It’s now twenty years since the Eye broke the story of the Bristol heart scandal (Eye May 8, 1992). It took seven years to get a public inquiry which, in 2001, declared that 30-35 more children under one year died from open heart surgery in Bristol between 1984 and 1995 than at other comparable units. A similar number were left severely brain damaged. The overriding conclusion was that to make the service safe, complex child heart surgery has to be concentrated into fewer, larger units with the appropriate staffing, expertise, resources, audit and training – and the crucial ability to expand. Twenty years later, we’re still waiting.

We have, however, had a further scandal in a small unit (Oxford), an estimation of another 78 ‘excess deaths’ spread over four units in eight years, two expert reviews calling for a reduction in the number of centres and the clinical director of the NHS – Sir Bruce Keogh (himself a cardiac surgeon) –declaring that ‘failure to reconfigure child heart surgery will be a stain on the soul of the specialty and will compromise the treatment of the most vulnerable members of the next generation.’ (Eye 20.1.10)

So why the delay? Politicians rarely show strategic leadership in the NHS, particularly when it necessitates the closure or down-grading of a specialist unit in their constituency. There are currently around 30 consultant heart surgeons who operate on children spread across 11 surgical centres in England. The latest review, Safe and Sustainable, is overseen by a Department of Health-mandated organisation called the Joint Committee of Primary Care Trusts (JCPCT). It managed to get all 11 centres to sign up to a process that was highly likely to recommend a reduction in the number of centres. After the most exhaustive and transparent consultation in NHS history, options were proposed for future centres which the Royal Brompton and Harefield trust didn’t like. Last year, it derailed the review by getting the process of choosing centres quashed, with the judge ruling the assessment had not taken proper account of the London hospital’s research strengths.

For good measure, the Brompton also threw in allegations of bias and impropriety against specialist advisers to the JCPCT who are connected with Great Ormond Street Hospital, the Evelina Children’s Hospital and Southampton General Hospital. The JCPCT appealed against the judicial review finding, and on April 19^th three Court of Appeal judges ruled that the Safe and Sustainable process for the public consultation was fair, lawful and proper, and dismissed as unfounded all of the allegations raised by the Royal Brompton Hospital. In the meantime, the Brompton has blown at least £1.5 million on legal fees that should have gone on patient care, and the process of making child heart surgery safe has been delayed for another year.

Stephen Bolsin, the cardiac anaesthetist who sacrificed his NHS career by blowing the whistle in Bristol, would doubtless be horrified that the culture of infighting, commercial interest and misguided institutional loyalty that blighted Bristol twenty years ago is still prevalent in the NHS now, and that babies undergoing complex heart surgery are still suffering ad a result. Professor Bolsin is flying in from Australia speak to the Patient Safety Congress on May 29^th in Birmingham. As Professor Bolsin puts it: ‘Improved ethical behaviour in health and social care is mandated by professional and managerial failings such as Bristol, Mid Staffs, North Staffs and ‘Baby P’. The benefit is a significant quantifiable cost saving amounting to billions of pounds each year.’ As the Royal Brompton has proved, litigation is a very expensive and harmful substitute for proper consultation.

MD

‘Richard Branson’s company becomes one of the first of many vultures to start picking over the rich, tender flesh of the NHS now that it has been splayed open by the (Health) Bill.’ So wrote pseudonymous Telegraph doctor Max Pemberton on the news that Virgin Care has won a £500?million contract to provide community services across Surrey and began running these services, as well as the county’s prison healthcare, on April 1.

When Telegraph columnists slate private healthcare provision, the government knows it has a problem but the groundwork for all this was done by Labour. In January 2009, it published Transforming community services: enabling new patterns of provision. ‘This guidance is intended to help PCT providers of community services to move their relationship with their commissioners to a purely contractual one and consider what type(s) of organisations would best meet the future needs of patients and local communities.’

