Britain - NHS under the ConDem sledge hammer

Oct/Dec 2012

The NHS in England is changing fast - much faster than anyone could have expected. The ConDem cuts and reforms look to be the last straw. Where will it all end? In fact the answer to this question depends, not on the government's plans, but on the ability of the working class and public at large, to prevent the situation from deteriorating further. Because we should make no mistake: if the present "reforms" are left to take their course, the NHS will be replaced by a system of health provision which will incorporate profit-making for the private sector as the norm, rather than the exception. And with that, will come the growing exclusion of the poorer layers of society - if not the majority of the working class - from decent healthcare.

This is why it is vital that the cuts and so-called "reforms" are not just stopped, but that there is a fight to reverse those made over the past decades, under whatever guise - be it privatisation, the so-called internal market, or the "grand theft" involved in Private Finance Initiative (PFI) deals which have placed what should be publicly-owned NHS assets into the hands of the private sector, and indebted the state to the finance sharks, for decades to come.

It is vital, because the NHS already falls far short of delivering on its much-quoted "founding principles" - and has fallen short of these for a long, long time.

The easy, free and universal access to a public health service, (rather than health "market") offering care at every level, appropriately and on time, is no longer an option for a growing section of the population, particularly in the poorer urban boroughs and semi-rural areas. To satisfy even that simple aim - which the NHS was supposed to encapsulate, would today require the unravelling of three decades of so-called "reform", not to mention vast new resources to be poured in, to repair the damage which has been done. But today, we are not only looking back at three decades of destruction, but we are looking ahead to qualitative changes which would end the National Health Service as a free, effective health-promoting public institution.

The present major onslaught against the NHS is the combined result, on the one hand, of the £20 billions-worth of direct budgetary cuts imposed in 2011 throughout the health service, to be implemented over 4 years. And on the other hand, it is the evolving consequence of the restructuring set out in the ConDem's "Health and Social Care Act" 2012.

This Act, pertaining to England only (not Scotland and Wales), was finally passed on 27 April this year, after 14 months of pause and delay - during which 1,000 amendments were added - on top of what was already one of the longest pieces of legislation in English history. It now comprises 473 pages (in its online pdf version!). But despite, or maybe because of, the rocky and delayed passage of this legislation, the Department of Health had already started to implement some of its proposed changes - even though it did not yet have the sanction of parliament (let alone the mandatory "Royal Assent"!).

GP commissioners - unsafe hands

One of the main changes which this Act intends to make, involves the abolition of those bodies known as Primary Care Trusts (PCTs) which are responsible for ensuring that each population (defined by geographical area) gets the health care it needs. This function, along with the bulk of the NHS budget - £60-£80bn - will be passed on to groups of general practitioners, initially called "consortia" but now referred to as Clinical Commissioning Groups (CCGs), reflecting their new role in "buying-in" or "commissioning" the diagnostic and therapeutic services which the patients (consumers!) on their books require. The 152 PCTs in England were grouped into 50 "PCT clusters" last year, to form, in turn, 41 Commissioning Support Services which are meant to help general practitioner groups get ready for taking over the PCTs' role.

An obvious problem, just for starters is that, since GP practices are no longer restricted to any specific geographical area, with practice boundaries being removed, the new NHS configurations mean the possible development of "black spots" where there is no cover by general practice and inevitably, therefore, no cover by essential NHS provision. In fact it would be a reversion to the bad old days before the local health authorities attempted to ensure equal access for all.

The date for PCT abolition and the Clinical Commissioning Group takeover is meant to be April 2013, probably coinciding with next year's April Fool's Day, which would be fitting. Especially since one of the most glaring problems presented by the reform, is the fact that most GPs do not want to become health commissioners - and certainly do not have the competence, nor indeed the time, to take on such responsibilities. This means that yet another layer of health managers will be created - probably in the form of private consultancies - in order to do the job for the GPs, at a price. And the irony is that their personnel are most likely to be the self-same managers who were employed by PCTs, if not the also-to-be-abolished 10 Strategic Health Authorities whose job it was to oversee them. All in all, these bodies employ 21,000 management and administrative staff, 18,000 of whom have already been made redundant, with the concomitant loss of expertise. The CEOs of PCTs are finally to be relieved of their duties in October, six months early. The role of overseeing the 200 or so new CCGs will fall to the "NHS Commissioning Board" - which will formally take over next April, but which was established for this purpose on 1 October this year. "Sir" David Nicholson who is at present the NHS chief executive officer at the Department of Health, will transfer over to lead this NHS CB.

