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Briefing: The NHS Reinstatement Bill 

The NHS Reinstatement Bill has its second reading in the House of Commons on Friday 24th February 2017. Here is a briefing written by Roger Gartland and adapted for NHSpace by Deborah Harrington.

What does the Bill do?

The NHS Reinstatement Bill abolishes twenty five years of commercialisation of the NHS.  Everything from Labour’s internal market and purchaser provider split to the Coalition’s NHS England and competitive tendering will go.  In their place will be provisions to bring the NHS back into public ownership, including reducing PFI debt, protecting the NHS from trade treaties and bringing the staff’s employment terms and conditions together under an NHS Staff Council. Most importantly, the Bill reinstates the duty of the Secretary of State to secure the NHS for the public good as a service in which private profiteering has no place.

What difference does public service make to the NHS?

In the current climate of cuts and closures the biggest impact of the bill will be substantial savings which can be redirected to patient care. Aneurin Bevan reported the cost of NHS administration in its first year as 3% of budget.

£10bn a year could be saved by ending the market in the NHS

In 2010 the Commons Health Select Committee found the cost of administration in running the NHS as a ‘market’ was 14% of budget. In April 2014 (in the week when Simon Stevens, after ten years at the top of “United Healthcare”  of America, took over as CEO of NHS England) Dr Jacky Davis, Consultant radiologist and co-chair of the NHS Consultants’ Association, stated £10bn a year, the 9% difference in administration costs could be saved by ending the market in the NHS.

Who supports the Bill?

The Bill was first put forward by Lord David Owen in 2013 as a response to the Coalition’s Health & Social Care Act. Supporting the Bill has been one of NHA’s policies since then. The Bill was developed by Professor Allyson Pollock and Peter Roderick and was first tabled in parliament by Caroline Lucas of the Green Party. A letter was published in the Guardian in support of the Bill with more than 300 famous names from the arts, sport and the academic world, such as Alan Bennett, Jonathan Pryce, Darcey Bussell, Helena Kennedy QC and Sir Raymond Tallis.

In addition Lucas was backed by cross-party support from 77 MPs; a unanimous resolution in support from Unite together with endorsement from the BMA and 63,733 names on a ‘38 Degrees’ public petition. But to carry weight the Bill must be supported by the Opposition – and that means the Labour Party.

To carry weight the Bill must be supported by the Labour Party.

Rachael Maskell MP, Unite’s Head of Health and an NHS physiotherapist for 20 years before being elected to parliament in 2015, called all Labour MPs to a meeting in June 2016 in the Commons to brief them, “on how the NHS is currently undergoing a massive reorganisation in order to reduce its services and to further privatisation, and how this will not be stopped without the NHS Reinstatement Bill.”

What’s happening next?

Margaret Greenwood, Labour MP for Wirral West, will bring the Reinstatement Bill back to Parliament for its second reading on Friday 24 February 2017. She tabled it under the parliamentary ‘ten minute rule’ on 13 July 2016. It is not likely to be given any time, but showing support for it is one of the best ways an MP can demonstrate a real commitment to bringing our NHS back into public hands. Ask your MP to make time to see Peter Roderick, the Bill’s co-author in the House of Commons tomorrow and Tuesday, 30 & 31st January.

www.nhsbill2015.org

‘Removing the four hour A&E target – stupid, or sinister?’

Having previously reduced the A&E four hour wait target from 98% to 95%, Jeremy Hunt wants to exclude minor injuries patients from the target. But is he just moving the goalposts, or is this part of the plan to create an ’emergencies only’ NHS with private firms hoovering up all the elective and semi-urgent work?

Big Up the NHS

So Jeremy Hunt has announced that he will get rid of the four hour emergency department maximum waiting target for the less serious cases (minors) as his only response the the looming NHS crisis. I spent 5 years as a medical director running emergency services for a large NHS trust so I know something about how it all works.

I believe that removing the four hour target for minors is a very bad idea. It will not help the emergency crisis and will cause permanent damage to the integrity of the NHS.

