Sunday, 5 November 2017


All the BFTF NHS related posts, brought together in one place....


Apr 2018

"The NHS trusts are claiming they should be classified as charities, meaning they would be eligible for a tax break. Charities enjoy an 80% discount on business rates, which is the equivalent of council tax for non-residential tenants of property. Universities already qualify for relief, as do some private healthcare providers, such as Nuffield Health, which is registered as a charity..." - Link

Asked local CCG why NHS had to pay business rates and whether any private healthcare companies in Nottingham or Nottinghamshire were getting businesss rate tax cuts by calling themselves charities.

Asked local Conservative Party the same thing.


Dec 2017 : Mental Health Treatment Trends

Seeing a lot of discussion about Mental Health Treatment, for example this from the Conservative Party:
Conservative Facebook Post Dec 2017

The Guardian explains that this is in relation to a forthcoming Green Paper, but that trials will only start in 2019, it is not clear where the money is coming from; and the only aspiration is to have about 1/5 of children covered by 2022/23.

It seems to be very difficult to find the data that shows the trends over time. It would be useful to know, for example, how the numbers of young people, the number of admissions, the treatment waiting times and bed occupancy rates have changed over time. Some partial data in the chart below:
Some data here

And also this Kings Fund article from 2010, which comprehensively lists the status of the various NHS targets at that time.

Mental Health Waiting time standards were introduced only in 2015

Most relevantly, this 2017 report by the Childrens Commissioner comments that :

I have conducted a thorough examination of the current system of children’s mental health care. In particular, I was interested to compare the systems for adult mental health with that for children. The results are shocking. There are enormous disparities. NHS England lays out clear expectations to local areas about what should be provided for adults, backed up by targets and benchmarks on success rates and waiting times. In contrast, there is no monitoring of how many children are seeking mental health treatment, no information on how many are accepted into treatment, how long they will wait or what outcomes they achieve.

There were no children’s mental health national targets until last year – now there are nine indicators, but these are not are top priority targets. . At a time when the NHS is under exceptional financial pressure, the system in place makes it all too easy for children’s mental health to be ignored. Nearly 60% of local areas are failing to meet NHS England’s own benchmarks for local area improvement.

The picture is even bleaker when it comes to early help for children with emerging problems. There is no clear expectation placed on local areas about which services should be provided, or how ill a child needs to be before they should receive care. No information is collected on which local services are available, and the evidence that has been collected, by myself and a range of other bodies, reveals a postcode lottery of care. ****************************

Dec 2016 : Attempted Suicide rates

Disturbing article by the Disability News Service describes how NHS data shows that, although only one in 15 adults (6.7 per cent) in the general population had ever made a suicide attempt, that rose to 43.2 per cent for ESA claimants, and as high as 47.1 per cent for female ESA claimants. They also show that two-thirds of ESA claimants (66 per cent) had thought of taking their own life at some point, compared to 20.6 per cent in the overall adult population. ****************************

Dec 2017 : Virgin Health Care sues the NHS

Disturbing to read that Virgin Health Care has successfully sued six Surrey clinical commissioning groups (CCGs) after they chose to award NHS contracts to a consortium of NHS providers (see also here)

BFTF asked the local CCG, and Labour and Conservative Parties some questions : Why is money being taken off the NHS bottom line? Why was Virgin able to win its case? How much did the tender process itself cost? Why did Virgin's contract bid fail? How much disruption are these constant bidding processes themselves causing to the NHS? Was the Virgin bid "cherry picking" the easy parts from that part of the healthcare system?


Dec 2016 : STPs

The Sustainability and Tranformation Plan for Nottingham NHS had been published at The plan has to provide for £628 million of cuts from the projected funding required over the next five years.

The local branch of the The Royal College of Nursing state that :
"It's staggering that such significant plans that are going to change the structure of the NHS have been devised with barely a word of conversation with the public about what the change will mean...It is impossible to cut £500 million to £600 million from the NHS and somehow not having a significant and adverse impact on firstly the availability of health care services on which public depend and also the quality of those services in our view..."

38Degrees are running a campaign to halt the implementation of the STP's. The campaign quotes Health Secretary Jeremy Hunt saying that the NHS should be "finding a way forwards to the kind of budgetary arrangements you would have in [US Healthcare companies] Valencia or Kaiser Permanente". 38Degrees also advised people to "..write to our CCGs, Councillors and MPs to say Stop the Contracts!..."

