The implications of the Government’s NHS changes, and what Labour should do about them: Guest Post by Dr Nick Palmer
Matt has challenged Anna Soubry and me to comment on the Government’s NHS policy. You won’t be surprised to learn that I’m not a fan of them. But I’d like to take the opportunity to say what I think Labour should do differently if we’re elected next time round. Miss Soubry failed to come to defend the Government’s policy at the recent meeting on NHS issues in Beeston, but if she’d like to debate it here or anywhere else I’d be very glad to have a constructive discussion.
Let’s get the obvious partisan point out of the way. David Cameron promised no top-down reform of the NHS. On reaching Number 10, he and his LibDem allies introduced a reform so top-down that it was already being imposed before it got through Parliament and so huge that a senior civil servant commented that it could be seen from space. Virtually every significant medical organisation opposed the changes, and all were ignored. As an example of a broken promise it’s up there with tuition fees as a startling example, and I’ve yet to meet anyone, including senior Conservative MPs, who actually thinks it was a good idea: by the end of the process, they were just pushing it through to save face.
OK, OK, you’ve read all that before, enough already. We are where we are. What next?
There are now three main problems:
- Secondary health providers (i.e. hospitals) are being required to compete, and are encouraged to improve their funding by expanding provision to paying patients, up to 49% of capacity (typical current level is 10-15%).
- Preventative care, a key function of the old Primary Care Trusts, has been stripped out of the obligatory duties of the new Commissioning Groups. This covers things like helping people stop smoking and testing for diabetes. Would you like to see disease prevented rather than tackled after it happens? Good luck – it’s now a local authority duty, and local authority budgets are being cut to the bone. Perhaps the local authority can persuade the Commissioning Groups to do it anyway, perhaps not.
- The payments system is loaded to favour simple operations (which the private sector like to offer) at the expense of complex operations (which are usually only provided by the NHS). When the system was 90% public, this didn’t matter very much. It is now an acute problem. Expect to see more and more private providers offering to fix broken ankles and give you hearing aids, and more and more NHS providers struggling to finance the complex work.
Now if Miss Soubry responds to Beestonia, she will tell you that point 1 isn’t a problem, since the hospital is required to spend its shiny new private income on improving their service. Very true. But suppose you’re a hard-pressed hospital manager trying to meet the rising cost of complex care? You need to raise your inflow of cash from somewhere. What part of your service do you improve with income from more paying patients? Pay to expand a loss-making operating unit? Hardly. Obviously, you build a new wing entirely for paying patients. It’ll pay for itself and more, and you’ve got loads of scope to expand, all the way up to 49% of your hospital. Your bottom line will shine. What a fine manager!
But, hang on, what’s the effect of that on patients? It increases the differential waiting time. In 1997, it was commonplace to have to wait two years for a hip replacement, or two months if you were willing to pay the very same consultant to do it privately. By 2010, the average NHS wait had gone down to two months, and the private edge was reduced to having nicer carpets, posher food and prettier rooms. But now we’re starting to get insurance flyers again saying “Insure now to avoid long NHS waits.” That is going to get steadily worse until the policy changes. That is why, “We face the end of the NHS as we know it” is not a hysterical partisan claim. It’s a sober statement of fact. The end result will be a stark choice when you need care: (a) Pay or (b) Wait.
What should Labour do about it? Well, I wouldn’t scrap the Commissioning Groups. The answer to an unnecessary monster reorganisation isn’t another unnecessary monster reorganisation. I’d do five things:
- Scrap the requirement to compete (with all it implies in international competition rules), and replace it with a requirement to cooperate.
- Scrap the incentives to expand paid provision.
- Put the responsibility for preventive medicine back in the CCG’s mandate.
- Make the Secretary of State ultimately responsible for health care again.
- Pay for all operations according to cost, without a bias to cheap and easy ones.
None of this needs major new legislation, or massive new funding, or gargantuan reorganisation. It just takes the insidious incentives to private paid-for care out of the system. Oh, and make that six things:
- Don’t go back to PFI. Labour did a lot of good for the NHS, but we made mistakes too, and we should learn from mistakes. The Labour promise in 2015 should be to be better than the Tories and LibDems, and better than we were last time.