The Health Bill cements and accelerates Labour’s vision of a competitive market for healthcare but may come a cropper if the public aren’t sufficiently involved in the decision making. Section 242 of the NHS Act 2006 makes clear that formal consultation is required in ‘instances in which the manner in which services are delivered, or the range of the services, will change.’ So the game is now on to hand services to the private sector while claiming they won’t change in order to avoid formal consultation with angry protestors who vehemently disagree with the giving large sums of public money and power to private companies and their share holders.

In September 2011, patient Michael Lloyd, 75, challenged the transfer of community services from NHS Gloucestershire Primary Care Trust to a private community interest company. His argument was that the PCT did not consult adequately on the proposals or give proper consideration to alternatives that would have seen the services remain within the NHS. The challenge went all the way to judicial review, with the PCT caving in on day 2 and agreeing to advertise for ‘expressions of interest for the provision of local services’ which may keep the service within the NHS. Or it may not.

Alas the judge did not clarify how EU procurement law will affect these NHS ‘outsourcing decisions’, but companies based in the EU and eyeing up the NHS market may have a legal right to be included in the tendering process, which would make it even harder, expensive and legally tortuous for the NHS to cling onto the provision of NHS services. As David Lock QC wrote in the Health Service Journal: ‘The duties of transparency, equal treatment and non-discrimination imposed by the EU treaty and the Public Contracts Regulations 2006 mean that all contracts placed with a body outside an NHS trust should be subject to a “degree of advertising” to allow healthcare providers located in another EU country the chance to bid for the contract.’

Despite this, a private hospital in Kent is already claiming it will offer the NHS and private patients ‘the only cardiothoracic and neurosurgery tertiary care beds in the county.’ The Clydesdale Bank last week agreed a £34m loan deal to help build and run the Kent Institute of Medicine and Surgery, which is due to open in the second quarter of 2014. Another £80 million will be provided by corporate and private investors, including around 100 clinicians.

Private provision in healthcare thrives when the NHS gives up trying (e.g. long term care of the elderly, psychiatry) and with so many hospitals and PCTs in huge debt, and the Department of Health facing a ‘significant’ accounts auditing problem, the choice for many NHS community and hospital services may soon be between private provision or nothing. And Labour started it all.

The Nicholson Health Service

On March 26, at 18:00, MD posted a draft copy of the Health Bill Risk Register on this site that had been anonymously leaked. The Government’s persistent refusal to publish it prompted angry debates in both chambers and widespread press attention. Yet a week after posting it, MD has received not a single press enquiry. A few papers picked it up, but the mood was one of intense apathy. The story was not the risk register, but the refusal to publish it, and now the Bill has passed, what’s the point of exposing the risks?

The draft register – which dates back to 15 October 2010 – is helpfully colour coded into red, amber and green, and the risks are largely red. In essence, the NHS top brass – lead by former communist party chief executive David Nicholson – are petrified that such a massive, unforeseen change in structure and the unpredictable consequences will see them lose control over money, strategy and power. The delay in the passage of the Bill has simply allowed Nicholson time to claw back his power to the point that the NHS is now more centrist than it was under Labour, rendering Lansley’s Bill the most pointless and expensive reorganization in NHS history.

MD was also leaked the Business Case for the reforms and journalist Roy Lilley has posted a document entitled Developing Great Clinical Commissioning Groups (CCGs)1. Both are Trojan horses for reclaiming power from commissioning GPs. As Lilley points out: ‘The N in NHS now stands for Nicholson.’ Commissioning Support Services that didn’t even appear in the Health Bill are now sprouting up everywhere, their leaders will all be appointed by Nicholson’s Board. They’ll tell GP commissioners what they can and can’t do and what they can buy, and for how much.