Let me explain.

The essence of the current “humanitarian” crisis is that thousands of patients get stuck on trolleys in emergency department corridors because there are no beds in the hospital to admit them. They suffer appalling indignity and discomfort while receiving second rate care. Ambulance crews cannot offload their patients so they become stuck in hospital car…

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Let’s End The NHS “Bottomless Money Pit” Myth

NHSpace questions the common assertion that the NHS is an insatiable resource sink.

Read about the NHS in the media, and you’ll find plenty of comments about how expensive the NHS is. Just the other day, BBC health correspondent Nick Triggle was referring to ministers being ‘frightened’ by ‘how much cash the NHS is swallowing’. The prevailing idea is that we’re already spending too much, and that the government is having to be tough and draw a line.

If you’re reading this, you’re probably willing to question this assertion. But if we want to keep the NHS running as a universal service, how much more funding does it need? Can we as a nation afford to spend that much? And is frontline care benefitting from the increased spending, or is it being siphoned off thanks to government reforms?

The NHS certainly needs more money to continue in its current form. Virtually every NHS Trust in England is now in deficit. If it were just a few isolated cases, you might blame poor financial stewardship. But, as the King’s Fund states, for the vast majority to suffer a shortfall indicates that central funding isn’t keeping pace with the demand for healthcare services.

If we actually want a universal health service able to follow current best practices, how much more do we need to spend right now? Based on the fact that NHS trusts were balancing their books up until 2012/13, NHAspace previously calculated that the NHS is currently underfunded to the tune of £15bn. This assumes that the cost of running the NHS had increased by around 4% each year, which is the historical trend. But can we afford to put in this extra funding?

The simple answer is yes. According to the OECD and WHO datasets, the UK still spends less (both per capita and as a % of GDP) on healthcare than France, Germany, Austria, Holland, Denmark, Norway, Belgium, Canada, Japan, and various other western nations. Per capita, the NHS costs less than half as much as the US healthcare system. But there’s no need to match US spending! Even with an additional £15bn per year, we’d still be lagging behind France’s expenditure per head of population.

The final question then – is the funding reaching the front line? A CHPI report estimates that, following the introduction of the external market by the Health & Social Care Act 2012, the NHS now has 53,000 contracts with the private sector, requiring 25,000 staff and an annual budget of at least £1.5bn to administer. Adding this to other administrative costs brings the total spent on market bureaucracy to an estimated £4.5bn.

Meanwhile the cost of PFI deals, in which the government has tied the NHS into loan repayments for several decades, is at least £2bn per year. And thanks to poor workforce planning and the resulting shortage of permanent staff, the NHS currently pays around £3.5bn per year to agencies for temporary staff.

Between marketisation, PFI loans and agency costs, at least £10bn a year of NHS funding is being diverted. (And that’s in addition to the £12.2bn or more being handed to the private sector each year to run the outsourced NHS services.)

So, next time you hear someone say that the NHS is a ‘bottomless money pit’, remember to point out that we can afford the NHS, but we can’t afford the government’s mishandling of it. We should increase NHS funding to meet demand, but we should also renationalise the NHS and stop the siphoning off of funds by the private sector.

‘There is a toxic culture at the top of the NHS’

A clear insight into the way NHS England try to gloss over what’s happening to the NHS. This is why we cannot allow politicians to shirk their duty to provide a functional NHS.

Big Up the NHS

I know because I have worked in several senior NHS positions and have seen it first-hand. It works like this…..

  • All major NHS institutions from NHS England down are managed by a board consisting of Executive Directors (EDs) who do the actual work and Non-Executive Directors (NEDs) who are there to hold them to account.
  • The EDs are appointed by the NEDs, who also have the power to remove them if they are not up to the job.
  • EDs are required at intervals to provide the board with assurance that things are going well and that if this is not the case that there are plans in place to correct the situation.
  • It is essential that the board accepts this assurance. If they are not assured they must report up to their regulator – usually NHS Improvement.
  • If they are not assured the easiest action they can take is to…

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How Badly Is The NHS Underfunded?

