Labour Pains

‘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

Justice for Debbie Westwick

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.

After the Bill

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.

Cameron’s Conflict

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.