Virgin Territory

According to Chief Inspector of Hospitals Prof Mike Richards, the NHS stands on a ‘burning platform’ with 11% of trusts rated inadequate by the CQC and 70% requiring improvement. Understaffing and overcrowding put patients and staff at risk every day. Meanwhile, private providers lead by Virgin Care are busy ‘conquering the community care space’ says HealthInvestor magazine. ‘A market worth around £10 billion has suddenly become a private affair…’ Virgin has already hoovered up over 400 health, social care and local authority services’ contracts, worth over £1 billion. It’s ‘quite the portfolio’ according to HealthInvestor, and other companies are lining up to conquer what’s left. ‘The chance to drink in a £9 billion pool in tantalising…’

There’s a clear underfunding and privatizing trend in NHS and Local Authority services. Between April 2013 and April 2016, 45% of the community health services that were put up for tender went to non-NHS providers. Private operators now run GP and out of hours services, walk-in centres and minor injury units, district nursing, diabetes, musculoskeletal, audiology, dermatology, physiotherapy, podiatry, rheumatology, mental health and other chronic disease services, urgent care, phlebotomy, anti-coagulation, sexual health, wheelchair services, prison healthcare, community hospitals, neuro-rehabilitation, frail and elderly care, health visiting, services for children with complex mental, physical and sensory learning difficulties, social care for adults and children and end of life care.
The whole range of community healthcare has now been privatized while Theresa May and Jeremy Hunt – and Tony Blair and Alan Milburn before them – have the gall to repeat the lie that the NHS is not for sale. The NHS has outsourced its very essence – much of the complex, difficulty care that requires close collaboration and team working has been contracted out. Virgin argues that such care was fragmented when the NHS offered it and that they have a much better chance of joining it up under one organization. The more they hoover up, the more they can join up.

Andrew Lansley’s Health and Social Care Act has allowed companies like Virgin to aggressively tender for any service they want, and to legally challenge the award of any contract that doesn’t allow them to make a pitch. Their pitch is deceptively simple. ‘Our aim is to make a real difference to people’s lives by offering NHS and social care services that are better than what went before, a great experience for everyone and better value for the public and the NHS. ’When the NHS pitches for services it tends to be far more downbeat, citing the reality of trying to keep an underfunded, understaffed service afloat in the face of rising public demand and expectation. It’s easy to see how the Clinical Commissioning Groups and Local Authorities who award the contracts fall for the optimistic swagger of Virgin. The company generally employs the NHS staff who were providing the services previously, and gives them smart phones, colour printers and other gadgets you have to fight for in the NHS. It claims that 93% of customers recommend it services to friends and family. If it can provide better services than the NHS for the same cost or less, then why not?

NHS commissioners are often naïve (remember PFI?), and get turned over in contracts, which companies aggressively stick to. ‘If it’s not in the contract, we’re not doing it’ rarely equates with universal healthcare. Yet despite some tough negotiating, Virgin Care has yet to make a profit in 7 years doing business.
In the year ending 31 March 2015, turnover was reported as £40.38 million leading to a gross profit of £5.2 million, but with administrative expenses of over £20 million, the company made a loss of £9.1 million. When will shareholders start demanding it balances the books and cuts back on smart phones? Virgin recently lost its Community Services Contract for children in Surrey. As a whistleblower told the Eye : ‘Virgin Care are now concentrating on recouping as much money as possible, asking for asset templates  to be completed, threatening removal of laptops and mobile phones with little thought for safe transfer of care. They have been restricting information sharing with the new provider and talking about intellectual property rights. Many staff are feeling anxious about being able to carry on with “business as usual” on 1st April.’ Meanwhile, the government is launching 10 year Multispecialty Community Provider contracts to take the pressure off hospitals. ‘It’s another lucrative opportunity for the private sector’ says HealthInvestor

Who wants to be Leader?

