Cash injection won't be enough to rescue NHSSaturday 31st October 2015
Discussion now centres on how big it will be rather than whether it will happen: but everyone it seems, except a few ostrich-like ministers, now agrees the NHS is headed for a massive, unprecedented financial deficit in 2015-16.
The deficit for the first quarter, the normally cheaper April-June of this year was close to £1 billion - more than the whole of last year. But with winter fast approaching and the hatches being battened down in hospital trust boardrooms discussing deficits in the tens - or hundreds -- of millions, it's clear that the total is likely to far exceed the grim warnings of £2 billion across the NHS.
The mailbag for applications to the slush fund that has been surreptitiously bailing out floundering trusts and foundation trusts - especially in the run-up to the election - is bulging with applications for loans or even simple handouts to keep services running. Unless more money is funnelled in, this will soon run short.
We know that this cash crunch is not accidental. While hospitals run out of money and staff, billions are being wasted on the bureaucracy of a competitive market in health - tragically opened up under Tony Blair, but since driven massively forward by Andrew Lansley's cynical Health & Social Care Act.
That legislation deliberately fragmented the NHS, forced local commissioning groups to put more and more services out to tenders from "any qualified provider," which have led to a whole series of ridiculous and failed contracts with private providers, many of them undermining local NHS trusts.
The Act also hived off responsibility for the NHS from the Secretary of State to NHS England and a gaggle of regulators. NHS England has since appointed Simon Stevens, a former top executive of US health corporation UnitedHealth - who has in turn connived with George Osborne to promote even more fragmentation through the so-called 'Devo-Manc' and similar local carve-ups.
The Act is already proving itself a costly disaster, but rather than save money and reintegrate the NHS by scrapping the dysfunctional market they have created, and giving herds of over-paid management consultants their marching orders, the Tories are forcing trusts to dismantle more services and contemplate closures.
Every problem is made worse by every statement of Jeremy Hunt- cheesing off junior doctors, demoralising and annoying GPs with incessant increases in their workload, and all health professionals with the ludicrous call for 7-day working for which there is no demand in primary care and no staff or funding for staff in already overstretched hospitals.
Now the government is hell-bent on worsening the staff shortages that are blamed for problems of poor quality care.
Cameron's gang's plans to slam the door shut on nurses expensively recruited from non-EU countries and give notice of deportation for tens of thousands of overseas nurses who are already part of the NHS workforce have been shelved, largely thanks to a concerted campaign including NHS employers and Simon Stevens, who has pointed out that ballet dancers would be excempt from the Tory restrictions, but nurses would not.
But don't underestimate the political risk Cameron is taking. Part of his blatantly dishonest pre-election pitch to his core supporters -- many of them elderly - was that he was "protecting" NHS funding (having already frozen funding for five years, with plans to make that a decade of standstill real terms funding, while the population and numbers needing health care have grown).
Many on the left will have dismissed this as laughable: but it's a certainty that millions of Tory voters took that into consideration, encouraged into that delusion by Labour's inept and unconvincing challenge on the NHS - hamstrung as they were by their limp acceptance of Osborne's fraudulent "austerity" agenda (which has not reduced but increased the deficit).
So let's not underestimate the importance of the recent extraordinary public criticisms by the chair of a major London hospital trust in the Daily Mail of all Tory papers, saying that people have been "conned" and that the NHS is going broke.
Of course he had an agenda: he heads an organisation that mobilises volunteers, so naturally his answer was that thre NHS is so broke that the only way forward was to run the NHS on the unpaid labour or millions of men and (mainly) women.
But this too will have come as something of a shock to Daily Mail readers, who like most Tories will be supportive of the NHS, concerned for local services, and assume that care would be available for them provided by professionals, not by keen (or reluctant) amateurs or their own family.
The current situation is reminiscent of the autumn and winter of 1987, in the aftermath of a massive Thatcher victory, when the impact of NHS cuts imposed in the April budget hit the hospitals, creating havoc with soaring waiting lists, cancer patients dying waiting for treatment and cuts in children's hospitals. These hit the Tory press - Daily Mail, Telegraph, Times - and combined with open revolt from top consultants and a huge petition of hospital consultants which Health Emrergency helped to organise.
