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Socialism and Health the magazine of the Socialist Health Association February 2011 Editors Opening So at last we have the Health Bill, all 367 pages of it, the Explanatory Notes, the Impact Assessments and the Parliamentary Research Paper. Many have already given their comments and the pick of these follows. The basic assessment remains the same. However it is spun or packaged up this is the attempt by the Tories to end the NHS as a public service, and a move to a full market with genuine competition for all NHS funded services.

It comes from the ideological belief that free markets and competition are better than cooperation, collaboration and partnerships. It is about changing patients into consumers, about breaking the NHS up as if it were just a series of independent health products and it is about denying communities and patients representatives any rights to decide how services should be run and organised. It is much the same as the approach being taken across all public services.

The irony in the idea that this is “Liberating� the NHS is obvious when you read the Bill. The powers of the Secretary of State to interfere in every aspect of the new system are staggering.

Far from being independent the new GP Consortia will be hemmed in by bureaucratic and legal structures operating from the top.

Meanwhile in the real world patients are starting to wait longer, more operations are being cancelled and staff are at risk of redundancy.

Irwin

This issue: Editors Opening

Page 1

News & Comments

Page 2

More News and Comments

Page 3

Market Stalinism

Page 4

John Healey Speech

Page 5

Guide to the Bill

Page 6

Guide to the Bill continued

Page 7

SHA Round Up

Page 8

Our Aims ..

Universal Healthcare meeting patients' needs, free at the point of use, funded by taxation

Democracy based on freedom of information, election not selection and local decision making

Equality based on equal opportunity, affirmative action, and progressive taxation

Editor Irwin Brown Socialist Health Association 22 Blair Road Manchester M16 8NS 0161 286 1926 irwin@sochealth.co.uk Please send contributions or ideas for articles

News and Comments Commenting on the Health and Social Care Bill Dr Hamish Meldrum, Chairman of Council at the BMA, said: “Ploughing ahead with these changes as they stand, at such speed, at a time of huge financial pressures, and when NHS staff and experts have so many concerns, is a massive gamble.

“The BMA supports greater involvement of clinicians in planning and shaping NHS services, but the benefits that clinician-led commissioning can bring are threatened by other parts of the Bill.

In particular, the legislation will allow competition to be forced on commissioners, even when they believe the best and most appropriate services can be provided by local hospitals.

“Forcing commissioners of care to tender contracts to any willing provider, including NHS providers, voluntary sector organisations and commercial companies, could destabilise local health economies and fragment care for patients.

Adding price competition into the mix could also allow large commercial companies to enter the NHS market and chase the most profitable contracts, using their size to undercut on price, which could ultimately damage local services.

“Commissioners should be free to choose the best and most appropriate providers, creating care pathways across hospital and community care boundaries, without fear of a legal challenge from private companies or the health regulator.

Royal College of GPs The RCGP said it ‘makes sense’ for health professionals to be involved in the planning of services, but the proposals risk ‘destabilising the NHS and causing long-term harm to patient outcomes’.

RCGP chairwoman Dr Clare Gerada said 'we must guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing public, private and voluntary sector providers, that delivers less choice and fewer services, reduces integration

between primary and secondary care and increases bureaucratic costs'. Patient choices as outlined in the Bill ‘run a risk of destabilising the NHS and causing long-term harm to patient outcomes’. The RCGP has also yet to receive sufficient evidence to be reassured the plans would prevent this from happening.

She concluded: ‘The NHS has for more than 60 years delivered a fair and efficient system of healthcare for millions of patients. We acknowledge that improvements can always be made, but we must work with the Government to protect the founding principles of the NHS; the stakes are too high to lose it now.’

BMA The BMA said ploughing ahead with the reforms at the speed proposed was a ‘massive gamble’.

The BMA supports greater involvement of clinicians in planning and shaping NHS services, but the benefits that clinician-led commissioning can bring are threatened by other parts of the Bill.’

‘Forcing commissioners of care to tender contracts to any willing provider, including NHS providers, voluntary sector organisations and commercial companies, could destabilise local health economies and fragment care for patients.

