deliver and it will always be possible to find wonderfully successful outcomes for people choosing Boots rather than the local NHS for their podiatry appointments because it is more convenient. And I’m sure it seems to pave the way for Individual Health Budgets where people  are given the money to ‘spend’ on the services that they need. Choice you see. Choice is what it’s all about.

I turn back and look at what has happened in social care. Choice has been extended in wonderful ways to those with the loudest voices but in some ways those with the highest needs have been left behind. That is my main concern about the introduction of private into public.

For some people, the people in the comfortable middle classes of Chipping Norton, this is fantastic news – they can access their IAPT (or equivalent) by a local provider when they are feeling a bit down. They can have their feet checked in a local branch of Boots instead of having to travel into Oxford. All’s well.

Those will be the areas where both competition and choice are the highest.

My concern is that people who experience the degradation of poverty will have quieter voices and less choice because there may be higher multiples of health difficulties and choice is determined through power. I can’t help but think of people who are restricted in their choice by issues of capacity. Will they be given advocates to assist with the process or will they just be ignored? Will the choice by made by GPs who are courted by these private companies, just as they are currently courted by drugs companies?

How equitable will the ‘new’ system be?

If we are extending choice, we have to extend safeguards and checks.

If we are extending choice, we have to extend quality.

It hasn’t happened in social care – there is no reason to believe or trust that it will happen in healthcare.

It does make me wonder – Are we all in this together? Really? With the impact analysis projects that are carried out to ensure equality, I know there are provisions to look at ability and disability, gender etc but are social class and income level also considered?

And think – Lansley considers putting ‘quality’ in as a concession – he was happy to go ahead with the Bill and with a pure ‘cost’ factor. This is his so-called concession but it is no concession at all if we don’t have a definition of what ‘quality’ is. After all, the CQC – too look at the Health Care regulator – defines ‘quality’ on the basis of paper documents and paper inspections given to them by provider services.

If that doesn’t wave any red flags, I don’t know what will.

This is a government of interests rather than representatives. The shame is that the last government was too and likely all the future ones will be as long as we allow our heads to be turned more quickly by celebrity gossip than the tragedies unfolding in our adult care services.

Means Testing and Social Care Funding

Community Care reports that  Dilnot who is chairing the latest in a long, long line of consultations into care funding has heard overwhelming opposition to retaining the £23,000 savings threshold before people have to start paying towards their social care needs.

Charges for social care are a delicate political issue so not content with one report, each government seems to want to commission a dozen until they find one that says what they want to say politically.

As someone who doesn’t have any ideological issues with means-testing, I find the constant pushing of limits hard to understand.

If someone has money, surely they can and should pay for a service and if someone doesn’t have the money, the state should subsidise. Seems quite a good system.

That’s not to say there aren’t problems with the system as it is at the moment. There are lots. It is overcomplicated for a start. There is an element of the ‘postcode lottery’ about it.

The costs are increasing rapidly and, this is the rub, no-one wants to pay for social care. No-one. Whether they have £50 in the bank or £5000 or £5000000 – people have become used to receiving health care free and seem to make assumptions about the provision of social care on the same basis until they are actually made aware of the costs involved.

One of the most perfidious arguments I come across is the ‘I/my mother/my gran worked hard all her life so why should she pay when Mr Brown who has been on benefits all his life doesn’t?’.

Perhaps because you/your mother/your gran actually have the money to pay and Mr Brown doesn’t.

There is a lot of righteous indignation around in this country with people measuring what they have against what others have and what they get against what others get and seeing things as ‘unfair’. Unfair is a government that gives those who ‘have’ a free ride even if they have assets in the hundreds of thousands and restrict access to services for people who have the same and higher needs and fewer assets to pay for them.

Maybe you would prefer Mr Brown’s life of poverty on benefits or in a low paid job to your life where you’ve received a dignified wage and been able to save?

Or does it all come down to stamping ones’ foot and wanting to save your children’s inheritance?

I know this isn’t a popular view. Certainly Dilnot is going to reject it. The thought of – gasp – having to pay for social care if you have savings is such an anathema to the middle classes who have the loudest voices in the political process that it seems already to have been summarily dismissed out of hand.

The thought of having to sell the home to pay for care has been put up as the massive failing in the current system. Is it a failing? I’m not sure. The houses are are discounted from the sums if there is a partner who is disabled or over 60 living in them.

A charge can be put on the home by the local authority so the sale can be delayed until after the death of the person in question. Rental charges can be used to pay towards care fees if the family doesn’t want to sell the home.

Anyway, that’s likely to change because the home-owning electorate don’t like to pay for care for their parents when Mr Brown-on-benefits my be getting something for free.