By December, to minimise the damage, Thatcher, for all her majority, was forced to back down and find more cash for the NHS. Then she followed up with her notorious "review" which resulted in the creation of the "internal market" (the first big costly reorganisation of the NHS).
Now we have a massive financial problem unleashed by Tory policies, and a newly elected Tory government to the right of Thatcher on most issues, but with a majority of just 12, and a real vulnerability if the cuts force through a massive round of hospital closures, as suggested by minister Lord Prior, who appears to have gone quite mad, and wants to axe 50,000 acute beds.
It seems likely that the cash crisis will push Osborne into concessions and providing extra cash in the autumn statement. Any extra cash seems certain to be followed, as in 1987, by more far-reaching and reactionary "reforms".
David Prior in the Lords has set up a commission to discuss the imposition of charges for NHS treatment: others are looking for ways of squeezing in an expanding role for private health insurance.
Options for even more privatisation are limited by the fact that the private sector itself has found it hard to run even one of the smallest district general hospitals (Hinchingbrooke) while the cash squeeze is also forcing down the cash on the table for new contracts - with big companies pulling out of some high profile contracts. So the profits are in running the NHS budgets rather than delivering front line care.
Now, while hospital trusts saddled with costly Private Finance Initiative contracts for new buildings struggle to meet their soaring bills from frozen budgets, Osborne's Fiscal Charter commits the government to minimal borrowing even for infrastructure - so any and every new hospital from now on will be forced into seeking private finance, and milked for excess profits.
All of which makes it urgent for Labour's new front bench to get up to speed with the situation and start hammering the Tories over their despicable record on the NHS and the crisis they have created.
We need a united campaign of local campaigners, health unions and Labour Party making maximum protest and challenging every local cutback and closures.
We need to exploit divisions in the enemy. We must take advantage of the fact that the Tory bar on recruitment of nurses from outside the EU has been challenged by Simon Stevens and NHS managers. We need to use the opposition of NHS employers to the brutal anti-union laws now being forced through.
Labour's new leadership has a golden opportunity, in the NHS crisis, to highlight the dead end of austerity policies, to line up with 'Middle England' as the voice of opposition to local cuts and closures - and to swing Tories away from Cameron using the brazenly broken pledges on the NHS.
To do so they need to seek out good expert analysis and advice, reach out to trade unions and local campaigners, and raise a coordinated challenge in a much more professional way than has been done so far. Any Blairites who get out of line on this must be slapped down publicly.
Labour should ditch the ill-conceived Efford Bill, and sign up to the NHS Reinstatement Bill drafted by Allyson Pollock and Peter Roderick, which aims to sweep away the costly and divisive apparatus of the competitive market in health care.
it's time to put the Tories to the sword over their ruinously expensive, chaotic and disastrous "reforms" that have brought the NHS to its knees while Osborne freeze drives it to bankruptcy.
It's not the NHS that is unsustainable, for all the Tories tell us: it's the Tory policies on the NHS which are unsustainable - and Jeremy Corbyn's team need to be making that point long and loud.
It's a winner.
Devolving blame as wheels fall off cash starved NHSSaturday 31st October 2015
About six months ago, in the run-up to the General Election, George Osborne and senior council bureaucrats in Greater Manchester unveiled a massive plan to devolve central government powers over public services - including the NHS, which is not a part of local government.
The so-called "Devo-Manc" plan was expected to put a combined budget of around £6 billion for health and social care in the hands of a newly-formed combined authority of Greater Manchester, which was required as part of the deal to appoint, and eventually elect a Mayor with executive powers.
But after all the excitement had waned, the harsh reality emerged. The brutal "Devo-Manc" proposals to integrate healthcare with what's left of social care budgets in Greater Manchester has now been exposed by the decision to press ahead with highly controversial plans to strip emergency surgery from six hospitals - Wythenshawe, Tameside, Wigan, Bolton, Bury Fairfield and North Manchester.
