Dismembering the NHS

Heath secretary Andrew Lansley’s muted apology to nurses – I’m sorry you seem incapable of understanding my reforms – may not be enough to save his career as the Lib Dems demand his head on a pole. But what’s spooking NHS staff far more than Lansley’s apparent inability to get his message across is the breathtaking insensitivity of Monitor’s new chair, ex-McKinsey man David Bennett. In March, Bennett gave an extraordinary interview to The Times, likening the NHS to a utility company. Now he’s trampled over the toes of NHS chief executive David Nicholson by suggesting that the NHS is heading for financial meltdown and many Trusts will have to make far bigger savings than the 4% predicted.

The notion that the NHS is going to be fed to the market and asset-stripped is something Lansley has been very keen to deny but Bennett’s comments are all the more potent because – if the Health and Social Care Bill goes through – Monitor is set to assume enormous power as the economic regulator for both health and adult social care. It will license providers of NHS services in England, regulating prices and promoting competition. So it’s absolutely vital that the Board is led by someone with a deep understanding of the complexities of health and social care, who appreciates how services are closely interwoven and dependent on careful planning and collaboration for survival and patient safety. So possibly not David Bennett.

If your electricity company goes under, you get another one. If you local hospital closes, you don’t. Healthcare has lots of demand but not enough money to pay for the supply. You can’t provide healthcare for all, free at the point of delivery, through competition because some patients – often the ones who put in the least money – are far more expensive and complicated than others. The NHS pools everyone’s risk and money, and the rich pay for the poor. This provides a decent, often excellent but occasionally dreadful service. It needs politicians to butt out, as Lansley is suggesting, but it also needs long-term collaboration, transparency and stability. Appalling failures tend to happen in the NHS with the combination of lack of money and massive structural reform. The Government has unwittingly created the perfect storm for another Bristol or Mid Staffs. Bennett’s promise of dismemberment is very close to the bone.

Bennett was chief policy adviser to Blair who, like Lansley, wanted the NHS to compete on quality not on price. Alas, Blair got sidetracked by opening up the NHS market and offering private companies cheap deals to cherry pick NHS patients, never mind the quality. The word ‘quality’ has featured hundreds of times in every White Paper and Health Bill for fifteen years but the only specialty where we have reliable data that provides comparative benchmarks on quality is adult heart surgery. Labour poured £105 billion into the NHS and yet much of it was wasted because commissioners had no proof of the quality of the care they were buying.

Handing commissioning over to GP consortia isn’t a quick fix to this conundrum. GPs might hear which services are going under by rumour and innuendo, or might favour other services based on personal experience or friendship. But without hard comparative data, you simply can’t commission or compete on quality. Ironically, the one area where we have the least information on quality and value for money is primary care. We think GPs are jolly good people doing a brilliant job in difficult circumstances but we don’t know how much of the care they provide is wasteful or unacceptably poor. So what qualifies GPs to be in charge of commissioning more than anyone else?

The health reforms at least have an outcomes framework, with NICE desperately trying to come up with 150 quality standards to guide commissioning. Once you set the standards, you have to audit services to make sure they’re achieving them and then identify the significant outliers who are killing patients. It takes time, money and good statisticians. So it’ll be several years before anyone can even begin to commission services rationally. By which time – if David Bennett is right – many NHS hospitals will have failed to reach their new 7-10% savings targets and will be on special measures pending takeover by private companies. Lansley’s problem is not that the nurses didn’t understand his reforms but – thanks to Bennett’s alarming candour – they understood them only too well. MD

Pause for Debt

Andrew Lansley’s one month pause to consider the 353-paged Health and Social Care Bill may at least give us the chance read it (12 pages a night is the maximum safe dose), but many appear to have made up their minds without bothering. 99% of delegates at the Royal College of Nursing conference gave him the thumbs down and now Nick Clegg has weighed in with ‘five key demands’ which are ‘non-negotiable’ 1. Competition should be driven by quality, not price. 2 GPs should not commission services alone. 3. GP consortia must not go ahead in 2013 if they are not ready. 4. The principles of the NHS constitution must be protected and 5. GPs must work local with councils.
If Clegg had digested the Bill and its hundred amendments, he’d know that these pledges have already been met, at least on paper. What happens in practice is anybody’s guess. Lansley’s original intent was to be ‘permissive’ and ‘local’. Strategic Health Authorities and Primary Care Trusts would go, leaving GP consortia free to decide their own size and make-up, and free to buy services from ‘any willing provider’ without too much in the way of accountability. After all, they were only being given £80 billion to spend.

