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.

Liberating the NHS – some thoughts

There has a lot been written since Lansley announced the new government White Paper on reforms to the NHS called ‘Equity and Excellence : Liberating the NHS’ My hesitation in summarising the points immediately came partly because the thought of another ‘transformational change’ was just about grinding my brain into smithereens. I don’t have enough digits to count the transformations and reconfigurations that have been planned and actioned over the last 10 years of my practice. I haven’t actually read the White Paper – work has been tiring! I have read a few summaries though so that will have to suffice as far as analysis goes until I find some more hours to plug into a day!

In very brief summary, there is talk of GPs taking over the commissioning of care and services in consortia and the abolition of PCTs. Hospitals will be forced to become Foundation Trusts and these Foundation Trusts would be able to lift the limits they currently have on provisions for private patients.

There will be an independent NHS Commissioning Board which will oversee the processes and public health functions will be handed back to the already overstretched (remember the council tax freeze!) local authorities.

More responsibility for the integration of health and social care services will fall back to local authorities and the Financial Times quotes Lansley as claiming that some of the expertise for commissioning mental health services might exist within local authorities saying

There were “sufficient synergies” between mental health and social care for councils to provide “very good support” for mental health commissioning, he said.

The problem is that we can very well assume that there will be little ring-fencing of local authorities already over-stretched budgets. Cuts are coming hard and fast. Supposedly the NHS and health budgets were protected. Local authority budgets are fair game.

Rethink and MIND have both issued statements raising concerns about the expertise that might exist in primary care to commission mental health services.

With Rethink’s press release explaining that

Rethink discovered that only 31% of GPs feel equipped to take on the role for mental health. While three quarters of GPs say they can take responsibility for diabetes and asthma services, less than a third felt the same for mental health services.

Rethink is concerned that unless there’s a national plan to up-skill GPs in mental health many of the 1.5 million people with severe mental illnesses may fail to get the treatment they need.

Meanwhile, Paul Farmer, the Chief Executive of MIND issued a statement saying,

“Transferring powers for commissioning to GPs presents an opportunity for them to develop mental health services that meet local needs and give patients the choice they want.

“However, GPs currently lack the specialist mental health knowledge and training to understand the complexities of mental health commissioning.

“There are already huge variations in the standard and types of mental health care patients receive depending on where they live. For example, access to talking therapies remains patchy, with people waiting months and sometimes years for certain treatments while antidepressant prescribing has soared. Any structural changes must not widen inequalities.

“GPs already have a heavy workload and asking them to add commissioning mental health treatments on to their to do lists will be an extra burden.

“It’s crucial that these new responsibilities don’t cut the amount of time they spend talking to patients.”

I wonder if it will be a case of those who are able to ‘shout loudest’ for their services will be the first to benefit from ‘choice’.

While supposedly this choice will be market-driven, it’s worth looking at the past experience of the  implementation of the ‘care management’ model of social care which was supposed to add purchasing power to social workers and institute a purchaser/provider split between the local authorities and a more extensive range of providers. What the free market managed to do in these circumstances was absolutely gravitate to far fewer choices by larger private companies who were able to drive costs down by employing temporary staff on minimum wages to provide personal care services.

Putting the budgets in the hands of social services teams led to the extension of ‘procurement teams’ who took bids from the private companies and forced the prices (and quality of care, incidently) lower and lower.

Unsurprisingly, these changes make me nervous. Not just because change is so very tiring but it is also costly in terms of consultancy fees.

Dan Parton in the Social Care Blog excellently summarises some of the implications for social care in general and basically finds that there is a span from very little to absolutely nothing mentioned about people with learning disabilities, mental health problems and dementia in the White Paper.

He ventures a guess that possibly these services will be mentioned separately at a later date but it is a very tentative hope. The problem is that the people who use these services are not the ones that the Health Secretary is likely to be thinking will be clamouring to support him.

The Shrink at Lake Cocytus also summarises his response. Again, there is the sense of reconfiguration fatigue that I can absolutely and completely recognise in my own reaction. He extends his fears that the commissioning processes which can be enormously complicated and time consuming will be picked up by large multinational companies who will happily – at a fee – do this job.

The other element packed into the White Paper and mentioned by Community Care is that NICE (National Institute of Clinical Excellence) will be given more powers to ‘drive improvement in social care’. This of course begs the massive question about the position of the current ‘Social Care Institute of Excellence’ and whether will be still actually exist or be consumed by NICE. While SCIE has charitable status and therefore has some independence from the government, if all it’s functions are taken over by NICE – and NICE having further statutory functions – it makes one wonder what might be left of the more distinctive SCIE and whether it is a sign of things to come where social care is marginalised further.

Indeed, SCIE’s response to the White Paper seems a little defensive and nervous

With regard to our future role, as care services minister Paul Burstow has made clear “SCIE … continue to have a role but it won’t be the same role they played directly alongside NICE in the past”. SCIE provides a wide range of services – including supporting the development of quality standards alongside NICE.  As an independent charity we explore innovative approaches to deep-rooted challenges (eg our new approach to serious case reviews in children’s safeguarding). We provide practical, accessible, evidence-based support to frontline care workers through our guides and learning materials, including digital solutions such as Social Care TV. Crucially, we capture and analyse information about latest developments in social care – and share that quickly with the sector (eg our updated guide to personalisation captures the latest developments in how to transform adult care services).

We will work closely with Department of Health and social care organisations to ensure that the personal care and support – as well as the health care – needs of individuals are supported by the reforms within the White Paper. We have the contacts and knowledge needed to ensure this happens.

There is a sense of ‘look, look, we ARE useful – we ARE doing good things’. I think it would be a shame as personally, I’ve found SCIE information very useful.

Indeed, David Brindle, in the Guardian expresses some of these concerns in a piece earlier in the week. , in a piece frighteningly titled ‘Is social care about to be swallowed up by health?’. It’s a look ahead at some of the possibilities that may lie ahead for the social care sector and it doesn’t look rosy.

I can’t say that the investigating some of the details of the White Paper has left me with anything except trepidation and a wish to fight and challenge some of the implications that haven’t been expanded upon yet.  I see it as absolutely crucial that the needs of those with social care needs are not forgotten or left behind through this process.

Interesting times.