The heat is on for NHS cutsThursday 14th July 2016
In the post Brexit political free-for all it's a nightmare scenario for the NHS.
Services were already struggling to cope with rising demand on a budget which falls each year to 2020 in real terms value and as a share of national wealth (GDP).
Nonetheless it seems that - however much rhetoric there may be about the importance of public health - there is no imminent prospect of the extra funding that's needed. Instead there's just huge economic uncertainty ahead.
The financial squeeze on the NHS flows from the decisions of the Cameron government back in 2010: George Osborne chose the path of austerity and cutting all public spending. He opted to cut the NHS covertly through a 10-year virtual freeze, designed to unpick the previous 10 years of increased spending - while claiming NHS spending was "ringfenced" from outright cuts.
There has never been any sign that the new Prime Minister, Theresa May, in any way dissented from this approach. Nor is there any sign that her chosen Chancellor Philip Hammond, who established a brutal reputation when he was a Treasury minister for driving through cuts, will substantially change Osborne's approach.
To make matters worse, the Brexit vote is already undermining the ability of NHS employers to recruit health professionals from the EU, who fear that they may not be welcome or secure in the UK.
Since the referendum May herself has refused to guarantee that EU nationals working here would be able to stay following the Brexit vote: that potentially includes the 55,000 or more already working in the NHS as well as many more in other jobs.
May as Home Secretary was an enthusiastic advocate of tighter limits on immigration: her notion of a 'one nation' approach appears to mean excluding people with origins in other nations.
In the midst of her major reshuffle, Health Secretary Jeremy Hunt appears to be almost unique in holding on to his post - despite, or perhaps because of his stand-off with the junior doctors. May's decision to leave him there signals no retreat from the imposition of a contract which the junior doctors have overwhelmingly rejected.
With continuing fears of recession there had been talk even from Osborne of freeing up infrastructure spending, but no hint of easing spending limits on health or local government, which is responsible for social care. Hammond is likely to be as mean-spirited.
However it's not just the health budget feeling the squeeze: social care has been slashed year by year since 2010. With more people living longer with more complex needs, they need social care - and councils are running out of 'efficiencies'.
The latest survey of all councils in England from the Social Services directors (ADASS) says they have to make further reductions of services of £371m for people needing care - and for their carers. This follows five years of funding reductions totalling £4.6bn, almost one third of real terms net budgets.
The proportion of social care savings expected to be raised from efficiencies has fallen from 75% last year to 55% in 2016/17 whilst outright cuts in services have increased from 18% to 39%.
ADASS argues that there are now "next to no further efficiencies to be made from squeezing provider fees paid, or raising income from fees and charges to customers".
Half the cuts will come from older people and almost 20% from personal budgets - a scheme dear to the heart of NHS England boss Simon Stevens. Only a third of social services chiefs were confident they will even be able to meet their statutory duties this year.
All this is bad news for the NHS service users, because most NHS new models of care and hopes for savings through 'integration' of services depend on social care: but it's even worse news for service users.
But big savings are still very much on the agenda on NHS budgets too.
Since just before last Christmas the new mechanism to drive cuts has been Sustainability and Transformation Plans (STPs), which have to be drawn up in each of 44 'footprint' areas across England .
Each STP is required to seek new cuts & "savings" to bridge improbably huge gaps between projected needs and available resources by 2020.
Each plan has to be checked by NHS England, whose boss Simon Stevens has initiated this latest top down reorganisation, hoping to ride roughshod over the structures put in place by the 2012 Health & Social Care Act to impose much more centralised control.
Stevens was reportedly planning to invoke David Cameron's support in pressing for financial discipline had EU referendum gone against Brexit: but since the vote the central pressure for savings is continuing, made more urgent by the latest revelations that despite extensive "creative accounting" reducing overt deficits by £900 million, the underlying deficit of trusts and foundation trusts last year was £3.7 billion.
Despite hugely ambitious savings targets, the most optimistic forecast for this year is a total trust deficit of £500m. NHS Improvement has responded by demanding trusts implement another £250m cuts.
And as this update is drafted NHS England has called for limits on spending on clinical staff - shocking Royal Colleges. NICE guidelines for safe staffing targets have been effectively discarded, with trusts told they need no longer invest to meet CQC or Royal College guidelines. Struggling trusts which have staffing of more than 1 nurse per 8 patients will be told this can no longer be afforded.
Trusts which appear to be making insufficient savings on "back office" services will be forcibly paired up with other trusts by NHS improvement. The heat is on.
