Archived entries for NHS

Civil Society and the NHS

 Who is calling for a rethink on NHS reform? Why is the government not listening?

On October 9th, around 2,000 UK Uncut activists and Health Workers staged a mass occupation of Westminster Bridge in protest against the proposed Health and Social Care Bill, which goes before the House of Lords this week. The ‘Block the Bridge, Block the Bill’ demonstration was held to draw attention to the swelling tide of public opposition against government plans to reorganise the NHS.

In drama and scale, this protest was the most impressive so far, although it was by no means the only demonstration held against the shake-up. Marches, occupations and other protests have been held up and down the country this autumn.

Yet the Coalition continues to stay the course.

Has it simply become an uncomfortable truth that our elected representatives are no longer responsive to the demands of civil society?

A central feature of liberal democracy is the presence of a vibrant civil society that articulates the desires and demands of the people and conveys them to government. Our civil society is made up of academia, activist groups, trade unions, community partnerships and consumer organisations, among others. These associations operate outside of state and government, but are supposed to play a vital role in shaping the agenda and tutoring government.

At the moment, however, it seems that no matter how loudly civil society calls for a halt to NHS reform, the government just will not listen.

On March 15th, Doctors attending the British Medical Association’s special representative meeting in London voted overwhelmingly for the withdrawal of the Health and Social Care Bill, stating that “the current plans for reform are too extreme and too rushed and will have a negative effect on the care of patients”.

On April 1st, a variety of organisations held an “All Together for the NHS” day that witnessed a number of unions and campaigners take part in actions in Stafford, Warwickshire, Wolverhampton and Stourbridge in Dudley.

This autumn saw a clamour of expert voices join the already deafening chorus of those opposed to the changes.

On September 6th, Christina McAnea of Unison said the bill at present signals the “end of the NHS”. Her concerns were echoed by representatives of think tank ‘The King’s Fund’, which said there was a “worrying lack of clarity” on the issue of greater competition.

Earlier this month, 400 public health experts signed an open letter to The Daily Telegraph calling on the Lords to reject the reforms, stating: “The government claims that the reforms have the backing of the health professions. They do not. Neither do they have the public’s support.”

This is just the tip of the iceberg. Others who have demanded a halt to the Bill include the NHS Confederation, BMA Chair Dr Hamish Meldrum, representatives of the Royal College of Nurses, Royal College of GPs, Royal College of Midwives and even The Archbishop of York.

When these protests are all listed together, it becomes clear that civil society is sending a loud and urgent message to reverse course.

Yet the government continues to frustrate attempts to kill the bill by exercising its right to manipulate the legislative schedule. In a scandal that has received far too few headlines, the Coalition tried to restrict the time the Lords had to debate the proposals to a single day. This for a piece of legislation that had 1,000 amendments added since its last journey through parliament.

However, the Coalition has listened to the public before and changed policy accordingly. In February, the PM shelved plans to privatise public woodland after 300,000 people signed a petition in protest of the sell-off. Michael Gove’s plan to withdraw funding from 450 school sport partnerships was delayed after Olympic athletes, head teachers and Labour MPs united in opposition against him. These reversals were both forced by the pressure placed on government by civil society.

On the issue of the NHS, however, the government remains stubborn. The reform bill has become a centrepiece of the government’s programme, and the Coalition feels safe in the knowledge that the revolt of civil society has yet to affect their electoral base.

Perhaps it is because this bill has come to symbolise the Coalition’s entire legislative programme that the government feels it cannot yield to public demand. To retreat from this would be to retreat from the whole project of state reform and thus fatally undermine the government’s purpose.

This is a radical, ideologically-driven government facing an angry, well-organised civil society. An unstoppable force is about to hit an immovable object. What will emerge when the dust settles?

Louie Woodall is a member of the Young Fabians and Assistant Editor of The Young Fabians Blog

Middle East Delegation Travellog – Cinderella, where are your shoes?

As part of our Middle East delegation 2011 travellog, Tasmin James reflects on her experiences of the Israeli health system.

When I came to Jerusalem for new experiences, I hadn’t expected these experiences to include a ride in an ambulance and a couple of days board and lodging in an Israeli hospital. So I might have missed out on some extremely interesting meetings and events, but instead I got a crash course in comparing and contrasting health systems in the UK and Israel.

