The BBC report that Unison, a large public sector union (disclaimer – I’m a member), is challenging the government’s plans to ‘shake up the NHS’ as proposed by the ‘Equity and Excellence : Liberating the NHS’ White Paper that was much discussed a few weeks ago.

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Initially I scoffed at the thought that this challenge would be going anywhere, but I think they have a fair point.

Basically, the issue on which the challenge is being made is an interpretation of  what a ‘consultation’ involves.

The Constitution of the NHS states that the public, staff and unions have a right to be consulted over changes made within the NHS and on the other hand, the Chief Executive of the NHS has sent letters out to all NHS chief executives telling them to implement the changes immediately.

Do I think the challenge will make any difference whatsoever? No.

I’ve been involved in a few NHS consultations around service reconfigurations in the past as a ‘member of staff’ and to term them ‘consultations’ has almost been an insult to ones intelligence. They have never been anything other than paper exercises in which the ‘men in suits’ have produced shiny documents about changes they want to make and have made no attempt to listen or consult.

Oh, there might be a 2 hour meeting in a hospital at the other end of the borough of which you are given less than a weeks’ notice or a page or two on the website with no structured form but just a free form invitation to ‘respond’ but never has the result of the consultation been anything other than what was proposed from the outset.

In fact, I’d venture a guess that the cost of the consultations and the associated consultants/project managers are wasting resources when a decision has already been made.

The truth is that there is no core wish or desire to know what ‘people’ want – whether those people are staff or patients within the service. On the most recent occasion, we were told about the ‘consultation’ which apparently had been going on for months, about a week before it finished and it was a matter that intrinsically involved every one of us (I use us to mean employees in the team in which I work).

It’s easy to be cynical until I was reminded of the constitution’s statement that this is an obligation. I wonder that it has been so flippant in its implementation.

Good luck to Unison though – I don’t expect them to have any long term success. The changes are coming but there does need to be a lawful implementation of these changes and if they need to consult, we have a duty to respond.

The consultation document is here.

For the record, the ‘local HealthWatch’ referred to is described in the document as that body

‘which will act as local consumer champions across health and care. Local Involvement Networks (LINks) will become the local HealthWatch.

Like LINks, their services will continue to be contracted by local authorities and they will promote patient and public involvement and seek views on local health and social care services. We propose that local HealthWatch be given additional functions and funding, so that they become more like a “citizen’s advice bureau” for health and social care – the local consumer champion’

So I thought ‘I don’t know what ‘LINks’ are – I’ll look it up. LINks (which currently exist) are

Local Involvement Networks (LINks) are made up of individuals and community groups, such as faith groups and residents’ associations, working together to improve health and social care services.

There is a proposal that they will have a greater influence and maybe it’s a part of the ‘big society’ and ‘consulting’ process but I do wonder and worry as to whether specific interest groups can position themselves in these bodies. It was the ‘faith groups’ part that worried me to be honest. I have nothing against faith groups – some of my best friends are very religious (true!) but I don’t want them trying to monitor or make decisions about how health care is delivered in my local area, thank you very much. I may have to do more LINk investigation at a later date because, for now, I want to concentrate on the discussion document.

These are the questions asked in the document

The Government would welcome views on the following questions:

‘Q1 Should local HealthWatch have a formal role in seeking patients’ views
on whether local providers and commissioners of NHS services are
taking account of the NHS Constitution?

Q2 Should local HealthWatch take on the wider role outlined in paragraph
17, with responsibility for complaints advocacy and supporting
individuals to exercise choice and control?

Q3 What needs to be done to enable local authorities to be the most effective
commissioners of local HealthWatch?

Q4 What more, if anything, could and should the Department do to free up
the use of flexibilities to support integrated working?

Q5 What further freedoms and flexibilities would support and incentivise
integrated working?

Q6 Should the responsibility for local authorities to support joint working
on health and wellbeing be underpinned by statutory powers?

Q7 Do you agree with the proposal to create a statutory health and
wellbeing board or should it be left to local authorities to decide how to
take forward joint working arrangements

Q8 Do you agree that the proposed health and wellbeing board should have
the main functions described in paragraph 30?

Q9 Is there a need for further support to the proposed health and wellbeing
boards in carrying out aspects of these functions, for example
information on best practice in undertaking joint strategic needs

Q10 If a health and wellbeing board was created, how do you see the
proposals fitting with the current duty to cooperate through children’s

Q11 How should local health and wellbeing boards operate where there are
arrangements in place to work across local authority areas, for example
building on the work done in Greater Manchester or in London with the
link to the Mayor?

Q12 Do you agree with our proposals for membership requirements set out in
paragraph 38 – 41?

Q13 What support might commissioners and local authorities need to
empower them to resolve disputes locally, when they arise?

Q14 Do you agree that the scrutiny and referral function of the current
health OSC should be subsumed within the health and wellbeing board
(if boards are created)?

Q15 How best can we ensure that arrangements for scrutiny and referral
maximise local resolution of disputes and minimise escalation to the
national level?

Q16 What arrangements should the local authority put in place to ensure that
there is effective scrutiny of the health and wellbeing board’s functions?
To what extent should this be prescribed?

Q17 What action needs to be taken to ensure that no-one is disadvantaged by
the proposals, and how do you think they can promote equality of
opportunity and outcome for all patients, the public and, where
appropriate, staff?

Q18 Do you have any other comments on this document?’

I may spend some time now reading the document and formulating a response – at least to those questions that I have an interest in – particularly Q17, I think. I’ll probably print the responses. The problem with consultations is that they can be done with little fuss or fanfare and the legal obligation is fulfilled. Often the decisions have been made in advance and would be best made as a group response rather than individuals responsing – indeed, some organisations make a business of it – but if it is a way of having voices heard at least, even if they don’t end up going anywhere, it is a chance that someone might stop and think about some of the implications.

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.