Health secretary Jeremy Hunt believes, rightly for once, that the NHS can only survive if more clinical staff become leaders. Yet most clinical staff don’t want to be lead by Jeremy Hunt or implement dangerous £22 billion austerity cuts, departmental closures and the private outsourcing policy of the government. Leading an organization where patients and staff are routinely harmed by the effects of unnecessary underfunding is a thankless task. The BBC’s week long exposure of the NHS crisis introduced us to the concept of ‘corridor nurse’ in scenes reminiscent of the nineties. Back in July, a Surrey woman died after being denied entrance to 3 hospitals and NHS England was warned of worse to come. Now many ambulance trusts aren’t able to fulfil their emergency response times, and staff are in tears in short-staffed departments that can’t cope with the demand. The service has always been glued together by goodwill but under Hunt, the goodwill has gone and staff are walking.

Under Hunt’s command, the number of junior doctors progressing directly into specialty training has fallen from 71.6% in 2011 to 50.4% in 2016, its lowest ever level (Eye last). This is sad, but unsurprising not just because of their work pressures, but because they feel undervalued and ignored by the Department of Health and NHS England. Many of the junior doctors MD has spoken to also believe that it is unsafe to blow the whistle about their working conditions and patient harm. As one put it: ‘It felt a lot safer when the BMA was behind us and 55,000 of us were united in exposing the dangerous understaffing in the NHS. But since the BMA capitulated over the new contract, it’s as if you’re on your own if you dare to speak up. And you have no legal protection.’

Junior doctors often take a career break after finishing their F2 training year, but the omens are not good for most of them returning to the NHS full time. ‘As a paediatric trainee, my workload was simply overwhelming. There were – and still are – rota gaps in every shift that we have to cover. Sometimes I’d be looking after 40 sick kids. I would worry about harming them when I was on duty, and then take it home with me and spending all my ‘down time’ worrying that I’d done something wrong because I was always multi-tasking very complex problems when, say, getting a dose of a drug wrong or missing the subtle signs of sepsis could prove fatal. Just driving past the hospital on my days off would make me feel very anxious. And before a shift I would sit in the car park and cry, and just wish I didn’t have to be there. I used to love my job, when the workload and stress were manageable, but they aren’t any more and I can’t return to the job until they are.’ Another junior doctor highlighted Hunt’s leadership; ‘You can’t blame Hunt for everything. The NHS has been underfunded for most of its 69 years, and that’s all of our fault. But I simply refuse to work in a system where I believe the leaders are both unwise and unkind. If Hunt had listened to junior doctors, instead of fighting them, we could have worked together to try to sort out some of the problems. To be blunt, I think the leaders of the NHS are either in denial about the true state of the NHS, or are deliberately running it into the ground so they can sell it off. Most of my friends aren’t going into full-time specialty training until the NHS becomes a safe and humane system to work in. And that needs a change of leaders as much as a change of funding.’

Some good news for Hunt is that people appear to have stopped living longer, at least for now. Researchers from the London School of Hygiene and Tropical Medicine have analysed the sharp rise in deaths in 2015 (30,000 more in England and Wales than in 2014) and linked to the ‘massive disinvestment’ in health and social care. If this is true, 2016 looks like being a bumper year for deaths. In the meantime, the corporate hoovering up of NHS services by the private sector continues apace. One senior NHS manager, who doesn’t wish to be identified, gave an alarming account of the process:

‘We lost our contract for community services – something we had run successfully for many years – to Virgin. I still don’t understand why, but I guess they made promises to the CCG that we realistically couldn’t deliver. We then had a meeting with representatives from Virgin to discuss handing over the contract. It was like an episode of the apprentice. These bright-eyed twenty-somethings were full of enthusiasm but clearly had no idea how to run the service. They wanted us to advise them, and to hand over all our knowledge and expertise. I thought ‘this isn’t how corporate take-overs work.’ If Sainsbury’s take over a Tesco branch you don’t expect the Tesco staff to hand over all their business intelligence to a competitor. But you do it in the NHS, because you don’t want to see patients harmed. I’ll be amazed if they make a success of it, but it’s the CCG who gave them the contract. It’s doctors doing the government’s dirty work.’ Clinical leader anyone?