The policy was openly questioned by NHS’s centrist chief executive David Nicholson. More surprising was his appointment – without competition – as head of the new NHS Commissioning Board. Nicholson is now busy centralizing what’s left of PCT’s in the hope of making £20 billion of savings. Non urgent GP referrals are being delayed across England, and lists of treatments that will no longer be available on the NHS have been drawn up (Eyes passim). The buck for these savings plans will then be passed onto the GP consortia. For example, in Birmingham and Solihull savings of £219 million will have to be made in 2011-2012 just to break even.

If GP consortia fail to make such massive savings, as many suspect they will, Nicholson will take back control and try to do it all from the centre, an approach that Labour tried with mixed success. The economic crisis makes management of the NHS in the next five years a near impossible task, particularly if you’ve kicked out the good managers along with the bad, and lost the expertise of some of the better PCTs.

GPs were chosen to kick-start commissioning because practices have defined lists of patients they can buy services for. But to do it well they have to join forces with hospital and social care staff, and allow patients to tell them which bits of the NHS work well and which bits are shit. The aim is for an integrated NHS where consultants would do clinics in the community, GPs would go on ward rounds and social workers would go everywhere, but many frontline staff are already doing two jobs, as those who leave and retire are not replaced. To prevent a future ‘Mid-Staffs’, the NHS needs to rediscover its humanity, and that simply won’t happen if the staff are burnt out.
Commissioning also has to be legal, and competition law is complex. All services have to go out to tender and any changes need public consultation. Whether consortia can achieve anything with a fraction of the management support of PCTs is debatable. With money so tight, commissioning better services can only happen if you decommission others, but no-one has figured out how to close anything in the NHS without a nasty, politicized, media frenzy.

Labour’s NHS was friendly if you toed the line but very intolerant of dissent, and many whistle-blowers had their careers destroyed and their concerns silenced. Getting rid of the SHAs may help, provided the bullies don’t all decamp to the Commissioning Board, but the bottom line is that the NHS is facing its toughest financial restrictions ever, services will close, waiting lists will rise and jobs will be cut. GPs are less likely to bully and more likely to tell it like it is, but they’re also more likely to shy away from commissioning if all it results in is unpopular rationing and negative press. It’s a tough time to be in charge of the NHS, which is why they gave the top job to Nicholson, the only willing provider. The new financial year has kicked in and the shit has hit the fan. All Lansley can do is sit tight and pray.

MD

Sort out diabetes and save the NHS

Diabetes is common and often undiagnosed. 2.3 million people in the UK know they’ve got it, another million don’t know they’ve got it and the incidence rises every year as we become older and fatter. Treatment can be complicated, and requires a lot of support, education and training, and close monitoring in times of illness.

It’s the commonest cause of blindness in the working population and can also lead to foot ulcers, nerve damage, infections, amputations, heart attacks, strokes, kidney failure, depression, serious pregnancy complications, erectile dysfunction and premature death. Poorly controlled diabetes knocks 10-20 years off your life and it costs the NHS over £1 million an hour to treat. So it’s vital, for both patients and NHS survival, that we treat it well.

The latest National Diabetes Inpatient Audit* is not encouraging. It looked at diabetic care in 93% of acute hospitals in England on a single November weekday in 2010, and found that people with diabetes had an average age of 75 and occupied 15% of beds. Their median length of stay was 8 days but only 9% had been admitted specifically for diabetes management. The majority (86.7%) had an emergency admission and 40% of inpatients were insulin treated. And now the bad news.

