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  • Beware this dangerous "silly season" for the NHS

    Monday 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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