One thing I am in favour of though, is the capping of care costs at a certain level if someone has very high needs. We used to have this in the local authority but as we’ve moved into more austere times, it has been abolished. While I think means testing is, by its nature, fairer, I don’t think anyone should be penalised if they have extremely high care needs.

The problem of course is that if people who have funds won’t and don’t pay – then who will? Why the state of course. Perhaps through the hideously conceived ‘insurance’ policies that the Conservatives dreamt-up pre-election which showed an ignorance of the details of care but could ‘insure’ someone with a lump sum payment (£8000 was suggested)  against care home costs in the future.  Another of Lansley’s gems. We really are seeing the measure of the man now.

I’ll be following Dilnot’s recommendations with interest. Just as I’ve tried to follow the very frequent and oft ignored proposals that have popped up again and again about the funding of long term care until the music stops and the government decides on the one that will win the most votes for them.

It’s a shame that so many games are being played in the name of ‘fairness’ where ‘fairness’ seems to only be referring to the wealthier, home-owning middle classes – but that’s where the votes are.

Cynical? Well, perhaps just a little bit!

Lansley, Nurses, Social Workers and Colleges

Yesterday, as a part of Lansley’s so-called ‘listening’ exercise, he found himself at the conference of the Royal College of Nursing (RCN) as they voted in favour of a  motion of no confidence in him personally by a fairly substantial 99%.  Rather marvellously when you take into account the 13 abstentions, only 6 nurses voted against the motion of no confidence. As was mentioned on Twitter yesterday, it seemed to be a miracle that 6 were to be found.

You’d have thought that that was quite a strong message for Listening Lansley to have paid heed to but no, he wanted to give a perception of listening (as if the vote of no confidence wasn’t a strong enough message!).

He asked for 60 specially chosen RCN representatives to talk to him while he ‘listened’ for 90 minutes in a room to which press were not allowed.

Well, nothing wrong with listening of course. I shouldn’t scoff but I can’t help it amid Lansley’s gruff and graceless apologies. Why? Because the listening should have been done before the plans were announced. The listening should be done with a whole wide range of people who have an interest in the health service.

He has got it wrong  but he doesn’t seem to want to listen as much as try and persuade and regroup around his message of privatisation.

The message from the Royal College of Nursing was strong, and powerful and it has caught the news media. People listen to nurses when they say things are wrong.

But we can’t forget how wrong the government got when they brought these proposals to Parliament in the first place. What does it say about a government that has to do its consulting AFTER it has taken a Bill to Parliament that has been so strongly attacked on all sides by public and professional opinion. It doesn’t exactly make one comfortable that we are ‘in safe hands’ as they like to promise at election time.  Maybe it’s because all the consultations they did before the Bill was presented were with private companies and party donors.

This is a government which is struggling under the surface and has been caught out already on many occasions by acting without any idea of what the plans that they propose actually signify. It is when they try messing around with the health service that people sit up and shout back but what about the other measures that they have proposed like the changes in the welfare benefit systems which seem force degrading and inappropriate ‘tests’ to claimants to jump through hoops to get the money they ‘deserve’.  This is what we need to speak up against as well.

And one of my sadder moments yesterday, when I thought about the impact of the nurses and the fact that they are at least being listened to for press purposes, is how we, in social work, have been poorly served by the organisations that supposedly represent our interests.

We should look at the RCN and what they have done and the effect a vote of confidence had on the ridiculousness of Lansley’s ‘listening’ exercise when with an almost unanimous voice they have humiliated him. Where is the nearest equivalent social work voice?

Community Care reports that the Chief Executive claiming that ‘he simply doesn’t believe’  Unison’s figures of having 40,000 social work members.

Honestly, is that the best he can do in rousing his members? Is that the best we can do as social workers when we should be at the heart of opposing the government agenda to heap the cuts on those who have the least? We just get into squabbles between Unison and BASW about who has the most social work members? Who is going to ‘lead’ the College of Social Work? Are we going to have a ‘Chief Social Worker’? Surely better to have a broad members organisation that can speak for all social workers rather than split members into different ‘camps’.  As for me, I’m a member of Unison AND a member of BASW. Generally, I’ve seen value in both.  It isn’t about a competition about who has more members and some people like me would be counted twice in the figures.

More than anything we can see the importance of having a strong, national voice as a profession and as representatives of a social care sector that is being and has been ravaged by repeated governments. Perhaps a broader College of Social Care might not  have been a bad idea.

The stronger the body the louder the voice.