Consequences

In 2009, NHS chief executive David Nicholson was set a challenge by Gordon Brown to find £20 billion in “efficiency savings” by 2015, as the NHS’ contribution to bailing out the banks and paying off the national debt. It was dubbed ‘the Nicholson Challenge’ by Brown, a tag enthusiastically embraced by the Conservatives to signal where the buck would stop if it failed. Nicholson was clear this was a one off, drastic squeeze in NHS funding that he hoped could be achieved by improving quality and productivity without affecting patient care. The fact that it was enforced as the horrors of the Mid Staffordshire scandal were unfolding, and yet were repeatedly ignored and denied by government, showed the dangers of prioritising savage savings over safe staffing of the NHS.

Nicholson’s failure to meet Mid Staffs campaigners and to act earlier on widespread concerns about appalling care contributed to his retirement, but his replacement Simon Stevens fell into exactly the same political trap. In promising to make a further £22 billion of fantasy efficiency savings by 2020 to fund his ‘Five Year Forward View’, the NHS is now facing over a decade of static funding in the face of rising demand and – coupled with massive cuts in social care budgets – parts of the service are in meltdown. The initial bail out of the banks in 2008 could have funded the NHS for eight years, but Theresa May and Philip Hammond still insist no more money can be found for the NHS, and that it has been given ‘more than the £8 billion extra over 5 years’ that Stevens asked for. The true figure is £4.6 billion, and NHS managers are once again prioritising financial savings over patient care.

The Mid Staffordshire Inquiry concluded that the NHS must introduce safe staffing levels for nurses in hospitals. Research has repeatedly highlighted the link between nurse numbers and patient safety, and the benefit of nurse to patient ratios below 1:8. The skill mix of the staff is also important. And yet the Health Service Journal has just published the culmination of a two year investigation into nurse staffing levels. It found 96% of acute hospitals in England are failing to meet their own planned level for nurse staffing during the day and at night, and that the situation is getting worse. It is not uncommon for a nurse to have to care for 16 patients on a night shift, and the HSJ found one nurse on an acute ward looking after 24 patients. 4 in 10 hospitals have declared a major alert in the last month because they were not able to safely cope with demand, and there are at least 24,000 nursing vacancies across the NHS. There has also been a 23% drop in the number of applications to study nursing at English universities in the wake of the government’s cuts to the bursary scheme. And under Jeremy Hunt’s leadership, the number of junior doctors progressing directly into specialty training has fallen from 71.6% in 2011 to 50.4% in 2016, its lowest ever level.

Despite the government’s boast to increase GP numbers by 5000, there was a reduction last year in the number of ‘whole time equivalent’ GPs, meaning any new recruits are thin on the ground and the job so stressful many are choosing not to work full time. Meanwhile, Simon Stevens has challenged Theresa May and Jeremy Hunt over their claims that the NHS has received £10 billion of new money but is still trapped into trying to enforce harsh financial controls without harming patients. The English NHS has been carved up into 44 ‘footprints’ which each devised a Sustainability and Transformation Plan in secret to balance the books by June 2016. Most have now been published and many are laughably deficient, particularly in their plans for safe staffing levels. NHS England will doubtless try to pass the buck for their failure down to local commissioners. Kent CCG has already had to ban routine operations from December 20 to April 1 to try to make £3.2 million savings.