‘Adding price competition into the mix could also allow large commercial companies to enter the NHS market and chase the most profitable contracts, using their size to undercut on price, which could ultimately damage local services.'

The Lancet There is a crisis in the National Health Service (NHS). The publication of the Health and Social Care Bill last week heralds dramatic changes for the NHS, which will affect the way public health and social care are provided in the UK. Those changes alone will have huge impact, but it is the formation of an NHS Commissioning Board, and commissioning consortia, that will once and for all remove the word “national” from the health service in England. The result, due to come into force in 2013, will be the catastrophic break up of the NHS.

More than 60% of GPs disagree with the general direction of the government's NHS reform programme, according to an RCGP survey.

The poll shows the strength of opposition within the profession as the BMA prepares for a special representative meeting next month to shape its response to the Health Bill.

The findings came as a separate YouGov poll last week found widespread public opposition to the use of private providers in the NHS. The poll of 1,800 RCGP members revealed that 61% of GPs disagree or strongly disagree with the general direction of the reforms.

Overall, just 21% think the reorganisation will lead to better patient care, while only 24% think it will lead to reduced bureaucracy.

Unison Unison, the public sector union, called the Health Bill a ‘disaster’ of Titanic proportions’.

Karen Jennings, head of health at Unison, said: ‘This Titanic health bill threatens to sink our NHS. The only survivors will be the private health companies that are circling like sharks, waiting to move in and make a killing.

‘Lansley has turned his back on the warnings from across the medical establishment that these changes are unnecessary, undemocratic and unlikely to deliver improvements in

Liberal Democrat MPs are more closely aligned with Labour than with Conservatives on health policy, new research into MPs’ opinions on the NHS reveals.

As the Health and Social Care Bill progresses through Parliament, it appears that MPs are split along traditional party lines on issues like GP commissioning and outsourcing to the private sector.

The research, commissioned by Westminster Advisers - a public affairs consultancy - and conducted by ComRes, shows that while 90% of Conservative MPs agree that “GPs should be able to turn to the private sector for administrative assistance with their new commissioning responsibilities”, just 26% of Labour MPs and 34% of Liberal Democrat MPs agree with this statement.

Similar splits emerged on issues such as whether the NHS should provide non-essential operations and services, whether taxpayer funded health services should be delivered by the private sector and patient top ups.

On the issue of health service outsourcing, nearly half (48%) of all MPs agree that “as long as services remain funded by taxpayers and are free at the point of use, the NHS should outsource more of its work to the private sector”. However, this breaks down as 84% of Conservatives, 24% of Liberal Democrats and only 12% of Labour MPs.

Market Stalinism

professionals. As they are allocating public money they must be publicly accountable – open and transparent in all they do – free from any suggestions of conflicts of interest.

The enthusiasm amongst some GPs for the Liberation proposals has now been replaced by scepticism as the contents of the Bill reveal the actual proposals. The Bill is designed to achieve a full market in health, a proper market with price competition, and most services subject to the any willing provider model, not what most GPs want.

The Bill is not about patients or quality. It enacts the belief (not supported by evidence) that a full market system will magically deliver improvements.

But balancing public accountability should be flexibility, they should be able to do what they think best for the community they serve so long as they use proper decision making processes and are open to scrutiny. Innovation and imaginative development of services requires the freedom to use whatever tools are most appropriate and this will vary widely between locations and populations.

Far from Liberation, political and bureaucratic interference is being built into every facet of commissioning. Consortia can be instructed what to do, how to do it, what services to commission and not commission, who can be in the consortia or not in the consortia and the boundaries. The amount allocated to consortia is determined by the Commissioning Board in whatever way they think. Consortia can be instructed and will be directed about how to commission and intervention can occur through the new NHS bureaucracy but also by a powerful economic regulator there to ensure the supremacy of free competition.

Just to make things worse, and to show the disparity between the emollient words of the Ministers and reality, we have now heard the Chief Executive (of NHS England and NHS Commissioning Board) talking to the Public Accounts Committee about how tight financial control will be exercised over consortia, at every stage. This will be possible through the sub national structure of the NHS Commissioning Board, formed from the 50 clusters being set up.

