David Cameron has made the Health and Social Care Bill into a confidence vote, just as Blair did, which if history repeats will lead to a brutal suppression of dissent, the silencing of whistleblowers and more buried scandals. The Lib Dems should be deeply concerned about this, but they’ve been briefed to give a positive spin on their contribution to the Bill’s improvements, to mask driving the getaway car.  See below – and please comment!

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.

 Lansley goes over the top

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.

More Chaos theory

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.

Dear Dr Hammond,

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

Hotline Fever

January 1 saw the launch of a new whistleblowing hotline – 08000 724 725 – for NHS and social care staff. It’s free, publically funded and available at weekdays between 08.00 and 18.00 with an out-of-hours answering service.  It’s run, for no obvious reason,  by the Royal Mencap Society. The charity understands the importance of protecting vulnerable patients but whether it has the advocacy and employment expertise to support staff  in what is often a suicidal career move remains to be seen.

Health Secretary Andrew Lansley is very keen on his new gimmick – “This will play an important role in creating a culture where staff will be able to raise genuine concerns in good faith, without fear of reprisal” – but it beggars belief that he can glibly promise both confidentiality and protection from retribution given how whistleblowers have been hunted down in the past (see Shoot the Messenger  Eye ). As soon as concerns are raised, the NHS pretty soon draws up a list of who the secret snitch might be in an attempt to shut him or her up. Threatening, counter smearing, paying off and gagging the source is far easier than investigating the allegations.

Theoretically, the hotline could be a force for good. It should document that an employee legitimately raised concerns through channels approved by the employer and demonstrate that the employer had knowledge of the concerns on a certain date. But there is no guarantee that NHS and social service employers will properly investigate the concerns or do anything other than pay lip service to promises of accountability and transparency. And if the concerns implicate those at the very top of the organization – such as the Mid Staffs scandal and the Gary Walker case (Eyes passim) – the NHS protects the most powerful at all costs.

Lansley would have been better advised to wait for the findings of the Mid Staffs inquiry before launching his hotline. Hundreds, perhaps thousands, of patients died as a result of substandard care, the chief executive claimed the mortality statistics were wrong and the strategic health authority and Care Quality Commission were complicit in the cover up. Only one nurse, Helene Donnelley, blew the whistle by reporting on the appalling care she witnessed on 50 occasions. She got no help from her union, was bullied by other staff and was sometimes too afraid to walk to her car in the dark. One consultant had also seen many patients put at risk and had reported it up through the organisation but again got no action. When asked at the Inquiry why he had not blown the whistle he replied: “Because I’ve got a mortgage to pay.”

Whistleblowers shouldn’t have to live in fear or remain anonymous on distant phone lines. They – along with patients and relatives – should be able to raise concerns openly and in person – and then be acknowledged if they help expose and prevent poor care. Each year, the chief executive of every NHS trust should be giving awards to those who have raised concerns and protected patients. Without a change of culture, a phone-line is pointless.

Meanwhile, solicitors representing a group of NHS whistleblowers may launch judicial reviews against the Care Quality Commission, NHS London and two London acute trusts – Ealing Hospital NHS Trust and South London Healthcare NHS Trust –  for failing to comply with their duties in supporting whistleblowers under the Department of Health guidance. (www.patientsfirst.org.uk). Just having a whistleblowing policy and a hotline does not make whistleblowers safe, and a professional duty to speak up is pointless if there isn’t a commensurate duty on managers to listen and act.

This point cannot have escaped Robert Francis QC, chair of the Mid Staffs inquiry, who sat through 139 days of public hearings, warned of a ‘tsunami of public anger’ and heard some limp buck passing between the Department of Health and the Care Quality Commission. He’ll also have discovered  how an organization that purports to care can be so brutal to those who challenge the system and put patients first. If you want a career in the NHS or social care  it’s often  safer to keep your head down and ignore bad care. That has to change in 2012.