See also comments and other background at The Kings Fund ; Patients4NHS; a BMJ blog ; HuffPo. See also reports by the Health Foundation on: Comparisons to other Countries
Current NHS Spending in the UK

38 Degrees "NHS Crisis Tracker" here. Nottinghams situation is that 21% of A&E attendees are only seen after 4hrs (max should be 5%) and there is a £628million funding gap)

See also another petition from 38 Degrees, this relates to fears that the Chief Executive of NHS England, Simon Stevens [previously global ops president for United Health of America] has created a plan to solve winter A&E crises by CLOSING more A&Es. He thinks if you close hospitals people will stop using them...To work [STP plans]they have to be able to prove they can clear their massive debts within a year. To do that they have to close services and sell land and hospitals.

...Simon Stevens says that to make the NHS affordable we, the public, must get used to no longer having a major hospital within easy reach...In 2013 there were 140 full A&E hospitals in England. We could be be left with between 40-70 A&Es. Closing A&Es is very bad for your health.


Nov 2015 : DoH "Consultation" on NHS Priorities

Department of Health VERY reluctant to publise their .... public consultation on NHS priorities (see also Daily Mirror and the Indy).

BFTF notes that, between 29th Oct and 19th Nov (i.e. prior to the media attention), the @DHgovuk Twitter account managed to Tweet about this important consultation exactly once, on the 29th Oct. In contrast, they managed to find time for over 60 Tweets about the Junior Doctors contract issue.

Was news of the NHS mandate consultation buried? You be the judge.


Oct 2015 : Commons Debate on NHS Staff Contracts

Video of the debate can be seen here and the Hansard record

Below are some extracts (from the Hansard record) that particularly caught BFTF's attention.

Helen Jones (Warrington North) (Lab):
“……Ministers criticise spending on agency staff, but the Government’s first act on coming into office in 2010 was to cut nurse training places by over 3,000 a year."

Aug 2014 : A variety of questions
Following the debacle of private eye operations at Vanguard Healthcare, asked NHS Nottingham, the city's Clinical Commissioning Group(CCG) how they would ensure that private companies would not be allowed to socialise the costs of their mistakes, nor hide behind "confidentiality agreements". They (after being chased for over a year) responded with:

"In Nottingham City we hold contracts with a number of providers; NHS and private and we apply the same terms and conditions regardless. All providers of services (NHS and private) are tightly monitored, both in terms of their performance and the quality of the services they deliver. So should there be an issue of poor performance this would be picked up and managed.

Thankfully we have not found ourselves in a position where we have had to terminate a contract, such as the situation you describe in Cornwall. This is not to say that it could not happen but we work very hard to maintain the contracts we hold and prevent this from happening. Of course problems can occur with NHS providers, big hospitals for instance, so it is not necessarily connected with being a private profit-making concern.

We do not enter into confidentiality agreements with our providers and performance reports on our providers are presented to the CCG’s Governing Body and are therefore available to the public. If you are interested you can see these on our website on the Governing Body section.

There are a number of mechanisms for capturing any concerns about a provider. We receive regular performance and quality reports from our providers, there are hard data such as re-admission or repeat operation numbers which would alert us to any problems and then there are a number of sources of soft intelligence such as GPs and our patients who tell us when they think there is a concern about a service. We also work closely with other local CCGs, NHS England and the Care Quality Commission, all of whom are stakeholders in the business of ensuring good quality services for our patients."

To a layperson like BFTF, this all sounds broadly reassuring. The CCG explains its role more fully in the NHS Nottingham "Patient Prospectus"

Update Sep 2015
Also asked the CCG how the managed conflicts of interest (for example, board members voting for services that they had a financial stake in). Very quickly received the following response:
The CCG has developed a specific Conflicts of Interest Policy to ensure that arrangements are in place to manage any conflicts and potential conflicts of interest. The policy applies to all employees and appointees of the CCG, all member practices of the CCG (single-handed practitioners, practice partners, or their equivalent) and to third parties acting on behalf of the CCG. A key part of our arrangements is the maintenance of our Register of Declared Interests and the register for our Governing Body members is available to view on our website [link].

The Governing Body and all Committees of the Governing Body (our key-decision making fora) all have an extract of the register (showing members' interests) included with papers at meetings. As an additional safeguard, we also have a specific item on every Governing Body and Committee meeting agenda to identify any conflicts of interest, or perceived conflicts of interest, in relation to any agenda item. This also ensures that any actions taken to manage the conflict are clearly documented.

To ensure awareness of this area, the CCG mandates training on conflicts of interest for all employees and appointees and we have previously run a Governing Body development session for Governing Body members on this area. The Conflicts of Interest Policy is available on our website at [link]

In addition, the CCG also has a Procurement, Patient Choice and Competition Policy that describes how the CCG will ensure that potential conflicts of interest are considered as part of the decision-making and procurement process. The CCG also requires that all potential bidders/contractors declare relevant interests as part of every procurement process.