You can already see the way consortia will be inspected, reviewed and monitored at every stage; the empire that is the NHS bureaucracy has fought back and won the day. This is top down in spades.

In the true spirit of localism around 25% of commissioning will now by national, the rest subject to detailed national regulation.

Liberation should make local bodies properly accountable then let them flourish.

Commissioning bodies must include, by right, both independent non executives and patient representatives alongside the clinical

There are services that are appropriate to market mechanisms such as the any willing provider model; where there is episodic care that can be relatively easily specified and priced, the quality can be measured, and there is little interdependence with other services. You need high volumes, good information supporting choice, patients prepared to be mobile and low entry costs for new providers.

In the greater part of the NHS these features do not apply and the purist commercial market approach risks damaging the quality of care. Some services are natural monopolies, such as national or regional centres of excellence. Much of emergency care, such as ambulance services, will best be delivered through a single provider, through a long term contract, maybe after a tendering process. In other cases there might be a pathway approach where a number of providers collaborate in delivering the best care. Sometimes making might be better than buying. Sometimes block funding gives stability and restricts unintended consequences. It is complicated.

But top down prescription and compulsion is wrong and the enforced imposition of a preferred model to satisfy some mantra about competition is dangerous. What is needed is a more subtle and nuanced approach. Competition needs to be used in a tailored way and only to solve particular problems.

Above all these should be decisions taken locally openly and transparently by clinicians, in partnership with providers, patients and the public.

That is not what the Bill provides.

Irwin Brown

John Healey’s Speech to the Kings Fund (Extracts) You are seeing that the NHS is already showing signs of strain in some areas, and with the extra pressure the changes are putting on the NHS, patients who have their operations cancelled or services cutback, and staff who see jobs cut, will become see themselves as victims of the Government’s handling of the health service.

With this wide range of views, of warnings, why are the Government forcing this huge internal upheaval on the NHS? For me the answer lies in the politics, not the policy. This is a Conservative plan, not a Coalition plan for the future of the NHS. The Lib Dems are hapless, helpless by-standers on the Government’s public service reforms. The main evidence of Lib Dem health policy in the Coalition Agreement programme for Government was the commitment to “elected local health boards, which will take over the role of Primary Care Trust boards in commissioning care for local people”. Well that lasted 61 days until Andrew Lansley’s white paper and simply brushed it aside.

This is a Conservative plan for the NHS. This is Andrew Lansley’s plan. No-one in the House of Commons knows more about the NHS than Andrew Lansley – except perhaps Stephen Dorrell.

But Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley.

The Health select committee concludes – in so many words – and as I believe, that these are the wrong reforms at the wrong time, “blunting the ability of the NHS to respond to the Nicholson challenge” to improve services to patients and make sound efficiencies on a scale the NHS has never achieved before.

In politics and public policy I think we often look and talk too much about “what” we’re doing, and not enough about “why”. The “why” questions: why the huge disruption and distraction, when the general aims are simple to achieve? Why the waste of £2-3 billion, when NHS finances have

never been tighter? Why now? These why questions have a straightforward answer.

Andrew Lansley is a Conservative. Like Oliver Letwin, George Osborne and David Cameron – who’ve all now given him backing – he believes in the free market. David Cameron said twice at Prime Minister’s Questions yesterday that the Government wanted a “level playing field” for private health providers. They believe that competition drives innovation, that price competition brings better value, that profit motivates performance, and that the private sector is better than the public sector.

I acknowledge the ambition but I condemn this as the core philosophy being forced into the heart of the NHS. It’s wrong for patients. It’s wrong for our NHS. It’s wrong for Britain.

The true intent of the plans is not set out in the aims of the white paper or the arguments ministers use in public. This is not a reform for the Parliament, it is a reform for the decade. The purpose lies in opening up all parts of the NHS to private health companies, and taking what remains of NHS out of the public sector.

It lies in removing the “N” in NHS, so there are no consistent service guarantees for patients wherever they live and no consistent national contracts for staff.