These cost-driven cuts follow on the downgrading of Rochdale Infirmary and Trafford General. They raise questions over the future of A&E and maternity services at all six hospitals - potentially the biggest round of A&E closures so far in the NHS.
However serious these developments might be, many of our readers may feel that the problems are confined to the North West of England, and nothing to do with Kent. But shortly afterwards came the announcement of a similar devolution of powers - to Cornwall, and George Osborne's offer to roll it out to "all major cities". It would be a big mistake to underestimate how many plans are already being laid: It's happening all around you.
A recent trade union briefing document identifies similar moves to establish similar "combined authorities," with schemes covering most of the Midlands, East Anglia, Essex, Surrey and Hampshire. Kent seems to be one of a minority of counties not yet to have made a move: that could soon change.
And with "devolution" of powers and an "integration" of a financially challenged NHS with the remnants of financially drained social services comes the possibility of forcing through unpopular hospital "reconfiguration" schemes aimed at saving money by drastically reducing the level of services provided.
The Manchester hospital cuts - under the misleading title of "Healthier Together" are just one of a number of almost identically argued schemes that are taking shape in England - across London, and many other areas.
All of them have their roots not in the quest for improved services, but in the aftermath of the banking crash of 2008, which threatened an end to a decade of yearly above-inflation increases in NHS spending.
The Labour government turned in 2009 to US-based management consultants McKinsey for proposals to on how to bridge a projected NHS cash "gap" of up to £20 billion by 2015.
This was a very limited investigation, since any discussion of the potential huge savings of billions that could be made by scrapping the bureaucracy of the new competitive market system in the NHS, ditching private providers, and tackling the various rip-offs in new hospital projects financed through the Private Finance Initiative was, predictably, excluded.
Instead McKinsey came up with a "report" consisting of 124 PowerPoint slides, which offered no coherent argument but a series of assertions, few of which were backed up by evidence, and none of which were seriously analysed to show potential costs and disadvantages.
A major focus, now to be found in every local plan for cuts, was the call to reduce demand for healthcare by keeping people healthy, tackling factors that can lead to chronic health problems such as obesity and smoking - all of which are desirable, but none of which can produce short-term savings.
Today's NHS England boss Simon Stevens is a fan of these proposals - but George Osborne has other ideas. He just slashed £200 million from an already pathetically small budget for public health services, making health promotion an even less likely route to savings.
McKinsey also proposed shifting health services out of hospitals to "lower cost settings" - which, without proof or explanation, they claimed could save £2.7-£4.1bn.
An additional shift to "self-care" and chronic disease management was expected to save up to £2.5bn, while "reconfiguration within local health economies" (hospital closures) was said to save up to £1.6bn, plus up to £600m from "estates optimisation" (flogging off the vacated buildings).
All of these figures appeared to have been simply made up, with no explanation of how these changes - many of them contentious or downright unpopular with local communities - were to be achieved.
Despite the vagueness of the proposals, NHS managers - egged on by McKinsey and other management consultants, and assisted by Department of Health and external spin doctors - have since produced plans based on many of the same flawed assumptions.
Back in 2012, McKinsey director Penny Dash admitted at a "community-based care workshop" that "there isn't very much evidence base about models of community care" - the very models McKinsey has been urging local health bosses to adopt.
In fact the evidence is stacking up to show that all of the big ideas being promoted by those trying to create a McKinsey-style "compelling story" and present a "case for change" share three important qualities - they lack any substance in reality and offer little if any cash saving. But all of them offer years of lucrative work for management consultants.
The biggest deception of all is the claim that by switching services out of hospitals it's possible to make big savings.
One of the most advanced schemes of this type is the so-called Shaping a Healthier Future project in west London, which aims to close four A&E units and two whole hospitals (Ealing and Charing Cross).
It was initially promoted in 2012 as a £190m scheme to help save £1bn from spending. Since then the scheme's cost has already escalated five-fold to £1bn - with no clear explanation of where the money might come from, or what the final plans might be. It's clear that any eventual "savings" could only come at a heavy price.