So far there is precious little information on the content of many STP plans. First drafts of all 44 plans - drawn up in secret, with only the blandest generalities published - were apparently submitted to NHS England at the end of June, according to the HSJ, which also reports that it is unclear when - or if - all the plans will be made public. Behind the scenes there are huge efforts to strong-arm and bribe local authorities to sign up to plans that cut local health care, but offer a token handout to social care budgets.
Many STPs have plenty to keep secret about: they centre on significant, controversial service reorganisation. More and more A&E units and other services are again at risk throughout England, threatening local access for communities.
Plans to axe services at Bedford Hospital for example would mean that the nearest hospital would be 19 miles away: patients are being offered the "choice" of providers up to 50 miles away. STPs offer the chance to override local concerns and impose cuts regardless of opposition.
But the cuts will of course run alongside privatisation: an NHS England director has also promised a conference of the right wing Reform think tank that STPs will offer plenty of opportunities for the private sector to get into contracts for estates management and new models of care.
So the Keep Our NHS Public campaigners that have renamed STPs as "Slash, Trash and Plunder" are spot on, and campaigners need to join with trade unions to address the danger of STPs and coordinate a response wherever possible.
That's why Health Campaigns Together has established an STP Watch page on its busy website, and organised a national conference in Birmingham on September 17, which will bring together information and experience and attempt to map out solutions.
We need to get together to weather the new, dangerous period for the NHS. I hope readers and their organisations will support HCT, come to the conference, share info on STP Watch - and help us build the strongest possible resistance.
May the Fourth be with you!Sunday 1st May 2016
EMERGENCY DEMO! NHS BURSARIES: VOTE IN THE HOUSE OF COMMONS on Wednesday 4 May
Labour's shadow health secretary Heidi Alexander has called an "opposition day debate" on the government's plans to scrap NHS bursaries for student nurses and midwives - on Wednesday May 4.
The Bursaries or Bust campaign says:
IF YOU CANNOT ATTEND THE DEMO PLEASE LOBBY YOUR MPs TODAY!
We will be assembling at Parliament Square to show the government that we will continue to fight NHS bursary cuts.
Ask your MP to support on the day
Heidi Alexander has called a debate based on the early day motion 1081 which has been signed by 139 MPs so far.
This is exciting. This means we can win.
JUNIOR DOCTORS, TEACHERS, PUBLIC SECTOR WORKERS AND EVERYONE ELSE - WE NEED YOU. TOGETHER WE CAN WIN THIS.
And don't forget
4th JUNE IS OUR BIG MARCH
We want 10,000 of you there!
NHS trust deficits hit £2.2 billion - and risingTuesday 16th February 2016
As Jeremy Hunt demands NHS trust managers clear deficits before they receive any of the £1.5 billion "transformation fund" in 2016-17, figures from a snap survey of trust board papers in early February by pressure group London Health Emergency show trust deficits are bigger than ever, with 138 out of 150 trusts in the red.
The total deficits for England's 150 acute trusts are now more than a massive £2.2 billion. Just nine trusts were in surplus, sharing a meagre total of £11 million between them, while three have not published figures on their websites.
10 trusts each face deficits of more than £40 million, while three have shortfalls in excess of £70 million, headed by Barts Health, the biggest NHS trust in England, with the biggest debt at a monster £134 million.
No less than 74 trusts are showing deficits above £10 million - the figure that triggered the crisis at mid Staffordshire hospitals in the mid-2000s, where management, desperate to clear deficits, sacked nursing and medical staff - reducing services to disastrously poor levels resulting in a national scandal.
A recent letter from Mr Hunt to foundation and NHS trusts now risks a further widespread repetition of similar cuts in staffing and reduced quality healthcare. Hunt has demanded that trust bosses "balance the books without compromising patient care" to stand any hope of accessing the limited new money allocated in George Osborne's Comprehensive Spending Review. He threatens that boards which fail to clear deficits will be removed and replaced - although it's far from clear how the many dozens of trusts now deep in the red could all be subjected to this treatment.
But it gets worse: further guidance from NHS regulator Monitor and the Trust Development Agency has urged trusts in deficit to agree actions including "headcount reduction" - in other words large-scale job losses. This could cause chaos in local services all over the country.
As the Mid-Staffs trust bosses discovered, larger sums can be saved more quickly by reducing numbers of higher paid nurses and doctors than by cutting back on lower paid staff: but the damage done to the quality of care can be equally severe and swift. All these panic moves run alongside Jeremy Hunt's attempts to create what he calls 'seven-day working' in the NHS with no extra staff and no extra money, by imposing an unsafe and unfair contract on junior doctors.
