Wednesday, 11 May 2011

DOOMSDAY: How today’s NHS could be unrecognisable in four years.

It’s no secret that today’s current economic climate has not been particularly kind to the British National Health Service. Despite the government pledging to maintain NHS spending, in real terms the NHS will have to make £20 billion of ‘efficiency savings’ to stay financially even. Even considering regular reports, press releases, and political figures making their opinion on the matter very well known, none of these stories really stick. Instead, the public gets a bit worried, and is then quelled by terms like “efficiency savings”, or assurances that health services will not by government politicians.

Whether it is wishful thinking, ignorance, the news calendar, or lack of proper resources, the stories never progress, meaning that the real situation doesn’t get told. It’s a sad fact that every story that comes close to this very real doomsday scenario is also immediately shut down, whether by the aforementioned leaders, or the massive amount of news generated by other events produce. I’d be the first to agree that swine flu is important, or new cancer treatment is newsworthy. It’s also worth noting that in the recent months there have been several high profile stories that have taken precedence over the long term future of the NHS. For example, the death of Joanna Yeates, and the discovery of her body on Christmas Day is a tragic story that should definitely be told. Important world news must be reported. It can be argued that there is a sensationalist tendency in some tabloids, which means that difficult and complex issues like NHS reform may not be reported.

The issue is that high profile NHS stories have been in the news relatively infrequently. It is crucial for the public to understand what the implications of proposed NHS change means in the long term as well as the short term. Just a bit of warning, this is not good news. In fact it’s pretty depressing. But don't worry; it is, according to the Government, just pessimistic speculation. However, if that’s the case, its speculation based on the opinions of health care professionals, their professional organizations, such as the British Medical Association, Royal College of Nursing and Professions Allied to Medicine, plus think tanks like The Kings’ Fund and NHS insiders. Even the Chief Executive of the NHS is opposing the proposed ‘reforms’.

It all started with a White Paper, now a parliamentary Bill.

The White Paper, a government document proposing changes and future plans for the NHS is entitled ‘Equality and Excellence: Liberating the NHS. With sections like “putting patients and the public first” and ‘Autonomy, accountability and democratic legitimacy’, one could be forgiven for thinking that this paper is entirely devoted to making everything better. Indeed, superficially, it appears the only objective is for the good of the public. But there’s something lurking under the language. Something sinister and Orwellian. It doesn’t seem right, in this economic climate that there is cause for celebration in the proposals. We must examine what is meant by the repeated phrase;

“Increasing efficiency”

It’s right up there in the world of creepy double meaning. Just like the change from “Ministry of War” to “Ministry of Defence”, “Increasing efficiency” is one of those phrases you cannot dislike. Efficiency is good! And they are increasing it, which is a positive outcome because we get more? Right? Well, that may be true, but what it really means is “Cuts.”

The worrying parts of the White Paper consist of plans to, “liberate the NHS” .One clause explicitly deals with this liberation stating that the present Strategic Health Authorities, responsible for delivering regional strategic health planning to provide key high level care such as heart surgery, organ transplantation, neurological care and so on, will be dismantled. At the county level, the Primary Care Trusts, currently commissioning services on behalf of GPs and their patients, will be replaced by GP consortia. These consortia will be encouraged to purchase services directly from “any willing provider” on behalf of the patient. There will be financial incentives to consortia to buy services from the private sector, which means that in future diagnostics such as pathology tests, x rays, scans, really any type of operation that a company is willing to provide, can be bought from any provider.

Now, this may include the NHS, but it also might include ‘social enterprise businesses’, or private medical companies like Nuffield or Bupa. While this all sounds quite good, in reality hospitals will be left with difficult and expensive care, with the common, easy procedures being ‘cherry picked’ by the private sector.

This may liberate the NHS, in the sense that GP's may buy services at a lower price, saving money for the NHS. Unfortunately, due to how public finance and how the NHS works, it also takes money away.

NHS funding works on a cycle system, working with Strategic Health Authorities and Primary Care Trusts. It is hugely complicated, which is the problem with the NHS in general; it requires so much management because of all the services it provides. One must understand that Foundation Trust hospitals, whilst they are financed by the NHS, are a business. They need to make money (or revenue) by providing efficient and economical services for which the department of Health pays. A specialist hospital that focuses on heart surgery will often have chosen this focus in order to provide an essential regional service of a high caliber, generating income, as in NHS finance, the money follows the patient. E.g. Southmead Hospital in North Bristol is a leading renal unit, because it has developed this service to a very high level.