STPs do radically increase opportunities for private companies to take over entire NHS services as well as buildings, but Theresa May was still parroting the Alan Milburn lie that ‘the NHS is not for sale’ on the same day that Care UK took over out of hours services in Gloucestershire. The business opportunities of a £120 billion NHS market will not be lost on Donald Trump, and given the desperation to achieve a trade deal with America, it seems very unlikely the UK would have the muscle to protect the NHS from an ‘America First’ policy and the might of their predatory private health corporations, one of whom (UnitedHealth) Simon Stevens worked for. But maybe that’s part of the plan. When politicians say they love the NHS, they mean they’d love it to be off the balance sheets and no longer their responsibility. Extra charges, insurance and top up fees aren’t far away.

MD is taking his health revolution on tour. Dates here

Blamestorming and Bedhunting

Politicians have always been adept at centralising praise and devolving blame, but for Theresa May and Jeremy Hunt to blame GPs for the meltdown in hospitals takes it to a new level of stupidity. True, the waiting times for routine GP appointments are rising (due to increased demand and a lack of GPs), but 86.3% of GP practices in England already provide pre-bookable appointments outside core opening hours. The limit on appointments is down to the number of GPs, and we have fewer of them per head of the population than comparable countries in Western Europe. Hence the alarmingly high levels of staff stress, unlikely to be eased by the government’s crude blamestorming.

We also have far fewer hospital beds per head (2.8 per 1000) than comparable countries, and are about to cut thousands more in an attempt to squeeze a further £22 billion of savings out of an already over-stretched NHS. Patients who go to emergency departments for a minor illness that a GP, chemist or sensible family member could have sorted out are easily treated. The reason hospitals are in crisis is because of the number of sick people turning up who need to be in hospital, and the cuts in social care preventing discharge. The lack of NHS intensive care and high dependency beds has absolutely nothing to do with GPs, and neither does the increasing cancellations – often repeated – for urgent heart and cancer surgery. The costs of standing down entire surgical teams because intensive care has no beds is considerable, not to mention the distress caused to patients and relatives. Without beds, hospitals are paralysed and highly paid and trained clinicians can spend all day on a bed hunt.

MD has been writing this column for 25 years, and although the NHS and social care system is not quite in the disastrous state it was in the nineties, when waiting times regularly exceeded 2 years and deaths in the queue were commonplace, it’s heading back that way. Our health spend is around 8% of GDP, heading for 6.6% by 2020. Civilised countries spend between 10-12%. UK NHS spend fell to 6.3% in 2000, when Tony Blair made a promise to match the EU average – but on the proviso the NHS accepted mass management consultancy, an expansion of outsourcing and private provision, diabolical PFI deals and a move towards American models of ‘integration’ and ‘accountable care.’

The Conservatives and NHS England have accelerated this corporatisation of the NHS whilst deliberately defunding the service, forcing departments to close because they cannot be safely staffed to cope with the increased patient demand and the costs of technological advances. May could take a lot of pressure off herself is she ‘did a Blair’ and agreed to fund the NHS to the Western European average. Yet despite months of terrible health deadlines and missed targets, a ComRes poll from January 11 and 13 asking ‘Who would do a better job at managing the NHS this winter?’ found 43% in favour of the government and only 31% in favour of Labour. If Labour can’t win on the NHS now, it can’t win on anything. And it leaves the government free to pursue its aggressive austerity agenda that is undoubtedly contributing to avoidable deaths, albeit of those unlikely to vote Conservative.

The social care crisis can be traced back to Margaret Thatcher’s decision to allow long term care to fall off the NHS. In the 20 years from 1979, over 100,000 long stay beds were lost from the NHS. Patients with incurable diseases were re-categorised as ‘social care’ rather than ‘medical care’, transferred to private nursing homes and obliged to pay the difference between social security benefits and the nursing home fees. In 1990, a 55 year old man was admitted to an NHS hospital with a severe stroke leaving him incontinent of urine and faeces, unable to talk, walk or feed himself. The hospital discharged him to a private nursing home in 1991, on the grounds that it had done all that was possible to cure him, and the NHS had no obligation to care for him. So much for cradle to grave.