It lies in overriding service coordination and planning with competition.

It lies in cutting back the comprehensive care the NHS provides from cradle to grave to a core of “designated” services that will have legal protection and guaranteed funding.

This is not what people expected to see when David Cameron says I will protect the NHS. This is why the NHS is the Prime Minister’s biggest broken promise to date.

Speech to the Kings Fund John Healey MP, Shadow Health Secretary

Guide to the Health Bill The Bill creates the NHS Commissioning Board which the July white paper promised would be “lean and expert” - and hand it what appear to be “surprising” and “draconian” powers over commissioning consortia - including setting standards for their creation, directing them, having them taken over and abolishing them altogether. The board will be able to hire and fire their accountable officers, as well as having extensive leeway to bail them out.

In relation to commissioning consortia - which will take on responsibility for the majority of NHS services - the bill includes few requirements for how they should be run or governed. They will have none of the defined independence from the government enjoyed by foundation trusts, but there is no requirement for them to have a board, or patient representatives, for example.

The bill also adds detail to consortia relationships with council-led local health and wellbeing boards, and the makeup and power of those boards.

It further develops the government’s plans for freedoms for NHS providers and greater competition. The removal of the cap on foundation trusts’ income from private patients could leave them open to competition law challenges, while Monitor could challenge NHS staff pension on the basis of an “unlevel” playing field between NHS and private providers.

Foundation trusts will be given further freedoms, including to more easily merge with and acquire each other.

However, those concerned by the impact of the market could be assured by provisions for oversight of the “taxpayers’ investment” in foundation trusts to be retained in a banking function “established by the DH”; and for tribunals to rule on whether NHS services should be “protected” from closure. The bill sets out how providers will contribute to a fund to maintain these essential services in the event of failure.

Health secretaries will be able to significantly shape the NHS through areas left to future regulations. They will also retain specified

extensive levers including directing Monitor - and through it providers; deciding what is commissioned by the NHS Commissioning Board; and directing local authorities’ over public health.

The Department of Health’s long awaited impact assessment for the reforms - showing the estimated cost, benefit and risk - includes the admission that the transition could mean NHS staff losing focus on patients. It also reveals the reforms are expected to cost £1.2bn in the next two years; the average redundancy cost per manager is expected to be £48,000; and planned management cost cuts would be at risk if consortia are too small.

The new NHS Commissioning Board is likely to have “surprising” and “draconian” powers over commissioning consortia under Health Bill proposals, analysis suggests. The board will decide whether a consortium should be authorised, whether it should be taken over, and will have the power to abolish it altogether. It will be able to direct consortia actions, and hire and fire their accountable officers.

The board will also be able to wrest funds from allocations to commissioners for the purpose of creating risk sharing arrangements and to bail overspending consortia out, implying that surplus generating consortia might not have their full underspends returned to them each year.

Meanwhile, in relation to the makeup of consortia themselves, the bill appears to continue the government’s light touch approach by setting out few governance requirements. Consortia will be public bodies and will not have specifically defined independence like foundation trusts, but there is no requirement for consortia to have a board or patient representatives, for example.

The bill suggests GP consortia will be made up of practices that are close to each other by referring to consortia’s “area”, although there is nothing specifically preventing consortia from developing that are made up of geographically disparate practices – creating organisations that some say would start to bear resemblance to US style health maintenance organisations.

Guide to the Health Bill The bill also leaves open the major question of whether consortia will have responsibility for anyone living or working in their area but not registered with a GP practice.

Wide areas of commissioning policy are left to further regulations, which means that while health secretary Andrew Lansley has given extensive powers to the NHS board, he will also shape how that power can be used.

The bill adds detail to consortia relationships with council-led local health and wellbeing boards, and the makeup and power of those boards. They will develop needs assessments for their patch, and consortia must consult them when publishing their annual commissioning plans. Health and wellbeing boards will be able to include a statement in consortia’s plans saying whether they think it accords with their needs assessment.

As with commissioning consortia, the bill presented providers with a mixture of new freedoms and potential restraints. The removal of the private income cap and greater freedoms to merge with or acquire other providers were set out in the 367-page bill and its various supporting documents, along with freedom from Monitor’s compliance regime.