There's equally little evidence for David Cameron's pet project - seven-day working in the NHS, much of which already functions seven days a week. Recent experiments in the provision of seven-days-a-week access to GPs have resulted in schemes costing up to three times more than they claim to "save."
In Manchester, just 65 per cent of the extra GP appointments were taken up, and the extended service reduced A&E attendance by a feeble 3 per cent - all of them minor cases.
Elsewhere 7/7 pilot schemes have cut back on extended evening access to GPs and some have closed Sunday sessions completely after finding far lower than expected patient demand.
The evidence that cost savings or reduced demand for hospital treatment come from developing out-of-hospital initiatives in primary care and community health services is very limited.
Repeated studies have shown there is no substance to claims from McKinsey and others that hospital admissions could be reduced and costs cut by the superficially attractive idea of concentrating extra resources on patients at high risk (cynically dismissed by NHS bureaucrats as "frequent flyers" because they are often admitted to hospital).
In fact high-risk patients make up less than 2 per cent of hospital caseload. Focusing resources on them diverts GPs and other staff from other patients' needs - and leaves the needs of the 98 per cent unchanged.
A Nuffield Trust study last year came to similar conclusions. The BMA is calling for other costly pilot projects on reducing hospital admissions through such measures to be scrapped since they are doomed to fail.
The buzzword of the moment - the call for "integration" of health and social care, trumpeted by Tory ministers, Labour politicians and by Simon Stevens - has come under scrutiny. Again there is no evidence it can deliver the expected efficiency savings.
Last year, for example, the Commission on Hospital Care for Frail Older People, set up by the Health Service Journal, concluded it was a "myth" that measures such as the "integration" of health and social care and improved services in the community would reduce the need for hospitals or bring cash savings for the hospital sector.
Agreeing that improving community services was desirable, the report argues that this could only delay rather than avoid the need for hospital stays.
"The commonly made assertion that better community and social care will lead to less need for acute hospital beds is probably wrong."
Better social care is perhaps an even more remote prospect than better community health services. Social service spending has been battered by the huge cuts that have cut local government budgets by up to 45 per cent since 2010, and is set for similar-sized cuts in the next five years.
Indeed there is little in the way of social care left for the NHS to integrate with. What remains is restricted to the patients with the most severe problems, leaving nothing to support those with moderate needs or provide preventive support to those with lesser problems.
Numerous studies have also challenged the core McKinsey/government argument for the "consolidation" of A&E services into fewer "major units," leaving only free standing urgent care centres, offering limited hours and services.
Studies by primary care specialists have concluded that most of the people who attend A&E do need to be there, shooting down the assertion that the majority are inappropriate attenders or simply minor cases.
A 2009 report commissioned by the Department of Health from the Primary Care Foundation specifically challenged "widespread assumptions that up to 60 per cent of patients could be diverted to GPs or primary care nurses," and argued that the real figure was as low as 10-30 per cent.
A report last year for the King's Fund also concluded that "a proportion of A&E attenders can safely be seen in community settings, but there is little evidence that developing these services in addition to A&E will reduce demand."
In any case, the cost savings from diverting A&E patients to other services are negligible. Care in other settings is only marginally cheaper - and requires investment.
The NHS spends less than 3 per cent of its budget on A&E, so even closing all of the remaining units would go nowhere near to solving the NHS cash crisis, which stems not from excess use of A&E but the political decisions of Osborne to cut NHS spending as a share of GDP.
In practice A&E cuts serve a different purpose, as a prelude to hospital cuts and closures.
Shifting care out of hospital to expanded primary care or community healthcare has also proved impracticable - there is a national shortage of GPs and practice nurses, worsened by 2010 cuts in training places.
Primary care budgets have been squeezed even more tightly than hospital budgets. There is no funding available, no plans and no serious commitment to develop expanded community services - and even if there were, it would not save any money.
As the picture of chaos grows, the deliberate effort to undermine confidence in the NHS has been intensified by Jeremy Hunt's outrageous attack on hospital consultants.
