Thursday, 20 January 2011

Equity and Excellence? - Balderdash and Piffle!

Defiance against proposed decimation of the NHS!

Here is a rehashed synopsis of the threat to our NHS that the new Health Bill poses. This a significantly edited version of notes provided by the astute and auspicious Dr Jackie Turner, who attended the recent Keep the NHS Public Meeting in Waltham Forest. Many of that group will be attending our protest on the 29th January.
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Implications for the NHS.

This Bill is probably the biggest re-structuring of the NHS since 1948 and was not declared in the election manifesto of either the Conservatives or the Liberal Party. They simply have no mandate for it.

The White Paper assumes it will cut bureaucracy and improving efficiency but the scheme is flawed and based on naïve assumption. Under the new bill the NHS is obliged to cut management costs by 45% over the next four years. There is a stated desire to improve efficiency by simplifying the structure of NHS. PCTs and practice based commissioners will be replaced by GP Consortia. No evidence has been provided to support the idea that this will improve efficiency?

What would be the result of GP Consortiums being unable to make the efficiency saving that this document requires? Would the NHS then be taken over by the private sector who are already hovering?

The US spend 17.4% of GDP on health, most of it goes to insurance companies and drug companies, their health care is amongst the worst in the developed world, people die on the streets because they can’t afford health care. Is this the fate for the future of Health in Britain?

Get ready for a catastrophe:

The Coalition Government justify the burdensome disruption and loss of jobs by saying they have a moral obligation to release as much money as possible to front line care. Could tax Vodafone, Phillip Green, cancel Trident, stop the war and there would be more than enough money to pay off the deficit, this is ideological and they choose to cut public spending rather than to collect revenue through the tax system, except to raise VAT which disproportionately affects the poor.

They expect the NHS to make energy savings and to develop more sustainable forms of delivery to help reduce costs! It would help if the Govt engaged in programmes to enhance sustainable renewable energy sources.


Cuts in social care will put additional strain on NHS budgets, “bed blocking.”

£80 billion given to GPs not trained to do it can not possibly be a pragmatic solution to the current problem. Many doctors are against the proposals yet there is no remit for an opt out? How will GPS set up consortia? They need to be big enough to minimise the financial risk. Different GPs have different visions, some boroughs have splits and more than one consortium. If Local consortia cross existing service boundaries it will cause confusion and error. Many GPs have expressed concern that if theye don’t cut costs, others will brought in to do it for them. This creates a conflict of interest and impacts negatively on Dr/Patient relationship.

It is time to rip PFI contracts Royal London is now the most expensive hospital to run in Europe. With burgeoning costs of £1million per bed and them having to pay interest for thirty years, to finance institutions that have wrecked the economy.

Below is a summary of key changes.

The NHS is required to find £20 billion in efficiency savings through the Quality Innovation Productivity and Prevention programme (QIPP).

Putting patients and the public first:

Information on “quality of care” must be readily available to facilitate better patient choice. This will result in the production of league tables,

Under this scheme there is no onus for bracketing the type of case mix which could result in spurious data as hospitals with sicker patients will have worse outcomes.

Local Health Commissioners will be able to impose fines on poor performers according to a prescriptive list produced by the department of health. This will create a risk averse culture that will undermine health provision and could also lead to contrived reports.

Hospitals will be allowed to undercut each other and fixed tariffs will be removed, Evidence supports such schemes decrease quality of care.

Every patient will have access to an open list permitting them to join with any GP Practice. Problems associated with this include:

• Competition will favour larger organisations – removing local aspect to service.
• Doctors no longer able to focus on good service as they will have to work on business aspects such as marketing.
• Lower cost service could mean poorer quality an increasingly competitive market.

Personal health budgets:

WHAT THIS MEANS: Confusion about who is commissioning, the patient or the GP consortia. Possibility of inequity if rich patients can “top up” their care budget

Developing the “Quality Outcomes Framework”:

The National Institute for Health and Clinical Excellence (NICE) will develop quality standards for the NHS commissioning board. NICE are expected to develop 150 standards in next five years, Stroke, Dementia and prevention of VTE already produced. NICE will also develop quality standards for social care.

Will resources be available to implement the budget? Moreover, has a budget been created to allow acclimatisation?