Savage cuts in social care funding have predictably bankrupted many nursing and care homes. Jeremy Corbyn’s idea to take them back into state ownership makes good sense, but is unlikely to happen. The government urgently needs to invest in general practice and social care, not blame it, and halt further bed cuts. But with no credible opposition, it might get away with running services into the ground, with the NHS becoming a poor service for poor people. Everyone else is expected go private (as many do in NHS England, the Department of Health, the CQC, the GMC and even the BMA). The NHS is still the place to go in an emergency, but you may have to fight for a bed.

The NHS in 2017

WHETHER you agree with the Red Cross that the crisis in social care and the NHS is ‘humanitarian’, or merely ‘human’, there is no doubt that millions of people are being denied the care they need or waiting too long for it.
Christmas was particularly bad, with a third of hospitals having to take urgent action to safeguard patients and reports of staff meltdown and deaths in the corridor queues. With so many hospitals overcrowded and on red alert, now does not seem to be the time for the massive cuts in bed numbers predicted by the McKinsey-heavy NHS Sustainability and Transformation Plans.
This crisis has been a long time coming. In September 2016, 32 percent of the most urgent ambulance calls weren’t responded to in eight minutes, the worst ever performance for that month. In quarter two of 2016/17, 9.4 percent of patients (558,000) waited more than four hours from arrival to discharge, admission or transfer in all A&E departments, the highest percentage for this quarter since 2003/4. More than 107,600 patients waited more than four hours for a hospital bed, up 70 percent on last year.
At the end of September more than 348,500 patients had been waiting 18 weeks or longer to begin treatment (up 9.4 percent on the previous September). More than 1,181 of these patients had been waiting more than a year. It was the seventh month in a row the target of 8 percent had been breached – the worst performance since that target was introduced in April 2012.
In September 2016 the total reported waiting list increased to 3.7m, an increase of more than 411,470 patients compared to January 2016. Some trusts have given up reporting but even NHS England estimates the true waiting list in September 2016 was more than 3.9m patients, the highest since December 2007. The proportion of patients waiting more than six weeks for a diagnostic test has now missed its target for the past 34 months in a row.
The overall waiting times target for cancer treatment is that no more than 15 percent of patients should wait more than 62 days from an urgent referral from their GP to receiving treatment for their cancer. This standard has not been met for the past two and a half years, and is up to 17.7 percent.
At the end of September 2016, 6,775 patients were delayed in hospitals, the highest number ever published and an increase of 29 percent since September 2015. The number of total days delayed increased to more than 196,000 in September 2016, the highest ever recorded and a 33 percent annual increase.
The number of urgent operations cancelled in November alone was 446, double the previous year. This prompted Jim Mackey, chief executive of NHS Improvement, to advise hospitals to cancel routine operations over Christmas to make way for emergencies. Children’s intensive care units in particular are struggling to cope.
The crisis in general practice is clear too. According to a 2016 survey of 831 practices by Pulse magazine, the average wait for a routine GP appointment is nearly two weeks, with a prediction it will rise to 17 days in 2017. 12 percent of practices surveyed in 2016 already had waits of three to four weeks.
The reasons for this ever-declining NHS performance are well known. Rising demand, flat-line funding, cuts in social care, inadequate investment in staff and community services, waste and lack of coordination in a marketised, fragmented service. Thus Tory manifesto pledges look absurd, particularly this one: “We will offer you the safest and most compassionate care in the world.”
UK health spending is just over 8 percent of GDP. France, Sweden, Denmark and Belgium spend 10-11 percent. There is no “right” amount to spend on the NHS, but the delusion that we can have the safest, most compassionate service in the world for so little must stop. Most NHS staff will bust a gut to deliver compassionate care, but with so many staff shortages, so little community care investment and so many waits for urgent treatment, the service is far from safe in 2017. The junior doctors were right. If we keep stretching the NHS, it will surely snap.
M.D.