Of course, that isn’t going to happen. It looks like we will be left with a College that few social workers who are on the front line will be interested in because we don’t have time for the politics within the profession. We have too much to do and need to focus on the politics of the country before everything that we know and love about this society is lost.  So while the College or Colleges (depending) spend all their time and money rewriting competencies or capabilities or capacities again and again and again ad infinitum – some of us will just be getting on with doing the actual work.

But the shame of it is that a College of Social Work/Social Care could perhaps have been a voice to shout against the Welfare Benefit Bill and the ridiculous tests that are put in place to make decisions as to ‘eligibility’  in the same way that the nurses are a voice to shout against the health and (oh the irony) social care bill.

We should be more like the nurses. We need to be if we are to survive and have relevancy.  We need to be listened to as well.  But in order to be listened to, we need to build support up amongst ourselves rather than squabble like schoolchildren. That is the pity.

Changes in the NHS – initial thoughts

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I’ll write more about the government proposals to reform the NHS after the Health and SOCIAL CARE Bill is published tomorrow. Oh yes, did anyone pick up that slight subtlety there that it is supposedly covering social care as well as health.. sneakily hidden in.. er.. the title of the bill. You wouldn’t have thought it.

But I shouldn’t be too cynical. That’s just the way that social care has and will roll.

The BBC have a great ‘simple guide’ to the reforms and what they may mean.

Most of my reservations are about the introduction of GP-led commissioning – so I’ll focus on that today.

I know it’s presented as being about more choice and more efficient services – but, as I’ve said before, when the Tories introduced the so-called needs-led agenda of the NHS and Community Care Act in 1990, the talk was about improving efficiency, cutting costs and providing more choice – hmm, those words seem familiar.

What were we left with?

Centrally commissioned services that led to ‘bidding wars’ and reverse auctions so that the company that could provide the service at the lowest cost would ‘win’ the contract. No choice – perhaps less choice as the cheapest options had to be sought regardless of quality.

Why does no-one look to the lessons that should have been learnt from the care sector? I know, there are some wonderful services out there and I don’t want to be dismissive but I feel strongly about the introduction of ‘the market’ to the care sector and I feel equally strongly about the potential failure of ‘the market’ in the health sector.

The US is hardly a glowing example of an efficient and cost-effective health care system after all.

I am not sure I buy into this ‘choice above all’ agenda. Choice is always going to be limited by cost. On a personal level, I live in one of the most deprived areas of the country. I don’t ‘know my GP by his name’. I don’t even necessarily trust the practice.  My current GP practice was ‘taken over’ by the PCT (Primary Care Trust)  for a while because of poor management and a few… financial shenanigans that led to all the doctors in the practice being dismissed. That’s a pretty big deal.

I wonder how a similar scenario would ‘play out’ in the ‘new world’ – where there is no PCT to ‘take over’. But Lansley and Cameron probably haven’t considered those kinds of scenarios. I just hope they remember that we don’t all have local village practices that we’ve been with for years and where everyone knows us and smiles at us in the street.

There are some of us living in very poor areas where some of the chronic health problems that are linked to poverty will very obviously and quite rightly take priority.

So would I get the same treatment for a more minor ailment and a lower priority ‘condition’ as someone in Knightsbridge? I’m not convinced.

Even less convinced because it won’t be my GP who is commissioning – it will be a private company that is hired by my GP. It will likely be the same people who worked in the PCT re-employed by companies like Care UK (a coincidence that they bankrolled Lansley’s private office?).  So it’s likely to be the same people, doing the same job (probably for less money) but for the benefit of shareholders rather than the public purse.

I don’t want to be a grumpy naysayer. I want the NHS to work and to work better.

I am worried though.

I await the publication of the Health and Social Care Bill with trepidation.

I  have reconfiguration fatigue already. The amount of  money my Trust must have spent on change, and more change and even more change and then some more adjustments to that change would probably fund another ward. Or have retained one of the few that have closed.

I want ideas that work. I want a system that works. I am just very sceptical. Perhaps it is up to the government to prove me wrong. I hope I am wrong.

Hospital Discharges or the Lack of Them

I’ve written a few times about some of the difficulties about managing and organising discharges from hospital so forgive me for reiterating previously presented points but I couldn’t resist because  there’s an article about it in The Guardian who commissioned a survey of doctors. ‘Bed blocking’ refers to difficulties in discharging patients home from hospital for various reasons when they are ‘medically fit’ to go home.

251 (50%) said the problem known as “bed blocking” – which costs the NHS tens of millions of pounds a year and forces needier patients to wait on trolleys – was worse now than a year ago, while 200 (40%) said it had not improved.