Commissioning GPs clearly need to be accountable for the £60 billion they spend but many will give up when faced with the 118 ‘authorisation requirements’, site visits and box ticking exercises they have to pass before they can be approved to take over from primary care trusts in April next year. The structure of the new NHS is now so complex, confusing and bureaucratic that Nicholson must be in raptures (see diagram). Lansley promised to ‘liberate’ the NHS. Instead, it has been shackled to the centre for good. Nicholson 10, Lansley 1

http://library.constantcontact.com/download/get/file/1102665899193-914/Developing+Great+CCGs+ver1.pdf

Chew Valley Asbestos Dump – Greed is My Valley

Residents of the picturesque Chew Valley have until April 19th to raise objections to 645,000 tonnes of asbestos and other hazardous waste being dumped on top of a windy escarpment over watercourses that feed into the region’s drinking water reservoir. The health risks of noise and air pollution from fifty lorries a day for ten years, plus the traffic congestion, accident and spillage risks in narrow country lanes are obvious. Bath and North East Somerset (BANES) only reclaims a thousand tonnes of asbestos a year, so allowing 64,500 tonnes a year – half of which would be asbestos –  would necessitate importing asbestos from all over the UK.

The long term risks are hard to quantify. The asbestos would be dumped in a shallow, quarry, raised up into a mound and covered in topsoil. At much smaller dumps in Somerset and Derbyshire, shoddy disposal has allowed asbestos fibres to escape into the air. As mesothelioma, the lung cancer caused by asbestos, takes up to 40 years to develop the consequences cannot be known. Bristol Water strongly opposed an initial successful application, because of the risk of soluble hazardous waste reaching the reservoir, but the planning application was overturned due to a failure by BANES council to advertise it properly.

The reapplication was sprung on residents on March 28, with just 21 calendar days to mount objections and with no legal or expert support from BANES. The applicant, Larry Edmunds, has no evident expertise in the disposal of hazardous waste and has once again failed to consult with local residents prior to application. He is, however, under intense pressure from Barclays Bank, who have lent him £1.6 million and are doubtless petrified they won’t get their money back. If successful, Edmunds and his partners Mark Foley and Arthur Bristow could make up to £20 million by selling the contract on. Barclays Bank’s ‘Sustainability Team’ has thus far failed to reply to a December 6 letter asking why the bank has loaned money to a venture that could be so hazardous to the health of Chew Valley residents (including myself) www.stopstoweyquarry.co.uk

Please sign the petition

http://www.gopetition.com/petitions/stop-stowey-quarry-2012.html

In July 2006, Debbie Westwick, a 43 year old nurse, was diagnosed with cancer of her left breast. She was treated at the Kent & Canterbury Hospital, where she worked, by oncologist  Howard Smedley and surgeon David Jackson. Unbeknown to her, Dr Smedley was subject to ‘supervision undertakings’  imposed by the GMC for reasons that they refuse to reveal. Mr Jackson was suspended in the middle of her treatment, subsequently sacked and referred to the GMC.

Westwick had surgery, (a lumpectomy, with lymph node sampling), in July 2006. The histology revealed 4 out of 7 nodes sampled were cancerous and that there was tumour left behind in two of the margins of the breast wound. She needed an urgent mastectomy and node removal but instead was given chemotherapy and radiotherapy. Debbie realised she needed more urgent surgery but her surgeon was now suspended and mastectomy and reconstructive surgery were delayed until September 2007. There were four fundamental failings in her treatment, all of which breached national guidelines: performing a lumpectomy rather than a mastectomy for a multi focal tumour; not removing the breast when the initial surgery failed to fully remove the cancer; not clearing the axilla of lymph nodes; giving radiotherapy when a mastectomy was indicated.  The GMC was supervising Dr Smedley so why wasn’t this picked up?

Debbie took legal action in 2009 and the trust settled for £155,000 without responding to the allegations. Westwick knew her time could be limited – she now has metastatic disease and is terminally ill – and was far more interested in understanding how her care could have failed so badly despite clear national guidelines in treating and auditing breast cancer care. Had other patients received substandard care? And why hadn’t the NHS and regulators acted promptly to protect patients from avoidable harm – particularly given that Smedley and Jackson were on the GMC radar?