As intimated above, in some parts of the country, PCT functions have already been passed over to GPs. This is probably because some general practices had already been buying-in their own patient care for years - a left-over from the days when the Conservative government introduced "consortia" of GPs under the "Fundholding", initiative. This was halted by the Labour government in 1997, and eventually replaced by a voluntary scheme for "Practice Based Commissioning" in 2004. Although this did not entail the transfer of actual budgets to GPs, they were allowed to "save" expenditure through efficiencies and then plough these back into patient services.

Anyway, this means that some GPs continued to "commission" their own services and have been quick to form CCGs under the new legislation and just as quick to undertake the role of efficiency-hunting, under the auspices of their PCT joint boards.

This is, in effect, the case in North West London NHS, comprising the eight health districts of Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, and Westminster. And it gives a good idea of the shape of things to come.

Here, clinical commissioning groups (CCGs), made up of GPs representing the NW London PCTs, have come up with a document entitled 'Shaping a healthier future'. In it, they propose their "reforms" to the local health service, including the Hospital Trust serving the area, since this will soon be under their "command", given that they will hold the purse strings for all "buying in" or "commissioning" of care, from next April 2013.

And judging from their proposals, it seems that the duly diminished healthcare in NW London will mostly involve being "out" of hospital. This maybe gives a clue as to why it is that the government has given GPs such powers over the health service and indeed the ultimate control of the lion's share of its budget. The fact that GPs are outside of the NHS - being independent contractors - and de facto private businessmen and women, no doubt makes them ideal candidates to preside over the next stage of NHS cuts and privatisation...

"Shaping a healthier future" proposes the closure of 4 out of 9 existing casualty departments - at Ealing, Hammersmith, Charing Cross and Central Middlesex Hospitals. The 14 week consultation with the public which ended mid-October, has, however, had unforeseen consequences: thousands of protesters marching against the plan and thousands more continuing with the campaign to keep all NW London services open!

So what do the GP leaders of the new Clinical Commissioning Groups actually say about all of this? To quote their "Shaping a healthier future" introduction: "We need a system where we can deliver the right kind of healthcare, in the right setting. In many cases, the best setting isn't in hospitals.(...) . When people do need hospital care, we have shown that making some services more central will mean that patients always have access to the best possible care". Of course, the correct setting for healthcare on the cheap is out of hospital - and certainly not in an A&E unit, or any other specialist 24-hour unit! But have they no comprehension of the fact that closing such units can have lethal effects?

Harrow PCT has offered local GP surgeries up to £4 extra per registered patient if they "optimise the use of outpatient appointments" to reduce their hospital referral rates. It wants GP practices to appoint an extra GP whose task it will be to review all their hospital referrals and cut these down by 10%! The PCT is meant to save £14.2m in the current financial year to meet the "quality, innovation, productivity and prevention" ("quipp") cost-cutting drive! It sounds like something out of an Orwellian futuristic satire - having been invented by Labour, of course!

No less surreal is the "Better Services, Better Value" (BSBV) review conducted by the cluster of PCTs/Clinical Commissioners now known as "NHS South West London" - which proposes to save £64.6million by the end of the financial year.

The GPs who designed these particular cuts, decided on where to make them across Kingston, Croydon, St George's and St Helier hospitals. Last month they decided that the axe should fall on St Helier A&E, because that would save the most money! So they now expect patients to go the extra mile - or ten - to Croydon University Hospital in the case of an emergency. And never mind if they do not make it in time.

It was probably due to his vocal opposition to this, that the Tory constituency MP Paul Burstow was removed from the health ministry in Prime Minister Cameron's last cabinet reshuffle. Another two outer London hospitals, St Georges in Ilford and Chase Farm in Enfield, now also face closures of their A&E departments bringing the total A&E closures in both inner and outer London to 7.