The ambulance was my first surprise. I’m pretty sure, although having never been in an ambulance, I can’t be certain, that I wouldn’t find my feet sticking out the back once I’d been wheeled inside on a trolley in the UK. However, at 5’10, I was too long for an Israeli ambulance. And for pretty much every hospital bed and wheelchair that followed. Even more surprising, the ambulance asked where we wanted to go. Surely they are in the best position to decide. And once at the hospital, the ambulance staff waited for my health insurance details to make sure they were paid. So it was rather more like a very fast taxi. Choice isn’t really welcome when all you want is to stop feeling horrific as fast as possible.

Hospital food was sadly not a contrast. At first I thought I was being a fussy foreigner but as I got talking to the other patients, I found out that it really wasn’t just me. While every meal arriving with two yoghurts or mini-cucumbers was obviously a cultural difference I failed to adapt to, it turned out that no one appreciated the dinner that was six bowls of gloop (and two more yoghurts).

Within the hospital there were no restrictions on visiting hours or mobile phone use. And chaos did not break out. Mobiles were everywhere. Doctors and nurses carried them at all times, answering whenever they rang with an impatient ‘Ken?’. And there were no restrictions on patients using them, which I thought was great, until I was woken one too many times by the Israeli equivalent of Crazy Frog.

I had reason to thank the doctors and their mobiles during my admission. I was cheerily oblivious at the time, but during my initial assessment, when the doctors had concluded that I needed to be hospitalised, the administrative side did not want to let me in until proof had been received from my health insurance. On paper. At 4am. It took a fierce phone call from the doctor sitting in front of me to get me through the door. At some point I witnessed a conversation that probably saved my life. For that particular aspect of the need for payment on delivery, I am very happy to remain absent from the NHS.

But to end on a happy note, an innovation that I would happily appreciate in the NHS is “clowns for all”.

Seeing them wondering around the hospital I’d assumed they were for children. But one evening, two clowns came to visit my ward. They came in, sang a song and made us balloon flowers. And for someone alone in hospital, with no family near by, it was great. This was much less confusing than the first clown I met, as I was being wheeled through the hospital. Feeling a bit groggy, I looked down and saw some giant shoes. The clown was also looking down.

‘You have no shoes.’ This was true, and something of a hospital faux pas. No one went beyond their bed without shoes. ‘Poor Cinderella, where are your shoes?’

I couldn’t answer. I was just wondering quite how strong the medicine I was taking was.

Tasmin James is a member of the Young Fabians and a delegate on the Young Fabian Middle East Trip 2011.

NHS reforms lanced by a Boyle

This week the Young Fabians Science and Society Network met with John Healey, Shadow Secretary of State for Health, to share our views on the latest NHS reform proposals and to hear his on how Labour plans to defend the NHS.

The National Health Service remains at the heart of British identity, embodying the best of our nation’s political and social values. Health Secretary Andrew Lansley’s plans, even in their current watered down version, threaten the future of an organisation that regularly polls as more popular than either the creation of the modern welfare system or the end of World War II.

The NHS was 63 years old on Tuesday, having starting life when Nye Bevan opened Manchester’s Park Hospital in 1948. Since 1997, when Labour gained power, it has had its best years: funding was trebled under Labour; 90,000 new nurses were added; and waiting lists were radically reduced. In the face of a sustained trend of NHS improvement, Lansley is proposing a reckless revolution that vexes the medical establishment.

Sir Roger Boyle, government health ‘Tsar’ and National Director of Heart Disease, has just announced his retirement in disgust at the Tory plans. Boyle was on the Today programme this week. He has worked under six health ministers of different political stripes but simply felt he could not continue in his role as the government voluntarily places massive extra strain on the NHS at a time when it is ill-suited to take it.

Given the current fiscal environment, the coming years were always going to be extremely difficult for the NHS. This would be no different were Labour still in power. What worries me and Boyle is that the Tory-led government is choosing this most inopportune of moments to ratchet up the pressure on the NHS by forcing through a full scale organisational resign. Never mind that the Tory government won power on a promise to end top-down reorganisation of the NHS – you could see this one from space.

Boyle says that “he feels in his bones that the current plans are not correct”.

Me too.

Given the financial squeeze on all aspects of healthcare delivery, we should be maintaining and supporting existing structures to ensure stability and continuation of services. Instead, Lansley is breaking up the organisational infrastructure in the face of strong opposition from medical and patient groups. Even if you think the structural reforms are in themselves good- and I don’t- this is certainly not the right time to be implementing them.

At a time of unprecedented financial pressure on the NHS, we should be perusing a policy of progress through gradual evolution (quite Fabian that) rather than opting to restructure when this inevitably means NHS staff will take their eyes off the ball and start to fear for their jobs.

Daniel Bamford is Networks Officer for the Young Fabians.