Prompt is not a word to feature much in the NHS complaints’ procedures or the GMC and CQC lexicons. Stage one complaints were lodged in May 2009, but a review of whether East Kent trust  breached regulations in cancer care and held adequate multi-disciplinary team meetings to pick up and act on serious failures has yet to be published.  Westwick complained to the GMC about Dr Smedley on 7^th August 2009. After expert review, case papers were served in July 2010. In November,  the investigation was halted for reasons which could not be revealed. Nor could any indication be given of when the investigation might recommence. In June 2011 Dr Smedley was referred for a public hearing by a Fitness to Practice Panel. In August 2011, the hearing was listed to start on 5^th March 2012. No details could be given of the charges until 28 days before the hearing.

In September 2011 the GMC approached Debbie to interview her as a witness. Unfortunately this coincided with her cancer returning. By the time she was fit to proceed, as of November 2011, Dr Smedley had applied for voluntary erasure. This was refused in January and a hearing was set for March 2012. The GMC then applied for a postponement as there was not enough time to investigate and serve the charges. Debbie complained about not being consulted and was told the GMC had no duty to do so as she is not a party to the proceedings. The GMC has now listed the hearing for 7 June – over 3 years since the original complaint. There is no guarantee that it will go ahead or that Debbie Westwick will still be alive if it does. But at least the care she now receives at Kent and Canterbury hospital is competent and compassionate.

Meanwhile, Mr Jackson’s GMC proceedings, (unrelated to Debbie’s case), have still not been heard. He faces 75 charges relating to his treatment of 16 patients between 1989 and 2007. In response to the Eye, the GMC said ‘Our procedures are designed to protect patients by making sure we stop unsafe doctors from practising.’ But suspending and striking off doctors, often years after patient harm has occurred and in such a secretive manner, is of no help in understanding how poor care can be allowed to carry on for so long unchecked, and it’s no help to harmed patients. If the Mid Staffs Inquiry does nothing else, it must ensure the NHS complaints system and regulators serve patients rather than destroy them.

Health secretary Andrew Lansley gave a surprisingly chipper performance at the Nuffield Trust Summit on February 29. The audience of health policy experts was divided as to whether he was demob happy or just convinced that his Health Bill will be voted through by May 9th, despite the final twitchings of the Lib Dem corpse. Lansley had the confidence of a man who’s brought his own power point slides, a luxury rarely afforded to him on Newsnight, and he proceeded to drown the opposition in detail. He is truly the health secretary who knows the most and listens the least.

Very few policy experts felt the legislation was necessary and many felt it would be counterproductive, imposing yet more bureaucracy from the centre. This view was echoed by the board of NHS Tower Hamlets Clinical Commissioning Group, who have written to the Prime Minister and asked him to withdraw the Health and Social Care Bill. The government has already ignored the objections of 27 professional bodies, but this CCG is lead by Dr Sam Everington, an innovative GP who was Lansley’s special guest at the Conservative Spring conference in 2010 and who’s practice in Bromley by Bow was Lansley’s venue of choice for his first major speech as Health Secretary on 8 June 2010.

Everington, a former adviser to Robin Cook, is bang on the money: ‘Your rolling restructuring of the NHS compromises our ability to focus on what really counts – improving quality of services for patients, and ensuring value for money during a period of financial restraint. We care deeply about the patients that we see every day and we believe the improvements we all want to see in the NHS can be achieved without the bureaucracy generated by the Bill. Your government has interpreted our commitment to our patients as support for the bill. It is not.’

Lansley’s stock response – to patients, policy experts or staff having to enact his reforms – is that they misunderstand them and that everything will be marvellous. So while other European countries are commissioning on a large scale to drive strategy and keep costs down, and letting clinical staff concentrate on treating patients, Lansley is passing the buck for buying NHS services to small CCGs, largely lead by workaholic GPs who have little or no commissioning experience. But hey, it’s only £60 billion of public money.