Closing the NHS gates

Up to now, of course, it was the PCTs which held the contracts of NHS general practitioners (GPs), thus acting as their employer. And while GPs have always been the "gate keepers" of the NHS - since every patient has to see a GP before gaining access to a specialist doctor, or even a simple diagnostic test, the PCTs have been acting as keepers of a second gate. It is they who have held the purse strings for buying services, whether it be drug regimens, or the "commissioning" of the healthcare ordered for patients by GPs, from NHS hospitals, NHS community services - or, indeed, from the private sector.

While arranging the services which patients need, conversely, they can also deny access to treatment, by preventing patients from receiving cancer drugs, for instance, on the grounds of cost. This seemingly arbitrary "postcode lottery", has affected some PCTs more than others. But it especially affects PCTs covering poorer populations, whose health is also therefore much poorer and who thus require greater expenditure. Indeed, "equalising" the allocation of central funds between PCT health populations - which was always attempted and never properly achieved - is a daunting bureaucratic task in a class society which, moreover, is not static. The changeover to commissioning by GP groups will make this unequal allocation even less equal.

Nevertheless, despite the dire implications of depriving patients of specialist and emergency hospital facilities, the same, or a similar scenario, is being enacted in many other (and some of the already deprived) parts of the country. For instance, the merger of maternity services in East Sussex, which would mean the closure of the unit at Eastbourne District General, causing women in labour to travel 40 miles on a single-lane road to Hastings. NHS Kirklees in Mid-Yorkshire decided it would have to save £75 million on the two hospitals in Dewsbury and Huddersfield and so Dewsbury hospital is currently under threat of closure. Trusts are deciding to rob one hospital to keep another open and vice versa.

But the protests against hospital closures, although locally quite significant, are not co-ordinated and are usually reported only in local newspapers and not in national ones. And as was pointed out recently by protesters in Eastbourne, after a large public demonstration against the closure of the District General Hospital's maternity unit - the trade unions representing the interests of the health service workers were conspicuous by their absence. As if NHS workers didn't have a vital interest in stopping these closures! Indeed, while health service jobs are disappearing, workers' terms and conditions are being radically altered, patients' treatments are being rationed and waiting lists are growing again. The RCN estimates that since 2010, over 61,000 nursing posts have disappeared. Several Hospital Trusts serving whole urban regions - like that of South London - are in serious financial straits.

Hospitals in the red

The picture across England of NHS secondary care is unhealthy, to say the least. Of course "commercial secrecy" now helps to mask the financial records of the 144 hospital groupings which have full Foundation Trust status - a status which gives them financial autonomy, with the ability to raise their own funding via private loans, for instance, and to use as they see fit, whatever surplus they might make out of efficiency savings. But even some of the Foundations are struggling. As for the remaining 102 "NHS Trusts" (in the pipeline, we are told, for Foundation status), many of these are unable to make ends meet.

The Audit Commission reports that the number of trusts running a deficit has more than doubled in a year. It rose from 13 in 2010/11 to 31 in 2011/12. Thirty-nine NHS trusts reported a poorer financial position in 2011/12 than in the previous year and 18 NHS trusts and foundation trusts received special financial support from the Department of Health. In fact the greatest number of hospital trusts in financial difficulty were in outer London - the area where there are most of the A&E so-called "reconfigurations" - i.e., where closures are meant to take place.

In the first quarter of this year, five NHS trusts forecast a gross operating deficit of £160m. These were South London Healthcare NHS Trust (with a £54m operating deficit), Barking, Havering and Redbridge Hospitals NHS Trust (£40m down), Mid Yorkshire Hospitals NHS Trust (£26m down), Epsom and St Helier University Hospitals NHS Trust (£19m down) and North West London Hospitals NHS Trust (£21m down). All these have been mentioned above because their plans for cuts. And all of these trusts are in dire straits for one reason and one reason only: they cannot meet the rising costs of their PFI repayments. At the beginning of the year, the government was forced to come up with an extra £1.5bn to help 7 Trusts pay their PFI bills. Of course, PFI interest repayments have become more and more costly, since they are linked to those same risky, sophisticated financial "products" which have caused such havoc in the economy at large and which certainly should have had no place in financial deals involving the health of the population, let alone anywhere else!