Hospitals also have to make money, to expand services and fund new buildings and facilities. Funding comes from the primary health care providers; GP's, who purchase services from the hospitals, which gives the hospitals money, which is provided by the Primary Care Trusts, whose focus is dealing with the money provided by the government and procuring services for patients. As I say; a cycle.

But this cycle is awkward. Money is lost in bureaucracy, but it does ensure that the right services are provided for patients. However, as demographic change, technological and pharmaceutical advances and diminishing resources collide, the costs are more than the money provided. A new MRI scanner costs more than £1million (An ordinary purchase).

The new White Paper has no incentive to buy services such as scans from hospitals. Instead, there is an incentive to buy from the third party providers, who offer this care more cheaply because they have much smaller overheads. This means that the Department of Health funds that were used to power the previously mentioned cycle, instead go in a straight line to third-party providers.

Presumably, the cycle therefore starves, and breaks.

This would be terrible on its own, but yet more factors exacerbate the situation. First, the conglomeration of GP’s called the GP consortia. With the White Paper, they are granted power that allows them to choose who to buy their services from, making competition inevitable between third-parties and NHS hospitals. And with the third-parties having better rates and lower overheads, the foundation trust hospitals would end up losing revenue. This proposes that should a hospital fail to balance its budget due to increased demand and inadequate funding, it will be allowed to ‘fail’. Also known as ‘going bankrupt’. However, the White Paper says nothing of what will happen to the patients or staff of the hospital.

Second, thanks to the economic climate, the NHS has to make ‘efficiency savings’ of £20 billion across the board. The official line by the government is that cutting administrations and management will mean that frontline clinical staff will be safe. However, NHS sources say that 75% of a hospitals budget is spent on staff, including management, and only 25% on consumables. They also say that 95% of staff are clinical, which means that if 20% of the budget is to be cut, where is this coming from? Well, clinical staff.

It is also worth stating that an average foundation trust has a similar budget to a FTSE 250 company, like WH Smith, the Daily Mail, and Easy Jet. No company that large would be able to function without a respectable amount of good managers, so even cutting management and administration would cause the workings of the NHS to suffer.

Whilst some jobs can be removed, people know that quality of care will suffer if too many clinical staff are fired, and financial success will suffer if too many administration staff go, both of which would undermine the governments standpoint. Instead, according to confidential sources, the plan of action is a jobs freeze. This means that vacant posts aren’t filled, and new posts are forbidden. No one is hired, and no-one is replaced. Staff will drip out slowly, care will suffer, and hospitals will be forced to stop certain services, specialist or otherwise.

But even with all of these actions, essential services and frontline staff will still be cut. With this, healthcare may become a postcode lottery. Hospitals with a catchment of less than 500,000 (government figures) may be classed as unviable, leading to their patients being absorbed into a larger hospital, which may be unable to deal with the influx of new patients. With this lack of hospitals in an increased catchment area, regardless of age, people will have to travel further for routine and emergency care. This means that it will be less of a postcode lottery, and more of a lottery as to whether people get to hospitals, or die in ambulances.

A final casualty of this fragmentation of patient care, brought about by the “efficiency savings”- competition, the stagnation of services available, and the lack of human resources, is patient records. When any NHS body delivers care, free at the point of delivery, but paid for by all through taxation, as it should be, records are kept. Regardless of where someone receives care, the healthcare professionals know one’s problems. One’s medical history is laid bare, greatly reducing the possibility of medical errors and actively improving care. If care is provided by third parties, records are unavailable to the NHS except by request. In an emergency situation, this may at best be a nuisance and at worst be life threatening. For example, a patient might need an emergency MRI, only to be severely injured because the NHS doctors were not aware of her heart pacemaker, inserted in a private hospital.

No healthcare system anywhere in the world has ever had to institute major systemic reform in an environment of diminishing resources and efficiency savings on a massive scale, whilst still maintaining patient care. No evidence exists to prove that this could happen, but a lot exists to prove that it couldn’t.

Aneurin Bevan, the post WW2 Minister for Health and creator of the NHS in 1948, said it should be the foundation of a welfare state ‘from the cradle to the grave’. In “liberating the NHS”, an organization we all rely on, NHS staff and patients have been hindered, handcuffed, and hung up to dry.

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