Happy Birthday NHS, you might not survive to see 64

Ahead of tomorrow’s Young Fabian Science and Society Network event with Shadow Health Secretary, John Healey, Young Fabian member Amanjit Jhund argues the Government’s reforms are just cuts by any other name.

On Tuesday the NHS turns 63. It’s a time for many of us to celebrate: for most of us it is difficult to imagine life without it.

Yet the Health and Social Care Bill is an attack on the NHS on an unprecedented scale. The concerns for many on the left and in the medical community is that while the aims of the coalition proposals are laudable they are simply being used to mask both spending cuts within the service and the increased privatisation of the NHS.

In fact,  many of the GPs that I have spoken to are fully aware that their budgets for commissioning will only be a fraction of those administered by Primary Care Trusts currently. One GP told me recently that “it’s just a way of pushing through cuts”. While most GPs are pragmatic about the changes and will do their best for their patients no matter which system they have to work within, it is vital that the coalition are held to account on this issue.

With David Cameron purporting to defend the NHS, we must expose the hypocrisy of his words as he presides over changes that will not only slash budgets but will also take the ‘N’ out of ‘NHS’.

Happy 63rd birthday NHS. I just hope you’re still around when I’m 63.

Further reading:

Book review: Talking to a Brick Wall

In this member post, Young Fabian member Amrit Caleyachetty reviews Deborah Mattinson’s book “Talking to a Brick Wall: How New Labour stopped listening to the voter and why we need a New Politics”, which was recently discussed by the Young Fabian Book Club.

As Labour’s chief pollster from 1983-2010, Deborah Mattinson’s book, Talking to a Brick Wall, may offer some guidance on regaining the confidence of voters in Southern England. Mattinson weaves together focus group discussions of middle-class swing voters and her own observations, to suggest that over time not adequately paying attention to voter’s expressed needs and aspirations, resulted in the decline of the voter-politician relationship.

Chapters 4, 5 and 8 provide evidence of what can be achieved when policy initiatives are carefully planned. The Working Family Tax Credits and increased child care funding were developed from a genuine understanding of the “squeezed middle” (p.76). Another example is when the NHS became crucial in determining Labour’s second term success (p.110) – voters identified key problems in the NHS and their need to see visible improvements, whilst surveys quantified support for a tax rise.

However, too little is said about voters’ ambivalence towards the government’s overall performance despite improvements in public services (p.120). Mattinson suggests that the voter-politician disconnect can be explained by the predominance of politicians and advisors with minimal real-world experience (p.287) and “Peter Pan politics”, where voters “live in a perpetual child-like state” (p.288). As politicians become increasingly removed from the vicissitudes of everyday life, they are less likely to understand the voter (p.290), a point highlighted with examples ranging from costly initiatives such as the Millennium Dome and the Iraq War (p.78, p.123), to the over-reliance of announcing large public funding initiatives which simultaneously attracted media superlatives and voter scepticism (p.109).

Voters preferred hearing examples of how policy would positively impact their everyday lives (p.112).

Yet the book offers no compelling evidence to suggest this is a new problem. Policies ensuring better parental leave, Sure Start, and Working Family Tax Credits, demonstrated Labour had the ability to understand voter’s problems and to attempt effective, sustainable solutions. As for Peter Pan politics, voters with inflated expectations create a climate where politicians – as Polly Toynbee writes – “lack the nerve to spell out the mountains to be climbed, and the true cost of getting there.” Politicians who are wary of ballot box reprisals are, understandably, less candid with the facts, which the media are all too ready to expose.

Mattinson’s ‘Citizen’s Jury’ of Harlow voters offer recommendations for reducing voter discontent. These focus on the role of politicians, their accountability and the voter’s need for more information (p. 313). However, if we focus predominantly on ideas for political reform, we may forget an important point: “…how did they [voters] know Labour had turned a deaf ear? It was because of what Labour did (or didn’t do), not because of what Labour said” (p. 318). Ultimately Labour will be judged upon how it views the intersection between society and market forces, and how its policies reflect this understanding.

Mattinson’s effort to synthesize the large amount of qualitative research into a coherent narrative should be appreciated. However, for some readers there may not be enough critical commentary and attention paid to how, despite New Labour’s political ability, a perception exists that there were more policy misses than hits. We’re left uncertain to the degree to which focus groups were used to decide policy details at the expense of economic or social justice arguments. And the book does little to explore why certain policies lacking merit were adopted.

This isn’t just a Labour problem. But if we talk about the need for a new politics, we must spend some time understanding why we didn’t fully achieve our potential.