Last month it became possible for hospitals to raise up to 49% of their income from private patients. It is not hard to imagine that this could turn into a mandatory way for hospitals to finance their free and universal care obligations - thereby sabotaging these same provisions because they are increasingly squeezed out by commercial incentives.

The Department of Health answers every warning of imminent cuts in essential services and rationing of treatment with the boast that the NHS made £5.8bn in savings in 2011-12 "proving it can meet the financial challenge" which the ConDem government has set for it. But how does that prove anything at all, when hospitals are in deficit and "failing" and when already patients are not just put on interminable waiting lists, but actually refused referrals point blank?

The unqualified provider

Up to now, the private sector was usually only contracted by PCTs to provide services which the NHS was unable to provide (thanks to cuts!), or if it was much cheaper, on the basis of competitive tender. But in the latter years of Labour, the private sector had space to grow and particularly so, when "Independent Sector Treatment Centres" were launched in around 2003 - that is, private surgical centres for anything from cataracts to hip replacements, paid for by the NHS. This lucrative, "competitive market" was however somewhat curtailed between 2006 and 2010 by public pressure, often as a result of the high incidence of complications in ISTCs and the growing opposition of NHS professionals (especially GPs) - due, on the whole to the poor performance and low standards of care and after-care, which prevailed. So much so, that the private sector began to complain of discrimination and unfair treatment, clamouring for a level playing field to be re-established and for a free health market - meaning freedom for the profiteers!

The ConDem "Health and Social Care Act" conveniently takes care of public opposition to private healthcare. It has inserted an "any qualified provider" clause into the commissioning guidelines - which puts the onus on commissioners to open tenders to all bidders, whether from the public, private or so-called non-profit social enterprise sectors. This allows the private sector the chance to undercut the NHS and therefore really does open it up to private sector takeovers, like never before. And the Act specifically encourages private sector cherry-picking! Indeed, the newly formed temporary PCT clusters are meant to identify at least three of their community services to put out to competitive tender before the end of the year.

Catalyst, a group of financial advisers specialising in healthcare, has written a report for profiteers in the health market. It has identified a £20bn "opportunity" in primary and secondary (hospital) care, citing the recent contracts won by Circle, Virgin Care and Serco.

Virgin Care, which is part of Richard Branson's empire, has already acquired a £650m contract to run 7 hospitals, dentistry services, sexual health clinics, breast cancer screening and other community services in the new Health secretary, Jeremy Hunt's Surrey constituency. In fact Hunt is said to have personally intervened to help the deal go through. Which at least denotes a certain consistency - since he is accused of having tried to facilitate Rupert Murdoch's attempted takeover of BSkyB when he was Culture Secretary! Branson's Virgin Care is also bidding to provide children's' health and social care in Devon.

The private healthcare company, Circle, is the first to be handed the running of a "failing" NHS hospital. Hinchingbrooke Health Care Trust in Cambridgeshire, which was threatened with closure due to its huge spending deficit, has thus been "saved". The 10 year franchise deal for Circle means that it will be allowed to keep the first £2m out of any year's surplus, 25% of any surplus between £2m and £6m and 33% of any surplus between £6m and £10m. The Trust has an annual income of £100m, but in order to clear its debts, it will need a surplus of at least £70m. And although 44% of that would theoretically go to Circle, there is little chance that there will be a surplus any time soon. In the past 10 years the Trust never made a surplus of more than £600,000. To achieve a first £2m within the terms of this 10 year franchise, Circle would have no choice but to make radical cuts. In other words, one way or another the future looks grim for this hospital.

As for Serco, which is better known these days for running prisons and providing security guards, it has, among other NHS contracts, the responsibility for providing out-of-hours GP services in Cornwall. It was placed under investigation in June by the Care Quality Commission because of serious allegations of patient neglect due to understaffing. Serco made a profit of £4.6bn in 2011 and is said to be bidding for many more NHS contracts despite its poor - if not life-threatening - performance in Cornwall.