After the Bill, the NHS will still be facing a huge budget crunch with hospitals desperately short of cash but trying to fiddle the figures and hide the scandals because they’re obliged to become Foundation Trusts. There will still be artificial divisions between community, hospital and social care, and huge variations in the quality of care in all three. There will still be an epidemic of obesity, alcoholism, mental illness and chronic diseases. And the Francis report into the Mid Staffordshire scandal (due in May or June) will make hundreds of recommendations for NHS reform and how we care for the elderly that may directly contradict the Health Bill.

As one GP put it: ‘Faced with all these pressures, our CCG is fast turning into Animal Farm. The Napoleons on the board won’t let one GP practice innovate and expand if it’s seen to take business away from other practices. If you do something off your own bat, you’re castigated for ‘not going through the correct channels.’ It’s no different from being under the cosh of the PCT. We have some GPs who are frankly dangerous and out of date, but no one is tackling that issue for fear of upsetting them.’

MD’s guess is that, after the Bill, GPs will pretty soon tire of commissioning and it will move back to the centre. The best hope for the NHS is for hospitals to join forces with community services and provide a joined up service for a large population, with excellent public health. Once services are integrated, they can compete for business if they must, but competition requires extra capacity and there’s precious little of that in the NHS. As Lansley himself said in opening his speech: ‘Coming back to speak to you is a triumph of optimism over experience.’ The same can be said for his Bill.

Why has David Cameron decided to go to war with the NHS? With just about every professional organization and journal opposing the Health and Social Care Bill, public support for it at 18% and Downing Street briefing the Times that the Health Secretary should be ‘taken out and shot’, Cameron has decided to be ‘at one with Andrew Lansley.’ In turning the Health Bill into a confidence vote, with the Lib Dems driving the getaway car, it’s extremely unlikely to fail. But it will hand Ed Milliband so many open goals in the run up to the next election, even he can’t fail to score.

It’s doubtful Cameron has read the Bill in its entirety -  it was unintelligible even before the 300 amendments – but Lansley does a very convincing line in whispered one-liners. The Bill will apparently ‘safeguard the NHS for the future’, ‘put patients first’ and ‘give frontline staff the right to determine how the NHS budget is spent.’ Lansley insists that to achieve this vision, the NHS needs a lot more legislation and a lot more competition, but there is no evidence-base for these reforms so  it’s a huge leap of faith getting staff and patients to trust him. Politicians rarely have jobs outside management consultancy or law, so it’s not surprising that the only professions lining up to make sense of chaotic legislation at £200 an hour are…. management consultants and lawyers. And many MPs have links with private companies that could benefit from the Bill. The potential vested interests in the NHS are about to be notched up by several orders of magnitude.

Support from GPs has fallen as Lansley’s promises haven’t stacked up. The fantasy that GP commissioning groups could be the size of bridge-clubs has been stamped on by the Department of Health. Small groups have been forced to merge into larger ones and forced again to have the same boundaries as the local authority. And the promise of less bureaucracy is laughable. The Bill has replaced three levels of management (DH, Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs)) with up to eight (DH, National Commissioning Board, 4 Clustered SHAs, 50 Commissioning Support Groups, 300+ Clinical Commissioning Groups, Clinical Senates, Healthwatch and Health and Wellbeing Boards.) Nobody has a clear understanding of what these organizations will do or how they’ll work together. They’re unlikely to liberate the NHS but the opportunities for tax avoidance are huge.

Even if frontline staff do get to play at deciding how the money should be spent, there is no evidence that they’ll do it well or have the time and energy to do it in-between patients. Labour’s massive drive for ‘world class commissioning’ was a big belly flop, not because frontline staff were excluded, but because the NHS doesn’t measure and compare outcomes to allow meaningful choices. If you buy a suit, you can feel the width and take it back if it falls apart. It’s harder to do that with a breast implant. So the NHS just buys the cheapest and hopes it doesn’t burst. The PIP scandal is an extreme example of what happens when you compete on cost (PIP implants were a fifth the price of competitors) without paying any attention to quality.