Responding to the figures Dr John Lister, Secretary of Keep Our NHS Public said:
"Five years of frozen funding under David Cameron's governments have reduced the NHS to a cash-strapped shadow of the service the Tories inherited when they took office in 2010. Hospital trusts are not just missing financial targets, but also missing targets for treatment of A&E patients, treatment of cancer patients, treatment of mental health patients, and struggling to discharge patients from hospital beds as a result of the brutal cutbacks in social care implemented year after year in Tory spending cuts. There are desperate and growing shortages of GPs. Even Public Health budgets, to reduce future NHS costs by preventing illness and promoting good health have been slashed back.
"But the latest call for trusts to balance the books by cutting staff is a sure-fire recipe for growing waiting lists, waiting times, trolley waits and all the misery some of us remember from the grim Thatcher years in the late 1980s.
NHS funding has been frozen in real terms while the population has grown, costs have risen, and staff have become more difficult to recruit and retain as pay levels have fallen steadily further behind since 2010, resulting in soaring spending on agency staff. Dr Lister adds:
"The only way to get the NHS back on an even keel is for substantial increases in real terms funding, an end to the bureaucratic costs and fragmentation of the competitive contracting system imposed by Andrew Lansley's disastrous health and social care act, and urgent steps to regain the trust and confidence of junior doctors and other healthcare staff, beginning with a reversal of Jeremy Hunt's decision to impose his unsafe and unfair contract."
Download the survey here
Full analysis of these figures by John Lister
Hunt cracks the whip over NHS bossesFriday 5th February 2016
"The floggings will continue until morale improves" appears to be the human relations strategy of Jeremy Hunt and Cameron's right wing Tory government in their approach to all sectors of the NHS.
Not content with goading the Junior Doctors into unprecedented - and inspiring - strike action, and cheesing off the majority of NHS staff with five years of real terms pay cuts and the threat of more to come, Hunt has antagonised tens of thousands of GPs with demands that they implement 7-day a week services that cost a fortune and put GPs under stress.
Ministers are pursuing their 7/7 NHS policy with absolutely no regard to evidence of the failure of most of the pilot schemes.
Health Minister Alistair Burt told the Commons Health Committee he was "not bothered" whether patients used the extra appointments his colleagues are demanding GPs provide on Saturday afternoons and Sundays. In fact patients have clearly shown they don't want them.
Nor do ministers seem to care that just one GP in eight has said they would consider the new 7-day access contract proposed by David Cameron, and GPs are debating instead whether to resign from the NHS if more funds are not provided for primary care.
Scarce cash and human resources are being squandered on gimmick ideas that don't work. NHS England has admitted that the level of take-up of the "midlife MOT" healthcheck for people aged 40-74 had been minimal.
The drive for 7/7 access to primary care runs alongside a similar campaign on hospital care, which is now a key factor in the Junior Doctors' dispute. Again it's based on prejudice and efforts to con the electorate rather than evidence, with Hunt cynically distorting the available statistics on weekend deaths in hospital to grab Daily Mail headlines.
Now, on top of all this, Hunt's latest diktat to the boards of NHS and foundation trusts shows he is keen to stick the boot into senior managers as well.
The tightest-ever squeeze on NHS funding since 2010 has brought the biggest-ever combined deficits, with almost every acute hospital trust and foundation trust deep in the red. Trusts face five even more savage years to come.
Already NHS performance is visibly falling back, bringing delays of treatment in A&E, delays in accessing cancer treatment, and record levels of delays in discharging patients for lack of community services or social care.
But instead of recognising these warning signs, Hunt has now demanded that trust bosses do the impossible - and "balance the books without compromising patient care" - or face whole boards being suspended.
It's a bluff in many ways: almost every hospital is failing on finances - and they can't suspend them all. But it cranks up the heat on already stressed hospital bosses, while giving them no way out.
Hunt has of course previously imposed arbitrary limits on the use of agency staff to fill growing numbers of vacancies for nursing and medical staff - while simultaneously proclaiming his commitment to enhanced levels of staffing, and urging the regulatory body the Care Quality Commission to get tough on this issue.
It appears that ministers, the Department of Health and the top bureaucrats in NHS England have all decided the best way to deal with the chaos that has been triggered by the spending freeze and Andrew Lansley's disastrous Health & Social Care Act is to shut their eyes tightly, plug their ears and ignore all of the evidence by just repeating the same impossible demands.