The constant, complex reorganisations and policy initiatives are fragmenting the efficient, publicly owned and run NHS into a myriad of piecemeal contracts, while the pressure to "integrate" with social care poses a major threat of the introduction of charges for care and the erosion of our NHS free at point of need - since the 2012 Health & Social Care Act, the Secretary of State no longer has any duty to provide healthcare.
It's never been more important to fight back against every cutback, every closure and every privatisation. The next few years will be crucial in the battle for the NHS, and for its reinstatement. We need to build the biggest, strongest campaign to make sure we have a chance to win.
John Lister is director of Health Emergency, and joint author of NHS For Sale (Merlin Press 2015).
Beware this dangerous "silly season" for the NHSMonday 17th August 2015
Eagle-eyed researcher Richard Grimes and the excellent Our NHS website have flagged up the fact that a newly-appointed Tory Minister for NHS Productivity, Lord Prior, has set up a fresh inquiry into the possibility of funding the NHS through user fees for service.
The proposal, made apparently informally in the course of a low-profile debate House of Lords, has all the trappings of a stitch-up, since only like-minded peers seem likely to be invited to take part in discussing this zombie idea, which keeps constantly resurfacing, with little if any public involvement.
It has been swiftly followed by a report from CIPFA - the Chartered Institute for Public Finance and Accountancy - which dismisses the chances of the NHS making the required £22 billion of savings over the next five years. It concludes from this that the government must either come up with more money for the NHS, or reduce services, or … "charge users more".
"To choose none of those is not a realistic option." We can expect an orchestrated campaign of such arguments to grow in the next year or so.
This raises the possibility of the new government publicly flouting David Cameron's previous explicit insistence that patients would not face charges for treatment or be required to take out health insurance. But we are in a period in which a newly-elected Tory government feels free to ditch its pre-election promises and earlier commitments, and crack on with the policies which will appease the right wing back benchers and the backwoodsmen who fund the Party.
Meanwhile Monitor, the NHS regulator, has written to cash-strapped trusts facing a massive £2 billion total of deficits this year, telling them in effect to disregard targets for waiting times, and tear up guidance on safe staffing levels, with all financial penalties suspended in a desperate effort to balance the books.
Monitor, too, is saying there is simply not enough money to maintain NHS services as before - again proving that Cameron's bland pre-election promises of an extra £8 billion for the NHS by 2020 is no guarantee that services will not be slashed to ribbons and the choicest services privatised.
We are entering a new, dangerous, silly season in politics. That's why the underlying principles of the NHS, as a tax-funded universal system delivering a comprehensive range of health care free at point of use, and free to plan and allocate resources according to need rather than market forces, are again being questioned - and constantly undermined.
In addition to the fact that it is socially regressive and economically nonsensical, the very idea of introducing user fees for the NHS is also a major electoral liability. Even the recent King's Fund Barker Review weighing up a series of unpalatable "options" rejected the idea of user charges, while suggesting a range of taxes, mainly on the elderly, to help pay for increased investment in the NHS.
But just because a policy is mad and unpopular does not mean that neoliberals don't aspire to do it.
The combination of the continued, tightening freeze on NHS budgets, coupled with demands for massive, unprecedented "efficiency savings" and the chaos of the new, dysfunctional system introduced by Andrew Lansley's Health & Social Care Act, also results in all kinds of common language being turned upside down.
"Devolution" - in Manchester, Cornwall and now increasingly planned for other areas of England - has been transformed from a progressive measure putting health services to some degree under democratic control, into a bureaucratic monster, with imposed mayors and arrogant decision-making by small cabals of self-important councillors.
Instead of a transfer of real powers to a more local level, budget pressures mean "devolution" is now an exercise in shifting blame for unpopular cutbacks and closures from central government - which since the 2012 Act no longer has any duty to provide health care - to unwitting but ambitious local authorities.
In countless 'Our Healthier Area' projects and Simon Stevens' Five Year Forward View, 'public health' and 'preventive' measures now no longer mean long-term interventions tackling the social determinants of ill health and designed to make the local public healthier. Instead they have become a magic incantation which is somehow supposed to achieve miraculous short-term reductions in use of hospitals and health services - and generate billions in "savings," irrespective of the £200 million slashed from public health spending in Osborne's budget.