37.1% of inpatients with diabetes experienced at least one medication error. 26.0% of charts had prescription errors and 20.0% had one or more medication management errors. Insulin errors were particularly common. There was marked variation in prescription errors across hospitals from none to 54.3%. 44 developed ketoacidosis (severe uncontrolled diabetes) and 266 severe hypoglycaemia (too low blood sugar due to over-treatment) during their admission. Only 27.5% of patients had their feet examined at any time during admission, 2.2% developed a new foot complication during their hospital stay but 49.6% of these had no input from the foot specialist team.

So despite record funding for the NHS, there is still huge variation, substantial error and sub-standard care in the in-patient management of patients with the most common, expensive chronic disease. The audit found, rather alarmingly, that 31.0% of hospitals had no inpatient diabetes specialist nurses, 29.8% had no inpatient dietician for people with diabetes and 26.8% had no inpatient diabetic foot service. Few were under a diabetes consultant (9.0%) or on a diabetes ward (4.6%) and 69.4% of in-patients with diabetes had not been seen by a member of the diabetes team, including 46% with a diabetes management problem.

These alarming gaps in care are for the mother of all chronic diseases, so I’d what to think what level of expertise awaits patients with rarer diseases. Insulin requirements in sick people vary day by day, sometimes hour by hour, and they need expertise beyond the generalist nurse or the inexperienced junior doctor passing through on a shift. So while the tedious, point-scoring NHS reform debate plays out in Westminster, the premature death and disease of patients with chronic diseases continues on a massive scale.
The NHS now faces the toughest financial restrictions in its history. If specialist diabetic nurses are either not provided or made redundant, and diabetic consultants are not appointed, it’s hard to see how the care of this pivotal disease will improve. Patients often know how to manage their diabetes best and yet the audit found only 12.9% had a say in their treatment plan and less than a quarter were allowed to monitor their own sugar levels. In America, it’s been estimated that a small improvement in the management of diabetes could fund universal healthcare. If you can sort out diabetes, you can sort out the NHS. Time to stop the point-scoring and get on with it.

http://www.yhpho.org.uk/Diabetes_inpatient_audit

The Health Bill Balls

Should you feel sorry for Andrew Lansley? The Health Secretary has been polishing ideas for his Health and Social Care Bill for seven years and has spent nine months travelling around England explaining the changes to NHS staff, patients and MPs. But in the last few weeks the BMA has voted for the Bill to be withdrawn and reconsidered, the Lib Dems have voted overwhelmingly in favour of amendments, a study by the Nuffield Trust has found that only 23 per cent of GPs believe the reforms will improve the level of care already provided to patients, and 220,000 people have signed an on-line petition opposing it.

The headline concepts of the Health Bill are hard to argue against – get staff involved in designing and commissioning services, give power to patients and focus on better clinical outcomes. Lord Darzi, the Labour health minister, proposed just that and by the time Labour left office clinical outcomes were improving and patient satisfaction was at an all time high.

Labour’s good fortune was to invest heavily in the NHS without having to pick up the tab for the debt. Despite improvements in services, overall productivity hardly budged and Lansley is right to focus on this. But instead of laying waste to two tiers of NHS management in one sentence, he could have kept the best of the Primary Care Trusts, ditched or merged the bad ones and put more clinical staff and patients on the boards.

Lansley’s biggest error has been to downplay what effect the debt-reduction program will have on the NHS. The Tories made a big song and dance of securing a tiny increase in funding, year on year, but high inflation may wipe that out. The NHS has always swallowed up money at a rate far above inflation, so even if Lansley kept Labour’s NHS structure, the service would still be facing massive problems in the next few years. But because the focus of the debate is so heavily on his reforms, he’s likely to be blamed rather than the recession.
Lansley is desperate for clinical staff to take more responsibility for determining how limited resources are spent, and many would be happy to be involved in redesigning services if they weren’t already working eighty hours a week. Most major reforms need pump priming money to get them started, to pay for training and locum cover, but there’s little of that about. And although GPs are very adept at running small cottage industry practices, it’s a big step up for them to work together in commissioning groups and make the kind of instant productivity improvements that the NHS needs to stay afloat.

But it’s the labyrinthine complexity of the Health Bill that may sink it. The Outcomes Framework starts very well. There are only five of them 1. Preventing People from Dying Prematurely 2. Enhancing quality of life for people with Long Term Conditions 3. Helping people recover from episodes of ill-health or following injury. 4. Ensuring people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm.