So the story of NHS underfunding has finally made it back into the mainstream media. It’s not like NHSpace haven’t done our bit since we were founded in 2014:

  • “Simon Stevens of NHS England will shortly be unveiling an NHS roadmap […] Looming large is the matter of the claimed £30bn funding gap, an artefact of the Tory policy to stagnate NHS funding rather than commit to real-terms growth.” – NHS England And The £30bn Funding Gap, October 2014.
  • “David Nicholson and Simon Stevens have both used their time as NHS England CEO to implement austerity measures, leading to a cumulative shortfall in funding of at least £35bn per year by 2020” – 5 Things You Should Know About STP, August 2016.

But how much money would be needed to resume normal service?

With the NHS being asked to save tens of billions each year, it’s a miracle that hospitals are only in approximately £3bn of debt right now. The ‘Nicholson challenge‘ from 2010 to 2015 demanded efficiency savings of £20bn. The ‘Stevens Challenge’ (the STPs and Five Year Forward View) is asking for another £22bn. Some of these savings come from cutting beds and staffing, resulting in the increased waiting times, rationing of care, and missed targets that we are increasingly seeing.

But some hospital execs aren’t happy making such swingeing cuts. There came a point where the cuts would go too far and lives would be at risk. This wasn’t palatable, so instead of making further cuts, those execs chose to run a deficit and put their trusts into debt. This graph shows just how common this practice has now become:

_88338474_nhs_deficit_624

Let’s assume from this graph that 2012/13 was the year that the NHS couldn’t take any more cuts. It’s also the year that the Health & Social Care Act was enacted. If we take the funding from 2012/13 (102bn for NHS England) and apply ‘NHS inflation’ of 4%, then this year’s funding should be £120bn just for the NHS to scrape by. For comparison, the 2016/17 budget is £105bn. So the NHS is currently about £15bn behind, increasing to a gap of around £35bn in 2020/21 if the government continue with their current plans.

The good news is that our NHS is truly a budget service right now, and we can afford to increase our spending.  If we were to catch up with the French, Germans, Canadians, Swiss, Japanese, etc, we’d spend about £35bn more on the NHS. The bad news is that the government, be it through ideology or deliberate maleficence, are refusing to spend that much. The great irony is that increased NHS spending would actually stimulate the economy, helping us get out of the austerity rut. We can only hope that the political choice to underfund the NHS will be overturned now that more and more professionals are speaking up.

Newspeak and the NHS

NHSpace is fed up with the various catchphrases used by the government and the media to spin stories about the NHS. Here are our top five, handily debunked and translated.

1 – Excessive demand / high bed usage

The NHS has seen a steady reduction in the number of inpatient beds, whereas the population has steadily risen and social care needs upon discharge have increased.

The overall number of ‘finished admission episodes‘ has increased by 2-3% each year, in a reasonably predictable manner. The same goes for emergency admissions, and the recently reported ‘unprecedented increase’ in emergencies is again only a 3% rise.

When the government say that hospitals are under strain from unprecedented demand, they actually mean unprecedented bed reductions and a lack of social care. If social care was properly funded then many patients could be discharged from hospital in a more timely fashion. And rather than year-on-year cuts, bed numbers need to at least increase in line with the population (around 1% each year).

2 – Overspending / hospitals in debt

The NHS budget has fallen in recent years, in real terms. We also spend less per head of population on healthcare than many other westernised countries. It should be clear that hospitals aren’t overspending, but are actually spending less than they should on their patients, all thanks to significant underfunding.

But the story goes further than that. To whom are the hospitals in debt? “The government had to lend cash-strapped hospitals a record £2.825bn in the last financial year” the Guardian reported in July this year. So state-funded hospitals are in debt to the state. Regardless of the fact that hospitals are being turned into independent businesses, they are still really underfunded rather than being in debt.