There also needs to be a distinction between the problem of not listening and selective listening. If you think the problem of a declining relationship with voters is mainly due to not listening, then the obvious response is to increase research on what voters want, adding to the library of information we already have on voter’s needs and aspirations. If you consider the voter-politician disconnect to be a selective listening problem, you would have to rethink whether adding to our existing knowledge would be beneficial.

Instead, you would want to improve on how we make policy decisions based on the information given; you would want more astute politicians with non-political experience relevant to their post to challenge questionable policies and demand relevant outcomes. And you would want politicians and their advisors to become more insightful of their tendency to become over-enamoured with the current political process – a process that engenders an academic detachment towards the very people who are the subject of their actions.

A clear message emerges from Talking to a Brick Wall: we can re-establish our relationship with voters by communicating, clearly and honestly, thoughtful policies guided by Labour’s progressive vision and grounded in low-middle income voter’s needs and aspirations.

  • Deborah Mattinson’s book, “Talking to a Brick Wall: How New Labour stopped listening to the voter and why we need a New Politics”, is published by Biteback.
  • You can replay the Young Fabian Book Club webchat with Deborah Mattinson by visiting the Young Fabian website.

Is Clegg’s NHS ‘muscular liberalism’ all a front?

I’ve been pondering the content of the policy statement Nick Clegg signed and circulated to the Liberal Democrat Parliamentary Panel yesterday, which is the focus of so much media attention this morning.

On the one hand it looks as if Clegg is a badly briefed imbecile, given much of his assertions have no basis in fact and his view of what Monitor should be sounds suspiciously like those of an economic regulator (the thing he seems so vehemently opposed to).

On the other hand, he could be supremely intelligent and pulling a fast one on his Lib Dem colleagues – and the public – to make it look like he is taking a principled stand whilst in fact arguing for little real change at all.

He is a politician, so I can’t really tell if he is stupid or liar.

According to the Guardian, the document says:

“We cannot treat the NHS as if it were a utility, and the decision to establish Monitor as an ‘economic regulator’ was clearly a misjudgement, failing to recognise all the unique characteristics of a public health service, and opening us up to accusations that we are trying to subject the NHS to the full rigours of UK and EU competition law.”

“I have come to the conclusion that we must not make this change. We must remove from the bill changes to establish Monitor as a competition authority. Monitor should be empowered to encourage informed patient choice and act against anti-competitive practices but only when this is in the interest of patients, individually and collectively, and in the interest of equality of access.”

This is nonsense for a number of reasons.

First, the NHS is not explicitly excluded from the “full rigours of UK and EU competition law”. Increasingly, healthcare services* are provided by organisations other than the state, with third parties competing for NHS funding to provide services for the NHS. This sort of activity is not outside the remit of competition law. While the proposals in the Health and Social care bill would extend this type of activity, the status of Monitor would not affect the fact that the NHS’ activities are currently subject to UK and EU competition law.

Secondly, no competent competition authority would, as seems to be implied, act in such a way that consumers would be worse off as a consequence of its activities. The whole purpose of competition law is to protect the interests of consumers, not business. Competition can be a mechanism of delivering higher quality products and services at lower cost, if it works correctly. That benefits consumers. There is also the academic point that if you were concerned about private firms making supra-normal profits, then you would probably want a regulator to ensure this didn’t happen, rather than arguing that there shouldn’t be one at all.**

Thirdly, I’m not certain that a organisation which is “empowered to encourage informed patient choice and act against anti-competitive practices but only when this is in the interest of patients…and in the interest of equality of access” could not also be an economic regulator. Other economic regulators – Ofgem, Ofcom – also have wider public policy objectives which sit alongside their responsibilities as competition authorities. Here Clegg appears to be saying that he doesn’t want Monitor to be an economic regulator, because that would be bad and Monitor should instead be…an economic regulator.

Given that the statement is so evidently nonsensical, I’m confused.

Clegg could be badly briefed on the intricacies of the NHS, of competition law, and of the roles and responsibilities of economic regulators.

Or alternatively, he could be using those complexities to fool his party – and the public – that he opposes the contents of the Health and Social Care bill whilst actually just reinforcing its contents.

Alex Baker is Secretary of the Young Fabians.

*There are a number of other activities which are quite evidently subject to UK and EU competition law. Like the NHS’ other procurement activity – office supplies, catering, cleaning etc.

**This raises a related point which is maybe Clegg is concerned about contestable funding in the NHS, and would prefer complete state provision of healthcare. If that is right, then his opposition to the Health and Social Care bill would be a lot more strong than just on the narrow point about the role, or status of Monitor.

Unnecessary surgery

In this guest post, Young Fabian Member Tom Keeley argues against the latest set of NHS reforms.