If the reforms focussed on those five outcomes, everyone would understand them. But they’re being translated into 150 quality standards and then they’ll be ‘fed into’ the Commissioning Outcomes Framework, the Commissioning Guidance and the Provider Payment Mechanisms of tariff, standard contract, CQUIN and QOF. Finally, the division of commissioning labour is split between the NHS Commissioning Board and GP Consortia, and the 60% of management costs that Lansley was so keen to save have been neatly reinvented.

Invested Interests

Under pressure from the BMA over concerns that the NHS is heading for a price-war, the Government has amended the Health Bill and removed references to the tariff paid for different services being the ‘maximum price’. This would have allowed private companies to undercut the NHS by cherry-picking easy cases. The price regulator Monitor can still ‘specify different prices for different providers’ based on ‘unavoidable’ cost differences. But it supposedly can’t mimic the absurdity of the Labour reforms and pay private companies more than the NHS to bribe them to take over services.

The BMA’s initial stance on the health reforms was ‘constructive engagement’, having been seduced by the idea that clinicians (especially GPs) would be leading the NHS. Alas, most GPs aren’t keen to be the whipping boys for a very optimistic £20-billion savings programme that will force them to openly ration services. Health Secretary Andrew Lansely’s safety net is to open up the NHS to ‘any willing provider’, and if GPs don’t take up the mantle of commissioning and providing health services, there are plenty of private companies who will. Under pressure from its membership, the BMA has become increasingly hostile to the ‘marketization of the NHS’ and held an angry meeting to debate the reforms on March 15.

These are old arguments, dating back to the Tory’s purchaser-provider split over 20 years ago, and Blair’s subsequent attempt to introduce the ‘constructive discomfort’ of competition into a bloated, self-protective, patchy quality NHS. The BMA has too many vested interests to list, but the evidence strongly suggests that price-competition in healthcare only works if you’re buying stuff (curtains, beds, machines that go ping) rather than services. Treatment is now so complex, from home to general practice to hospital, that collaboration rather than competition is far more likely to improve the NHS. Different bits of the service working in silos, not communicating and obsessed with protecting their pot of money gives you a crap, disjointed service.

Health secretary Andrew Lansely is an identikit Blair, favouring competition on quality, rather than price. We know what quality doesn’t look like (Mid Staffs, Maidstone, ten percent of general practices) but very rarely to patients get a seamless service throughout the NHS with no unnecessary visits, waits, harm or duplication. Lansely’s mantra is ‘no decision about me, without me’ but most patients are clueless about the reforms, have no representation in the GP consortia and are not being consulted about how to improve services or how an increasingly tight budget should be spent.

In the event, the BMA bottled it, deciding not to oppose the Health Bill just to shout grumpily at it. The BMA will never strike, even if the members were brave enough to call for it, but Lansley knows that without the engagement, support and leadership of doctors, his reforms are doomed. The Health Bill is ridiculously complicated and policy is being made up on the hoof, but there is no escaping the cuts in services that the financial crisis has precipitated. GPs in consortia are not keen to put their heads above the parapet to announce that local services will have to merge or close simply because there is no money, and are hoping Primary Care Trust managers will do the dirty work before they go under.

If the Government sticks to its budget, closures are inevitable in the next five years, particularly of hospital services. The only way of avoiding harm to patients is for the rest of the NHS to collaborate to try to redistribute the workload. But the market system won’t allow this. Foundation Trust hospitals have been cut free from Whitehall and some are sitting on substantial profits that they aren’t sharing with their impoverished neighbours. Hospitals with huge PFI debts simply aren’t viable in the long term. Patients want the cosy certainty of good quality healthcare on the doorstep when they need it, but unless there is huge investment in community services this isn’t going to happen. The NHS was founded on a pooled-risk principle, where the healthy and rich subsidise the unlucky and feckless. If it focuses on collaboration and prevention, it might just survive as a patchy provider for all. If it allows Foundation Trusts, private companies and GP consortia to chase and keep profits, then you wouldn’t want to be unlucky or feckless.