So Hunt now tells trusts they are supposed to be "equally focused" on treating patients and on "how they can leave hospital" - much of which he knows is out of the control of NHS trusts, and hinges on a largely dismembered social care service that has been hopelessly underfunded, fragmented and privatised to death by local councils in most areas. 80% of "Better Care Fund" projects to link health and social care were failing at the last count.
Hunt's statement itself shows the monumental task he is setting NHS managers: it estimates that to save £400 million across the NHS it's necessary to make a 1% improvement in staff productivity. Not only is this a hopelessly vague assertion, but it means that simply to clear the £2-3 billion or more of deficits that trusts will carry into the new financial year, "productivity" needs to be increased by at least 5% - and much more in heavily indebted trusts.
Even NHS England boss Simon Stevens, in his hugely optimistic Five Year Forward View did not expect to achieve "efficiencies" of more than 2-3% per year - while he too ducked out of any discussion on how exactly these "efficiency savings" were to be achieved.
The managers who are expected to deliver these results are even less confident than Stevens. A survey of the Healthcare Finance Management Association in November found 88% were unconvinced that their organisations could deliver 2-3% efficiency savings, and 84% believed the Five Year Forward View is unachievable because trusts lack the resources required.
More than half said that quality of care could only be maintained or improved if the promised extra £8 billion funding by 2020 was available soon: 94% felt it was needed in the next 18 months. Instead George Osborn's Spending Review statement soon afterwards offered a very different prospect, with extremely lean years from 2017 onwards.
Nonetheless Hunt, whose previous involvement with the NHS was limited to signing up with other right wing Tories in support of plans to break it up, is now robotically repeating that none of the £1.8 billion "extra" funding ostensibly allocated to the NHS in 2016-17 will be available to trusts who do not balance the books.
He has told hospital bosses there is "no choice" to be made between delivering high quality care and having a good grip of finances. Hospitals which perform poorly on either measure will face closer scrutiny and intervention from regulators.
But reaction to Hunt's statement by NHS managers reading the Health Service Journal ranged from anger at the way they had been set such an "impossible agenda" to cynical suggestions that where boards are suspended the next step could be to wheel in Hunt's "mates" from one of the 'big four' costly management consultancies to develop a "pie in the sky turnaround strategy."
What's clear is that this latest ratcheting up of pressure on NHS management is likely to drive forward plans for cut backs and closures by hospital and mental health trusts, rationing of care by local commissioners reducing the range of services available, and attempts to force staff to work under even greater pressure with unfilled vacancies.
Hunt's top-level bullying of managers and trust boards is almost certain to trigger a new round of bullying by these managers and their subordinates across the NHS. And every "failing hospital" will of course be pilloried in an obedient mass media and Tory press as reasons why the NHS itself is "no longer sustainable".
This is no accident or mistake. Hunt and the Tories are not just blindly creating chaos.
Since Andrew Lansley's first day as a Tory health secretary in 2010 they have been seeking ways to fragment the NHS, undermine confidence and public support for it, and give more contracts to private providers, more opportunities for private insurers to attract new customers, and more scope to promote the idea of imposing charges for NHS treatment.
That's why it's so important for Labour to develop a clear alternative approach from top to bottom, based on a commitment to dismantle the costly and wasteful market mechanisms begun under Tony Blair and now driven forward by Cameron, end contracts with private providers, stop any further haemorrhage of cash through PFI, and reinstate the NHS as a public service, publicly funded through taxation, and publicly provided.
A Bill setting out a clear way to achieve this has been drafted by Professor Allyson Pollock and Peter Roderick. It was supported by Jeremy Corbyn and John McDonnell. It has now been tabled in this parliament by Green MP Caroline Lucas. Labour Parties need to press for Labour MPs and shadow health secretary Heidi Alexander to back the Bill: two Labour Parties in Bristol have already declared their full support.
But CLPs also need to be part of new moves to build a united resistance to the Tory onslaught on the NHS, bringing together health campaigns, trade unions, pensioners, and doctors' groups at national and local level to fight cuts and privatisation.
Health Campaigns Together (www.healthcampaignstogether.com) is organising an activists' conference on January 30 for which tickets are already sold out - and will be seeking support in every area as it gets going this year. Make sure you and your CLP are part of it.
The NHS is under the most ferocious ever attack. If we don't fight for it, we can lose it. When it's gone, it's gone.
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