By this September, PCTs had already completed the first wave of contracts for the provision of community health services under the ConDem's "any qualified provider" stipulation. 398 contracts were signed with 37 private sector companies. And while Labour's shadow Health Secretary, Andy Burnham called it "the biggest act of privatisation ever seen in the NHS" he also made it clear that he was against the "market in the NHS, but not private companies"...! Of course, Burnham must remember the many privatisations "by stealth" that his own party introduced.

The above-mentioned contracts cover 8 NHS areas in England, and are worth £262m. Private providers will now be responsible for the provision of musculo-skeletal services, adult hearing loss services, wheelchairs for disabled children, and psychotherapy services for adults. What is more, ambulance services in the North-West will now be run by the private bus and rail transport company, Arriva, for a profit!

When the PCTs are gone, it will be the responsibility of the Clinical Commissioning Groups, comprising sets of GP practices, overseen by the government's supervisory body, the NHS Commissioning Board to ensure that these services remain available...and free... at the point of need, once they have commissioned them from "any qualified provider". But there is no guarantee that charges will not be introduced - "to get that little bit extra" at some point in the near future. Or even to get any of the service at all.

Commissioning bids from "any qualified provider" kills two birds with one stone: first, it allows the private sector a legitimate role in the NHS, and second, because this process has involved cuts and further rationing - including through the vetting and possible vetoing of GP patient referrals - it places the private providers in a position to offer the missing and rationed services at a price, if patients are not allowed to get them on the NHS. So the private sector can come in and take its prize, and make even more to boot, while the NHS cuts even more of the services it currently provides - leaving these cherries too, for the private sector to pick.

Hitting the staff

As mentioned before, the Royal College of Nursing estimates that 61,113 posts in the NHS across the whole of Britain have been either lost already, or are under threat, since April 2010. One way in which hospitals have got around the consequent staff shortages is to increase the length of shifts to 12 hours - or more, with overtime! This has become "normal" even if it puts seriously into question the ability of nurses to remain attentive over such a long period.

Already 20% of nurse training places have been cut over the last 2 years. In this context it is not too surprising that three Birmingham hospitals were exposed earlier this year for their plan to bring unemployed workers onto the wards as unpaid "helpers", to feed patients, serve drinks, run errands, etc!

On top of the cuts in staffing, which are the result of the annual 4%-5% cuts which each part of the NHS must find each year until 2015, the government's new immigration policies, if implemented, mean that potentially half of the nurses from abroad now working in the NHS would be forced to leave the country! This is because the pay threshold imposed for migrant workers from outside the UK is £35,000 and above. The UK Border Agency estimates that 48% of migrant nurses, 37% of school teachers, 35% of IT/software professionals and 9% of secondary school teachers would be thus excluded.

Of course, not only are NHS staff losing their jobs and being forced to cover for those who have been sacked, by working long hours and then working overtime, but they are being paid less to do it - after the public sector pay freeze was extended for yet another year. Their pensions have been cut, into the bargain and retirement age is set to increase to 67 years! And now "regional" pay agreements are on the agenda, to further reduce wages.

This is why there is every reason for NHS workers to go onto the offensive to defend their terms and conditions. After all, the service the NHS delivers is offered by the people who work in it, and by defending themselves, they defend the service. There has never been a significant strike movement across the NHS in all of its history - only sectional strikes and never across the whole organisation. Today again there are signs of a fight here and there - the latest being the strike vote in Mid Yorkshire Hospitals NHS Trust against job cuts - where 88% of administrative and clerical staff, including medical secretaries and receptionists, voted in favour of strike action and 96% voted in favour of action short of a strike.

Of course, given that Unison, the largest public sector union is under such tame leadership, it is possible there will not even be a strike and certainly no attempt to spread the fight.

But in considering action, let us be realistic: the NHS, unlike so many other public services still remains more or less intact. Of course it will not remain so for long, if the ConDems today, or their Labour successors in government tomorrow, get their way. Nor will it remain so, unless the workforce and the public at large stand up to defend it. That is what must be done. Preparations need to be made right away.