Listening to Andrew Lansley you might believe that GP Consortia are the cure for everything wrong in the NHS.  An idea that will, at once, improve care, reduce cost and give people a say in their treatment.  The “silver bullet” bringing our health outcomes in line with Europe’s.

However, a cursory glance back at two decades of attempts to move care closer to general practitioners should leave anyone in doubt of these claims.  Or perhaps anyone without their ministerial career staked on it.

Governments of all colours have repeatedly returned to the idea of GP commissioning.  Their stated aim is always “improving care”; while in reality their concern is cost control.  Initiatives from GP fundholding to Practice-based Commissioning from total purchasing pilots to locality commissioning have all shown the limitations of GPs buying health care.  Limitations that should be great enough to stop anybody from handing over the majority of the £110 billion NHS budget.

Acting as the buyers of health care doctors can modify their referral rates, make very limited “one off” savings in their prescription costs and exert a downward pressure on waiting times.  But, this comes at the sizeable cost of increasing inequity and reducing patient satisfaction.  GPs have been shown to be incapable of reliably influencing the organisation and delivery of hospital care through budget negotiations.  And, with this ineffectualness comes increased management and transaction costs, as the buyers of health care lose their economy of scale.

When GPs are given a budget responsibility they understandably, and quite wisely, revert to what they know: providing more community services.  While there is good evidence to suggest that the provision of primary care services can improve health and reduce the pressure on hospitals, it is far from being the answer to every health problem.  Furthermore, this throws up an obvious and unavoidable conflict of interests.  GP consortia could commission themselves to provide care.

The greatest problem however, is reserved for the fact that in general GPs are not keen on the idea, or prepared for the reality.  While a good number of “pathfinder” consortia have voluntarily formed, this is about self-preservation.  These pathfinders have, very wisely, given themselves two years to gain experience in the buying of health care, before taking full control of and responsibility for the budget in April 2013.  Lansley should not mistake this for enthusiasm: when a gun is held to your head, jumping off the cliff is a good option.

The obstacles to consortia succeeding are considerable.  Lansley has perceived the limited success of past efforts to be an indication of potential; when in fact it is simply the limit.  GPs should have a role in the commissioning of health care, but this should be limited to a role in the commissioning of primary care, without full devolution of the budget.  If the government of the day seriously wants GPs to succeed in doing anything more, a full 5-year regional trial of policy and a massive overhaul of medical training should be considered an absolute minimum.

In his shadow role Lansley had every potential of being a competent Secretary of State for Health.  A knowledgeable minister who would protect the NHS from the worst of the cuts, while allowing it a period of calm in which to make the required budgetary savings.  As it is, he has, to quote David Nicholson (NHS chief exec), proposed the biggest change management system in the world – one so large “that you can see it from space”.  He has done this with little grounds for hope of success.

We must stand by our NHS

In this guest post, Young Fabian member Martin Edobor argues that we might fight the proposed changes to the structure of NHS service provision in the UK, or risk undoing many of the improvements Labour achieved in its time in government.

Upon reading the Coalition Government’s NHS white paper, I was both shocked and dismayed with their plans to restructure the NHS. The proposals are likely reverse the progress that has been made under Labour, where the NHS delivered a new level of health and equality to the people of Britain.

One of the major proposed changes is to give GPs the power to commission the vast majority of health services for patients, which would result in the closure of Primary Care Trusts (PCTs) – the bodies currently tasked with commissioning healthcare from NHS providers. At this moment in time a reorganisation would be the wrong direction to take; in this period of financial uncertainty, the NHS requires stability.

Michael Dixon, Chair of the NHS Alliance, has argued that only 5% of GPs are ready to take over commissioning. While the chief executive of the NHS, Sir David Nicholson, has suggested that the quality of current GP practice-based commissioners isn’t at the level which would be required to transfer commissioning to them under the proposed timetable. At this moment in time, most GPs are simply not prepared nor ready to commission services for their communities. By pushing forward with this reform, the Coalition Government are placing the quality of GP services at risk.

Another major announcement is the increase in patient choice of providers, but this is likely to lead to privatisation by the back door. Allowing private firms greater opportunities to win NHS contracts may result in a two tier system, where those with money will be able to receive better care than those without.

Edward Davies, editor of BMJ Career Focus, claims that the white paper was ‘expected and little more than a logical continuation of 13 years work from the previous government’. He couldn’t be more wrong: the British public did not vote for a re-organisation or privatisation of the NHS. For that reason we must do all we can to oppose this white paper, in order to maintain the quality of the service the NHS provides.

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