The answer to reckless privatisation is intelligent socialism – by which I mean finding ways to provide decent service to people who need it, regardless of their ability to pay. If I’m the Labour candidate next time, that’s part of what I’ll be arguing for.
Over to you, Miss Soubry. You’re a Health Minister, and appear in the press denouncing over-large croissants and the deplorable size of modern cakes. For all I know you might be right about croissants. But are you willing to debate the fundamentals of your Government’s strategy in your own constituency?
‘Over to you Miss Soubry’ – don’t hold your breath!
This is 100% why we need you back, Mr Palmer. Not only because I agree with everything you’ve just said on the HSC act, (and your proposals are clear and achievable) but because, unlike our current MP you’ve *said it*; you’ve nailed your theses to the church door – and I know you mean what you say.
I hope we can soon say “welcome back”; we’ve missed you.
What has happened to the article on Soubry’s expenses?
A legal issue: I’ll explain later.
FROM THE OFFICE OF ANNA SOUBRY MP for BROXTOWE
You have removed an inaccurate and defamatory article about Anna Soubry from your web site which was written by a Dr. Eoin Clarke. He has removed the article from his web site and posted a full and unreserved apology accepting he had published wholly inaccurate figures and had made false allegations against Anna Soubry.
You are aware that Dr. Clarke agreed the apology with Anna’s solicitor but you have not posted Dr. Clarke’s apology on your web site nor apologised for publishing an article which you did not check, which was factually inaccurate and which made false allegations against Anna. Dr Clarke has also agreed to pay the costs of Anna’s solicitors.
Anna Soubry has no desire to engage in legal action against you given that you would have to bear those costs. Recent events have shown, though on a far more serious and damaging level , the need for anyone who publishes allegations against another person to verify them and stay within the law. In the circumstances please would you publish Dr Clarke’s apology which he has agreed with Anna Soubry’s solicitors.
Please see the post I have followed this up with. You state:
Poor Nick Palmer our MP in exile as opposed to Miss Soubry our MP in…..(somewhere else; not here with the plebs).
I think Broxtowe has been a poorer place since Nick was ousted. I might not agree with everything Labour stand for, or how they do it, but I think Nick was, and hopefully will be again a good MP
What a well written and considered piece – the voice of reason and common sense. If we don’t return Nick at the next election we deserve everything we get.
Not sure I really mean that!
I agree; great analysis and good practical solutions.
Such a well thought through and written piece – a pleasure to read.
Here’s hoping to see Nick back in his former capacity of our MP from 2015…..
Thanks for the kind comments everyone. If anyone who isn’t on my list for email updates would like to be, please drop me a note on firstname.lastname@example.org.
Also, this is a good moment to join whichever party anyone favours, since I expect that all parties will be selecting their candidates for 2015 in the second half of 2013. Most parties have a qualifying period of 6 months before you get to vote on the choice.
Well said Nick. I would only add one word of advice to anyone who faces the possibility of needing health care before the election: move to Scotland or Wales, these countries never embarked on ideologically-driven reforms of their health services.
I don’t understand where some of Nick’s conclusions of what Labour would/should do have come from. In particular I think Nick’s case for CCG’s taking over the preventative health role from the local authority needs more analysis than is given here. The PH budget that goes to the LA is, I understand, ring fenced so lessening the strength of his arguement that cash strapped councils will raid it – the issue is whether the centrally allocated PH budget is realistic/sufficient to combat CVD, obesity and the health of an aging population. Those same councils will be trying to ensure adult care services are effective and efficinet so preventative health measures will be essntial to their action plans especially with hte aging population. It is in a local authority’s interest to get PH delivery right.
By going down Nick’s path of giving the PH budget to a CCG it could leave a private CCG to determine how it uses preventative and other budgets e.g. is it more profitable for them to do minor reactive operations and leave the complex to the public sector trusts rather than a campaign for peope to have good food and so prevent the need for the operations. This actually plays into his concerns about competition.
Nick may be right that with the right targets and controls and a scrupulous CCG his might be a good solution but what he has concluded here does not cover all four corners of advantages and disadvantage of PH being in either the LA or CCG.
I’d like to understand a lot more as to why he has come to that conclusion before I could support that proposal
Thank’s for that well written article.