Autonomy Accountability and Democratic Legitimacy:

The NHS commissioning board (NHSCB) will calculate budgets for local GP practices and will allocate these directly to consortia. Consortia will be held to account by the NHSCB. There is only one board for whole country, which will no doubt lead to a lack of understanding of local needs, quirks and demographics. A one size fits all approach. The existing Strategic Health Authority (SHA) and Primary Care Trust (PCT) structure is to be abolished.

Currently there are 11 SHA’s for England covering the regions. One exists for London all Primary Care Trusts (PCT) are accountable to their designated SHA. The Equity and Excellence bill threatens to remove both tiers of authority – PCT’s and SHAs. They will be replaced by the National Commissioning Board responsible for managing individual contracts with GP practices, dentists, pharmacists and optometrists as well as managing the agreements with GP Commissioning Consortia. GP Practices will be allocated to Consortia if they have not already joined. This programme is scheduled to go live in April 2012.

It is likely that there will be regional offices of the National Commissioning Board but this will mean a London office with responsibility for contracts with around 1000 GP practices. The existing relationship between PCT’s and practices needs improvement. However, there is understanding of the local community. A more distant relationship with a London office of the Board and GP practices will ensue in a colder bleak new world of health.

The Coalition Government believe that GP’s only need light touch regulation because patients can use choice to vote with their feet, if they are unhappy with their GP practice. Vulnerable groups who are most in need of a good GP practice are the least likely to be able or willing to shop around for a new GP!

GP commissioning consortia will be able to choose which services they commission themselves and for which activities they may choose to buy in support from external organisations.

It is a frightening observation that already some PCT’s are already reorganising before the Bill is ratified. It would seem the process is already a done deal!

NOTE: Changes welcomed by UnitedHealth Group President Simon Stevens “But the new plans go much further (than Labour’s reforms) – on consumer choice, pro-competitive market regulation and the severing of day-to-day political control of the NHS.” Financial Times July 15th

GP Consortia will receive a maximum management allowance to reflect the costs associated with commissioning. It is not clear how much will be allocated to consortiums, or if they much previous PCT budgets?

Shadow GP Consortia are to be in place by April 2011 (Tower Hamlets are in process of electing our shadow board). PCT’s will continue to operate till April 2013, then they will cease to exist. In the interim they will support GP consortia as they take on increasing responsibilities for commissioning. There is a high risk that we lose good PCT staff. Furthermore, what cost implications will arise from the two groups working in tandem from 2011 – 2013?

The govt will not bail out consortia who fail

Consortia will be free to buy services from any willing provider and providers will compete to provide services.

A new “Healthwatch” body will created as a new consumer champion. They will be able to investigate poor service.

This body will limit the ability of the Secretary of State to intervene in NHS operation. This allows politicians to deflect blame when things go wrong?

There will also be a significant devolution of power from the Health Secretary to the NHS commissioning board who will be responsible to monitor the regulator “Care Quality Commission” and the GP Commissioning Consortia.

WHAT THIS MEANS: The Secretary of State for Health no longer has day to day responsibility for running the NHS or particular hospitals or commissioning consortia. They can sink or swim. If they sink, then they get taken over by the private sector. Besides, this is there not need for an overriding vision.

Freeing existing NHS providers:

All NHS trusts are required to become foundation trusts within 3 years. Employees have the opportunity to run them as employee lead social enterprises. Where will the overall vision come from?

This could bring about a move away from national pay and conditions. Foundation Trusts are already able to determine pay for their own staff. Employers would also be responsible for leading negotiations on new employment contracts”. The BMA have already rejected the national pay freeze.

There will also be a removal of the cap on how much foundation trusts can earn from other sources e.g. private patients. This could result in the squeezing out of NHS Patients by more lucrative paying patients.

Foundation Trusts could more easily merge, creating monopolies that would be bad for competition. It is rumoured that talks for a Whipps Cross Hospital merger are advancing as this article is being written.

A monitoring body is to be set up to regulate economically all providers of primary care from April 2013. They will also be responsible for licensing NHS providers, who will not be able to practice without a license. Will such an operation not require significant new funding…?

The Care Quality Commission will inspect providers. They will make judgement against NICE standards. Providers can be shut down for failing to reach quality standards as well as for financial failure. This may cause the loss of many local facilities not able to gear up to the change, due to logistical and operational burden and lack of support and funding.

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