A merger between two foundation trusts will require only the agreement of the majority of both organisations’ governors – rather than having to de-authorise and re-apply to Monitor as at present.

The health secretary obtains significant powers to direct Monitor and through it, foundation trusts and other providers subject to Monitor’s powers.

The removal of the private patient income cap created a “high” risk foundation trusts would be challenged in the courts by private sector competitors on the basis of state aid law.

The bill also set out the system for identifying so called “designated services” which will be protected even if a provider goes bust. For services which are not designated, the bill laid the ground for a commercial lending regime.

With Monitor losing its compliance role, the responsibilities of foundation trust members, directors and governors were spelled out, with the latter able to summon directors to answer questions.

Big questions remain over what Monitor’s interest in establishing a “level playing field” will mean for tariff payments made to providers once the additional expenses of private providers is taken into account.

A full tariff system is introduced with a rules basis for services not on payment by results. There is power to pay higher tariffs to private providers, estimated in the Bills explanatory notes to be 14%.

The tariff is also set at a maximum level introducing the idea of competition on price for the first time.

It has been made clear by Ministers that the intention of the bill is to create a genuine market with genuine competition, with most NHS funded services being open to “any willing provider” competition.

Much of the dense legalese that forms the Bill is actually about amending previous legislation as PCTs and SHA and a few quangos get the chop. But it does also contain the legislation to bring the market right into the centre of the NHS and opens services up to private providers who will have the full force of EU Competition Law behind them

Health and Social Care Bill Committee The non-Labour members of the committee considering the Bill between now and Easter is: Brine, Mr Steve Winchester (C) Burns, Mr Simon Chelmsford (C) Burstow, Paul Sutton and Cheam (LD) Byles, Dan North Warwickshire (C) Crabb, Stephen Preseli Pembrokeshire (C) de Bois, Nick Enfield North (C) James, Margot Stourbridge (C) Lefroy, Jeremy Stafford (C) Morgan, Nicky Loughborough (C) Poulter, Dr Daniel Central Suffolk and North Ipswich (C) Pugh, John Southport (LD) Shannon, Jim Strangford (DUP) Soubry, Anna Broxtowe (C) Sturdy, Julian York Outer (C) The Government supporters on the list are the people we should be putting pressure on. If you know anyone who lives in these constituencies please let us know.

Annual General Meeting Our AGM is on Saturday 19th March 2011 at Wesley's Chapel 49 City Road, London EC1Y 1AU, starting at noon. Old Street is the nearest station. This determines the policy of the Association according to our constitution.

All members are welcome. This includes members of affiliated organisations, including Unison, Unite, Society of Radiographers and GMB.

Conservative Health Policy - what does it mean for the NHS? Linda Burnip Disabled People Against Cuts Dr Neil Goulbourne Martin Powell Professor of Health and Social Policy University of Birmingham Zoe Mayou Unite Health 12.30- 3.30 pm Friday 18th March Bath Place Community Venture, The Old Library, York Road, Royal Leamington Spa, Warwickshire, CV31 3PR Cost free. There is a cafe at Bath Place where lunch is available from 12

The Sharp End of the Big Society What will be the effect of Government policies on the disadvantaged? with Kate Green MP Wayne Farah Migrants Rights Network Steve Hynes Legal Action Group Alan Maryon-Davis Hon Professor of Public Health Kings College London Gareth Morgan Ferret Information Systems on Benefits in the Future - Welfare after the White Paper Tuesday 22nd March 10am- 3pm St Marks Church 245 Old Marylebone Road London NW1 5QT Cost (includes lunch) £10 for members of the Socialist Health Association and affiliates. This includes lunch

Membership of the Socialist Health Association Martin Rathfelder—Director Free entrance to local branch and central council meetings; reduced fees for our conferences; SHA Journal Socialism & Health and frequent email bulletins about developments in health politics; voting rights as a member of a Socialist Society affiliated to the Labour Party; opportunities to contribute to the development of health policies.

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