The poll was conducted for the Guardian by Doctors.net.uk, an online professional network to which 90% of UK medics belong.

My bed

I’ve previously mentioned my distaste for the term ‘bed blocking’. I continue to hold that view. It seems to create a sense of misplaced guilt. There is a much longer term failing of systems that leads to this problem and there are often genuine fears, risks and complications that make discharges more difficult than initially presumed.

Having been on the end of many countless angry telephone calls from doctors and nurses about ‘my patients blocking their beds’ – and – please forgive me if I repeat an oft-spoken personal anecdote – having heard a doctor actually blast off to a patient about the cost of keeping her in hospital (it may have been a valid point but it shouldn’t have been made on a ward with other patients within earshot), I think it didn’t need a survey to know that things are getting worse.

For me, the problem lies with higher initial criteria for accessing lower level support at home and the increased charges.  The removal of virtually all preventative services will lead to a higher strain in acute services.

I just wonder where the 10% who thought the problem had improved came from.

It’s obvious that a reduction of the eligibility criteria (FACs) will lead to more people not being entitled to care at home. The other, perhaps more important aspect is the increases in fees that local authorities are charging for care. Some people just don’t think they should be paying for care and there is a mentality that grew up with the establishment of the welfare state that believes absolutely in the ‘I’ve paid in so I should be able to take out when I need’ that resents paying for what is needed.

I’m not making a moral judgement about that, by the way. I absolutely support a social ‘trampoline’ that sits underneath us to not only catch us when we fall, but to help us bounce back up to a level that allows us all to participate in society at a dignified level.

Going back to the Guardian article

One respondent to the survey said patients with severe dementia were spending months in beds intended for those with acute medical problems because the NHS does not have enough places in wards specialising in dementia care. Another said that as many as 80% of the patients they see on an elderly ward “are fit to leave an acute bed but there is nowhere else to go”.

I can think of many examples from my own caseloads and certainly on my teams’ caseloads which concur with these statements. Far worse though are the months spent in psychiatric hotels when no suitable placements have been found. We have a serious shortage of beds not helped (obviously!) by a few wards which had specifically cared for older adults being closed down in a money-saving rush. Money saving? It all spills over. Now there is nowhere to transfer some of those patients in the general hospitals. There are people who need hospital admissions who cannot access beds or are placed on inappropriate wards. It costs a lot.

While there are initiatives that have helped ease some of these problems – the re-enablement service that provides a spike of (yes, free) home care support to help someone in the weeks out of hospital and the provision of both interim and intermediate short term residential and nursing placements while a solution to find someone either a longer term placement or some rehab to get them home.

Neither of these services in our area at least, have been sufficiently tailored to people with dementia. There is a general wider feeling in general services that when someone has dementia they may not be able to get the most from a rehab service.

This is my concern about Lansley’s push into promoting intermediate care and speeding up hospital discharges.

The Department of Health said it was making an extra £162m available between now and the start of April to help patients leave hospital sooner and live independently at home. “It’s really important, particularly at this time of year, that we help people to leave hospital as quickly as they can, when they are ready. The latest figures show that 2,575 beds are unavailable due to delayed transfers of care,” said Andrew Lansley, the health secretary.The money is intended to free up hospital beds by helping older people get more support before and after they leave and to reduce the high number who return to hospital soon after discharge.

The problem in my eyes, and yes, I accept that I see a particular area of social care in focus due to the nature of my job , is that not everyone can live independently at home and there is a lack of good quality local placements which has as much led to a delay in discharge. Subsidising home care for six weeks just masks the issue that people are being asked to pay for their own home care in the longer term. Sometimes the issues relate to unsuitability of housing and no-one can sit out a housing waiting list in a hospital – nor can the intermediate or interim beds accommodate them.

Locally, I can say absolutely that we need more resources available to people with dementia. We need wider work on understanding and supporting people with dementia by care staff. It isn’t an easy job and a lot of people don’t necessarily want to do it – especially at minimum wage and poor contractual terms.

I think the government’s NHS ‘efficiency’ savings may come unstuck by failing to comprehend the links and costs between health and social care. There’s been a perfunctory nod in the direction of social care by the ‘additional money promised’ by the Health Secretary and Care Services Minister  but anyone who thinks that that money will be safe in the face of cuts and non-ring fenced local authority spending is living on a different planet.

It isn’t good. It isn’t looking good. No matter what Lansley says to people who don’t see this situation every single day and whom he manages to fool (indeed, maybe he has fooled himself and truly believes his own figures), things are not going to get better.

And from someone who desperately wants to be an optimist at heart, it’s difficult for me to say that.