I tend to agree with the comments of Christopher Frost, i.e. didn’t always ( in fact, I rarely) agree with Labour’s way of tackling a problem,
but I do want an MP who thinks for themselves, rather than be a ‘yes’ person, simply to further their political career.
Go for it, Nick.
[…] Palmer has informed us that he has written an article about the NHS in the ‘Beestonia Web Site‘ you may like to see his views on this subject which is close to the Nations […]
I fully agree with Nick’s assessment and view on what needs to be done. The reorganisation was cynical move by the Conservatives who still see themselves as the saviours of the NHS. I have been raising these very same issues directly with my MP for the past two years to no success. The government health minsters seem to have a dim view of NHS managers and they constantly talk about these mythical administrators that must be removed (nice words with little meaning but capture a mood with the public).
If we are to retain the Commissioning groups as now seems to be the case then the following actions should happen:
They must learn a broader knowledge of stragey and the wider health system, they are far to biased and narrowly focused at the current time.
They must be more focused on development and support rather than being the another set of chiefs with the big stick
The groups must have a wider range of roles and skills, they are still far to doctor centric.
Unless we tackle this serious issue head on with some real debate we are going to see extensive irreversible damage to the NHS as we know it. If unchecked we will end up with NHS boards being sacked like premier league managers as a public show of action to a failing system and used as a sticking plaster for a system dying from the roots up. Stratch below the surface of the NHS right now and the signs are very clear to see already. What’s the collections approach? Send questionnaires to all patients to ask would you recommend this hosital to a friend, who cares treat me and treat me well, something the PCT and SHA were actually doing pretty well already…………….
Some six months ago I had occasion to see a consultant at QMC. I asked him about these proposed changes to the NHS. He stated the end result would be the situation which Nick highlights in his “problem 3.” as follows
3.The payments system is loaded to favour simple operations (which the private sector like to offer) at the expense of complex operations (which are usually only provided by the NHS). When the system was 90% public, this didn’t matter very much. It is now an acute problem. ankles and give you hearing aids, and more and more NHS providers struggling to finance the complex work.
As todays Youf say ‘ nuf said’.
Interesting to see Gary’s comments. My understanding is that the preventative medicine budget has indeed gone to the local authority, but not that it’s ring-fenced in any well-defined way. If that’s mistaken, I’ll rethink my criticism on that point. The concerns about this are not originally from me, by the way – they are from people involved in CCGs, so I’ll be surprised if they are entirely misplaced.
Historically, i’m told that preventative medicine was a local authority function until 1974. I do think it belongs more naturally with the CCG, and Gary’s point about a CCG potentially having other priorities leading to perverse results needs to be tackled directly with constraints on CCGs – preventative medicine isn’t the only aspect of that. as Gary says, the issue does interact with social care too, and a wider point there is that the split of health and social care from the old DHSS is something i’ve never understood or supported. Since we don’t another monster reorganisation, ‘ll refrain from suggesting bringing them formally back together, but encouragement to close cooperation is vital. Andy Burnham made an offer to support a brake on NHS spending if the money saved went to reinforcing social care (the Tories routinely quote this as “Burnham wants to cut the NHS”), and whether that’s right or not there is no doubt that the two need to be looked at together.
With Nick’s proposals I’m still worried about sufficient controls on CCGs to ensure preventative health plans are delivered in a way that is most effective and cost-efficient and does not result in CCGs lining their pockets from routine and even moderately complex acute care. Chris’s plea for less ‘Doctor centric’ CCGs is a good one.
However I agree it will be essential to look at health and social care funding and delivery together to get the right balance to deliver long, independent and active lives at least cost to the public purse.
PS sorry to bleat on about ‘ageing population’ but it is a massive problem for government and us all – to reassure you I’m not just looking after myself, I intend to be here for a long time as an exemplar. Keep cycling!
Probably the most pressing priority is how to deal with those CCGs that are already demonstrating signs of being out of their depth. Are the SHAs which are now little more than defunct and staff departure lounges really going to manage the CCGs.
(I know absolutely nothing about this and will have to be corrected by people that do but…)
The Commissioning Groups will be managed by a brand new massive quango: the Commissioning Board (“the greatest quango in the sky”).
Unfortunately, the Board is currently struggling to recruit experienced staff – a risk which should have been highlighted in the suppressed Risk Register.
Sourpuss is using the form of political defence. Attack Attack Attack.