The one bit of Lansley’s reforms that makes sense is the Outcomes Framework. Until we have robust data comparing the harms and benefits of different treatments, clinical teams, hospitals and GP surgeries, commissioning will remain a confusing, wasteful mess. At the moment, there is very little hard evidence that patients benefit from their care in the long term. We cut them open or dose them up with pills but have no idea whether we do more harm than good. MD has argued for published outcomes since exposing the Bristol heart scandal in 1992. Twenty years on, and adult heart surgeons are the only profession putting their results on show to allow commissioners and patients to choose. If the NHS is going to compete, it has to compete on getting patients better, not balancing the books by fobbing breast cancer patients off with cheap silicon meant for mattresses.

Measuring is not the only solution. An open, transparent culture that ensures management act on poor outcomes rather than deny it as in Mid Staffs, is equally vital. At present, the best smoke alarm in the NHS is patients, relatives and staff speaking up when they encounter appalling care, and yet the brutal suppression of whistleblowers (Eyes passim ad nauseum) shows how much NHS culture needs to change. Alas, when a Prime Minister stakes his reputation on reform, the NHS nearly always becomes more brutal and bullying, and buries bad news. Cameron is about to repeat Blair’s mistake.

The first point is obviously bollocks, given that Andrew Lansely has just given an exclusive interview to the Health Service Journal on ‘Why Competition is Crucial for NHS reform.’

Health and Social Care Bill: Top Lines for Lib Dems to Remember when doing Media Interviews:

 No more competition:

Liberal Democrats were clear that the NHS mustn’t be treated in the same way as the gas, electricity or utilities markets. That’s why there’s no longer any mention of promoting competition in this Bill. Instead, the number one priority hardwired above everything else is the interests of patients.

No favours for the private sector:

Labour rigged the market in favour of the private sector by giving them ‘gold plated’ contracts and paying them £250million for operations they didn’t even perform. We’ve made sure there won’t be any more special favours for the private sector by making it illegal for any future government to deliberately favour the private sector.

Secretary of State still accountable:

Liberal Democrat peers have secured changes to the Bill that ensures the buck still stops with the Secretary of State.  These changes mean the Secretary of State will remain politically and legally accountable for a comprehensive national health service. 

No decisions behind closed doors:

GPs and other doctors shouldn’t be allowed to spend public money without being required to tell us how they’re going to use it.  Changes pushed for by Liberal Democrats mean that commissioning groups will now be open, accountable bodies required to meet in public and subject to FOI laws.

Evolution not revolution: The pace of change has been slowed down to ensure changes are not rushed into. There are no more arbitrary deadlines so people only take on extra responsibilities when they are ready and able to.

Substantial change and scrutiny:

This Bill has undergone substantial change and unprecedented level of scrutiny. The Government have put down over 1,000 amendments, dedicated over 200hours to parliamentary scrutiny, and –for the first time in 9 years recommitted the Bill to committee stage.  No one can argue that this Bill hasn’t undergone substantial changes.

You’ve got to admire Health Secretary Andrew Lansley’s lack of insight. Having united every Royal College bar the surgeons against his reforms, his website insists: ‘Andrew frequently visits hospitals and GPs across the country, listening to clinicians and NHS professionals and is well respected across the medical profession for his knowledge fo (sic) the NHS.’ And there’s more: ‘Aside from being appointed as the Secretary of State for health, Andrew’s proudest career achievements thus far include transforming the public’s view of the Conservative Party’s commitment to the NHS.’

This detachment from reality is not entirely Lansley’s fault. He tours the NHS tirelessly on largely pre-announced visits where the bad bits are hidden and the staff are too polite or frightened to blow the whistle. Even the collective chorus of dissent over his Health Bill coming from nurses, midwives and doctors hasn’t thrown him off his stride. This, Lansley claims, is just payback for the government downsizing their pensions.

Only 1% of doctors responding to a BMA survey thought the pension proposals are ‘fair and acceptable’ and two thirds said they would be prepared to take some form of industrial action. But Lansley knows doctors won’t strike and that the public aren’t bothered by the issue. Never mind that doctors renegotiated their pension agreements three years ago to ensure they were ‘affordable and fair’. In a recession, junior doctors aren’t going to win much sympathy by saying their annual pension will be slashed to £68,000.