3 – No money left

The UK government cannot actually run out of money per se. If they spend too much and don’t apply enough taxation, then inflation will rise, but an increase in NHS funding doesn’t have to mean an immediate ‘NHS tax’. (Government spending is a matter of macroeconomics, and isn’t like a household budget.) The government could choose to provide an additional investment in our NHS in order to bring NHS funding in line with our European neighbours.

Every additional £1 spent on the NHS would boost the economy by £3 by supporting jobs and keeping people healthy. That means a £30bn injection of funding, which would represent a 3.8% of GDP increase in state spending, could increase the UK’s GDP by 4.4%. And this is nothing compared to what the King’s Fund think we could support. Their analysis suggests that, in the next few decades, the NHS could be funded to a much greater extent and still be affordable.

So far from there being no money left, the government could invest in the NHS and reap the economic rewards. Instead there is a political choice not to spend.

4 – 7 day NHS / weekend effect

The NHS is already open on weekends, and most specialties have consultants on-call and doctors on-site 24/7.

Hunt’s 7-day NHS is actually part of a top-down reform, pushed upon doctors at a time when government-enforced cuts mean that the NHS is already stretched too far. Forcing staff to work longer hours whilst using STP hospital closure plans to close departments isn’t safe, so Hunt needed a stick to beat them with.

This is where the weekend effect came in. A study commissioned by Hunt’s department, interpreted wrongly by Hunt, and quoted in press releases before it was even published, was used to attack doctors for working safe hours. How dare they only work one-in-four weekends when Hunt had proof that patients were coming to harm? But, as academics have revealed, Hunt’s weekend effect was based on flawed data and a downright flawed interpretation.

With his weekend effect rubbished, Hunt is now trying to make the conversation about doctors’ salaries, when in fact it’s about overstretching an understaffed service.

5 – Sustainability and Transformation

The Sustainability and Transformation Plans are supposedly about creating a modernised NHS. In reality, sustainability actually means financial restrictions and transformation means enforced closures and outsourcing. Any NHS organisation failing to follow the STPs will be denied what little new funding there is to be had, and will face a ‘failure regime’.

The end game here is for the government to whittle the NHS down into an basics-only service with a few large hospitals offering emergency and major illness care only. A two tier system will emerge, where a significant amount of routine care will be available privately and not funded by the NHS.

Doctors’ Strikes: Time For One Final Push

An open letter from the NHSpace blog to all those doctors considering what action to take.

Dear doctors,

You’ve come a long way since the ballot on industrial action last year. You’ve forced the government to come back to the table at least twice, and got concessions out of them. You did this by maintaining a united front, and by being honest and measured whilst your opponents were being deceitful and excessive.

That’s why you still hold the cards. Hunt went all-in months ago with his ‘imposition’. He has no greater sanction left, and can only harm you in the court of public opinion. And so Hunt is trying to convince the public to turn against you.

“Hunt’s contract is far more damaging than any strike. He’s stretched the NHS so thin that people are already falling through the cracks.”

But he hasn’t succeeded yet. A new poll shows 57% of the public still support the strikes, and 51% believe Hunt should not have been reappointed. You can still win the public relations battle. Just do the following:

1 – Be team players. If the public think that doctors are divided over the contract and the strikes, they’ll lose faith in you.

2 – Be constructive. If you don’t like the strikes, focus your energy on talking about the issues you want fixed, rather than attacking your colleagues.

3 – Keep the message simple. The government are still pursuing the ‘7-day NHS’ line, which is easy for the public to follow. So remember: Hunt’s contract is far more damaging than any strike. He’s stretched the NHS so thin that people are already falling through the cracks.

4 – Expect to win, and soon. The government may have put on their poker face, but underneath the pressure is showing. If you can keep the public on your side, the government will have to cave in soon.

Regardless of what you think of the strikes, you must work together to win this fight. The very future of the NHS depends on your actions in these coming days and weeks.

Best wishes,

NHAspace