The mantra of "integration" of health and social care services is also echoed by all the main parliamentary parties. In itself it's a desirable goal - if the objective is to extend the NHS principle to social care and scrap the present means-tested charges.
But in place of any genuine "integration" we are faced in real life with the disintegration of an under-funded, largely privatised social care system, which will be further torn apart by another five years of cuts under George Osborne's plans for local government.
The NHS, too is visibly disintegrating: Clinical Commissioning Groups are one after another restricting the range of services they will pay for, capping numbers of treatments, and finding excuses to exclude smokers and overweight patients from treatment, and conniving with local trusts as they flout targets for patients to wait no longer than 18 weeks for treatment.
Different CCGs are now adopting different, contradictory plans for future services: in Somerset, GPs appear ready to pool part of their primary care budgets with hospital budgets and social care to create a new "outcomes-based" system of commissioning services.
But in the North East, a Health Service Journal report reveals Northumberland CCG is proposing a completely different scheme to hand the bulk of its budget and commissioning functions to Northumbria Healthcare Foundation Trust, to be administered by a "provider led Accountable Care Organisation" - not yet established.
The Trust would deliver emergency and acute services as well as community health, and it already runs a number of GP practices. Other GPs in the area would be encouraged to group together in federations: they too would work under contract with the trust.
The scheme appears to break down the "purchaser/provider split" that has dominated much of the NHS since Margaret Thatcher's government introduced a costly "internal market" in 1991, later transformed by Tony Blair's government and then the Lansley Act into a full-scale competitive market involving the private sector.
However the establishment of an Accountable Care Organisation also worryingly copies similar organisational structures in the USA, where ACOs run by private insurers operate in the private sector. This raises obvious fears of a future privatisation - if the private sector could be assured it could make a profit after being stung by a series of losses from NHS contracts to deliver clinical services.
But while the first NHS ACO is being set up, other CCGs are following different lines. Some are dividing up whole "pathways of care" and groups of services, with each going to "lead providers," many of them private companies. These include Bedfordshire (contracts for Musculoskeletal services and dermatology); Nottinghamshire (who disastrously awarded a dermatology contract to Circle, resulting in the collapse of specialist services in Nottingham as consultants departed rather than work for the company); and Cambridgeshire (where a long wasteful saga of seeking to contract out Older People's services wound up eventually giving the lead provider contract to a consortium led by local trusts).
The most notorious case is Staffordshire, where the contract for End of Life care seems certain to go to a private provider, while the even more controversial cancer care contract is in chaos after the only Staffordshire trust in the consortium - University Hospitals North Midlands - pulled out of negotiations, arguing that they could not guarantee to treat a rising caseload with the limited funding on offer. Only the Royal Wolverhampton Hospitals Trust is hanging on.
The Staffordshire CCGs that have been driving the process, shamefully egged on and financed by cancer charity Macmillan, are now left with a lame 'consortium' led by support service provider Interserve, which has no clinical expertise, and now no prospect of being able to offer a viable or accessible service.
But with so much prestige now at stake for the CCGs, which have defied local opposition to press the scheme through so far, there seems little chance of them seeing sense and scrapping the whole farcical process to negotiate a fresh contract with the trusts.
It's a crazy, dangerous time for the NHS: the unthinkable is not only being thought, but put into practice by senior managers desperate to balance the books, while the Tory right look for ever more avenues for private sector takeover.
It's a time for health campaigners, health unions and the growing numbers drawn into progressive politics by Jeremy Corbyn's astonishingly popular challenge for the Labour leadership to get together to build a new, bigger and united challenge to a Tory government with a wafer-thin majority.
Another NHS is possible - and affordable if the scrounging rich would only pay their share of tax. To reinstate the NHS and protect it we need a movement that is stronger and more powerful than before. While the Tories dream up more unthinkable policies, let's make sure we keep our eyes on the prize - and focus our anger on the enemy in front of us.
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