More of an issue is making doctors work until 68. MD finds general practice tough enough at the age of 50. The thought of another 18 years trying to safely treat someone of 86 with seven diagnoses in under ten minutes is daunting. Or it would be if his job wasn’t disappearing at the end of March. The big threat to doctors is not their pensions, but that the NHS can no longer afford to employ all of them.  Many clinical staff are facing the axe, alongside managers, and it’s impossible to make such cuts without affecting the quality of care. Ask anyone at Mid Staffs hospital, past or present.

Lansley believes his Health Bill will keep up the quality in the face of cuts. He immodestly compares himself to Nye Bevan, fighting for vital reforms in the face of self-interested professional opposition. Those who are against him just don’t understand the Bill. Even Malcolm Grant, the chair of the NHS  Commissioning Board (NHS CB) finds it ‘unintelligible.’ The NHS needs to keep improving and clamp down on poor care but overall, survival rates for cancer and heart disease have risen dramatically. So why the need for such massive reform?

Anyone hoping for answers from the NHS CB – the unelected uber-quango that’ll run the NHS – may be disappointed. Last week, it published details of its ‘design’. 63 pages of wonk including such gems as: ‘The NHS CB will deliver improved outcomes through matrix working, by hard-wiring into the ways of working’  and ‘The NHS CB will have a consistent approach to leading change and transformation running through the matrix working approach. The change model will have two components:  massive improvement approach; and having clear principles for the application of that approach.’ All that disruption for this?

Lansley has at least set up a Whistleblower hotline, curiously run by Mencap, for those who wish to raise awkward questions (Eye 1305.). MD called  08000 724 725 and was told: ‘The number you have called will be charged at a rate of 14p a minute and will appear on any itemised bill. If you do not wish to continue, please end the call now….. Thank you for calling the whistleblowing helpline for health and social care. A Customer Service Adviser with you shortly… MENCAP is now closed.’ The line then went dead.

The NHS has to make 4% savings and, as the Health Select Committee pointed out, the chaos of Health Bill is making this harder. Patients will suffer and whistleblowers won’t be heard. But at least the hotline is bringing in money, even when it’s closed. Genius.

When MD  asked health secretary Andrew  Lansley to reduce his unintelligible 358 page health bill to 140 characters or less, he wrote: ‘Putting patients and their doctors and nurses in charge, accountable for the results they achieve.’  Some staff were initially won over by the promise of liberation from political meddling,  less bureaucracy and more control over how the money is spent. But while most now long to be liberated from Lansley, they’ve now realised there is no freedom  if you’re  shackled to an unelected  economic regulator,  Monitor, and an unelected National Commissioning Board.  Worse still, the complexities of competition law and competitive tendering are likely to make the NHS more bureaucratic, not less.  And it’s the economists who’ll be in charge, stupid.

If Lansley had wanted evolution, rather than revolution, he would simply have slimmed down the existing Primary Care Trusts, put clinical staff on the board alongside the best of the NHS managers and let them figure out how best to spend the  money and focus on the quality and safety of care. By throwing all the cards up in the air, he’s created chaos, uncertainty and the perfect storm for another Mid Staffordshire scandal. The fact that even the more moderate  health unions – the Royal College of Nurses and the Royal College of Midwives – now oppose the Bill outright and are calling for its withdrawal should make the Government reconsider. But it won’t.

Equally alarming is the confusion at the very top. Monitor is the make or break organization of the government’s reforms.  David Bennett – an ex-McKinsey Blair adviser – is both chair and chief executive. Monitor was set up by Labour to be the independent regulator and assessor of NHS Foundation Trusts but under the Bill it becomes the sole economic regulator for the whole of healthcare – including the independent sector – in England. It has to regulate prices, licence providers, integrate care, prevent anti-competitive behaviour and support the continuity of services.

So Monitor has a special and long-standing relationship with NHS Foundation Trusts and yet also has to regulate the entire health sector. It sets the exam for everyone but has a vested and conflicting interest in ensuring Foundation Trusts pass it with flying colours. In an article in the Health Service Journal, Bennett warns that Monitor may face “numerous” allegations of improper conduct unless it can clearly separate its future healthcare regulatory role from its responsibility for Foundation Trusts. The revamped Monitor is hardly up and running in its new role and it looks as if the quango may have to split in two, or at least have two chief executives.

Given the financial climate, Monitor is going to have to make tough decisions and if it is perceived to have favoured Foundation Trusts over, say, the private sector than the NHS will be submerged in a succession of legal challenges. If a quango stuffed full of competition economists hasn’t got a handle on how competition law will affect the NHS, spare a thought for the virgin clinical commissioners. The bureaucratic complexity of having to make local decisions in the interests of patients while obeying national guidelines, regulatory rules and competition law will either make them panic and put everything out to competitive tender. Or they’ll spend a fortune on ‘commissioning support services.’ Or both.

The Scottish and Welsh NHS eschew a competitive market because there is insufficient evidence that it delivers better healthcare. In England, forty one ‘commissioning support organisations’ have already been proposed to help GPs make sense of the Health Bill. The only certainty in this chaos is that lawyers and management consultants will do rather well out of it. As for patients, Lansley’s promise of ‘no decision about me without me’ is beyond satire.

I am writing to you early this week as we are about to announce the results of our latest survey on the Health and Social Care Bill. I’d like to again thank the very many of you who took the time to respond; you have no idea how much this has helped me to determine how the College moves forward, as well as providing me with personal assurance that we are doing to right thing for our patients and our profession. We received more than 2,500 replies, and nearly three quarters of you who responded said that you felt that it is now appropriate to seek the withdrawal of the Health and Social Care Bill.

When asked if the College should call for the Bill to be withdrawn as part of a joint approach with other medical royal colleges, more than 98% of you strongly supported or supported such action. Even without a joint approach, more than 90% of you still said that you either strongly supported or supported the College in proceeding alone in calling for the Bill’s withdrawal. I expected a good return, but I am staggered at the level of response.

The results are very revealing, but we must look before we leap, which is why I have written again to the Secretary of State and given him another opportunity to meet with us, inviting him to suggests ways in which we can move forward. Ultimately, should the situation warrant it, we will call for the withdrawal of the Bill itself, but I really hope that these survey results will prompt some positive action, and tangible change to the Bill as it progresses to the Report Stage in the House of Lords. The three areas which remain of key importance – and which the responses to the survey reiterated are: The Secretary of State’s existing duty to provide, or secure the provision of, a comprehensive health service throughout England, must be retained Clarification on the face of the Bill that commissioners will not be required to open up services to competition unless it can be demonstrated that this would be in the patient’s best interests and compatible with the requirements of patient safety and the ability to provide integrated care

The introduction of further safeguards on education and training, including robust mechanisms to ensure the provision of sufficient post graduate training places, and the long term retention of post graduate deaneries But let me be clear. We are not a trade union. This is not about political point-scoring. It is about protecting the principles of the NHS for our patients now and in the future. I will of course keep you informed as things unfold. Other news this week in brief. You may have seen my comments responding to the second phase report from the independent NHS Future Forum. While it does concern me that questions about patients’ lifestyle choices are being proposed as part of every consultation, we did a fulsome response to the report in which we welcomed many of the recommendations. It contains some excellent proposals for strengthening the role of the GP within the NHS, and I am particularly delighted to see the emphasis on extended training.

Getting more GPs, who are trained for longer, and spending more time with their patients through longer consultations, are our priorities and it is reassuring to see them gaining wider support. Its really good to see Steve Field continuing to lead the Forum. The Forum is increasingly becoming a driving force for Government policy making, so it can only be to our benefit to have a former Chair of Council, and practising GP, at its helm, particularly as we progress with our bid for extended training.

 Best wishes,

Clare Gerada, Chair RCGP