Oct 2014 : Dysfunction in us Healthacare
US academic Molly Worthen has written about her experiences of negotiating the privatised US healthcare system during her pregnancy.

It is not a happy story.
"My husband and I pulled into the parking lot for our first prenatal appointment 15 minutes early, excited to see the first ultrasound of the gummy-bear-sized creature in my belly. But before we laid eyes on a nurse or an ultrasound technician, the receptionist ushered us in for a meeting with a far more important person: Tami, the “financial counselor.”

where an administrator handed them a worksheet and explained the $1,100 fee that they had to pay up front - and which did not include hospital charges or many other items. When Molly's husband asked how much they would have to pay in total, assuming it what a routine birth, the response was :
“Oh, I couldn’t tell you that,”

Nor was their insurance company any more helpful, and neither could anyone give a cost for a specific treatment, saying that such information was "confidential". This level of dysfunctionality, of course, does not come cheap - US citizens paid some $200 billion in excess administrative fees in 2009, much of which could be emininated if the US adopted a public single-payer system of the kind that most developed countries favor.

And the US system does not even really provide much healthcare - Molly found out that her family could have to pay up to $20,000 per year if a health crisis struck them after the child was born. Molly sums up her findings thus :
"A truly free market requires all parties to have access to the same information—and the time and expertise to interpret that information. Healthcare, by contrast, is an economy of specialized goods that most lay people don’t fully understand, in which insurance companies and many healthcare providers have a vested interest in concealing prices from consumers....

...What we have here is not a free market, but a failed one. Healthcare seems to be the only unpriced good in America. Most of us wouldn’t even buy groceries without comparing prices first. Imagine a store with no price labels at all—only the products aren’t corn flakes and cantaloupe, but appendectomies and hip replacements. Even in non-emergency cases, when consumers might have the luxury of comparing hospitals rather than calling an ambulance, most of us would rather trust the advice of our doctors than shop around for, say, bargain-basement chemotherapy.

If I, with my fancy PhD and free time to spend on the phone with clerks and bureaucrats, haven’t been able to figure out the cost of something as commonplace as having a baby, how must other people fare? "

Aug 2014 : The Coalition Agreement - what is says about the NHS

The Coalition Agreement set out the how the Conservative and LibDem parties were going to govern the UK. It can be found here. Below is what it says about the NHS. You may wish to read it and decide whether the Government has done what it said it would do. A few of the promises shown below.

"The Government believes that the NHS is an important expression of our national values. We are committed to an NHS that is free at the point of use and available to everyone based on need, not the ability to pay. We want to free NHS staff from political micromanagement, increase democratic participation in the NHS and make the NHS more accountable to the patients that it serves. That way we will drive up standards, support professional responsibility, deliver better value for money and create a healthier nation.

We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.

We will significantly cut the number of health quangos.

We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.

We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services.

We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers."

June 2013 : Why is Lewisham A&E under threat?
BFTF has been distrubed to read reports of proposals to downgrade the high-quality A&E department at Lewisham Hospital in South East London. So far as BFTF can tell, this is being considered because the South London Healthcare NHS Trust (which runs the Queen Mary's (Sidcup), Queen Elizabeth (Woolwich) and Princess Royal (Orpington) is struggling to meet the PFI payments on the latter two hospitals.

Note that Lewisham Hospital is not part of this financially struggling group.

Politically, there is plenty of blame to spread around here, with PFI originally being championed by the previous Conservative administration, the specific Queen Elizabeth PFI contract being negotiated by the previous Labour administration, and with closure of the excellent Lewisham A&E being used as a sacrifical lamb by the present Conservative Liberal Democrat Coalition to save the struggling Queen Elizabeth Hospital.

Cyncially, while the NHS is prevented from using surpluses in one area to subsidise deficits in another (a rule imposed by the previous Labour administration) it is a very different story when cuts are being considered - which is why the excellent, and financially sound, Lewisham A&E is under threat (from the present Conservative Liberal Democrat administration).

According to the Save Lewisham Hospital campaign, the reasons for the downgrading of Lewisham A&E are based on a deeply flawed interpretation[Word File] of data.

BFTF is fearful that something similar could happen in Nottingham and has sent an email to the local Labour MP and to the local Conservative party saying that they should both be ashamed of the part their parties have played in the causing the present situation in Lewisham.

Example of how private healthcare companies have taken on a lot of debt, and need to service this.

In 2011 the former Tory leadership candidate Michael Portillo admitted that Cameron and the Tories had lied to the public about their intentions towards the NHS: "They did not believe they could win an election if they told you what they were going to do because people are so wedded to the NHS."

NHS: "no more top-down reorganisations"
Perhaps most infamously, the Conservatives repeatedly promised before the general election that there would be no more "top-down reorganisations" of the NHS (Andrew Lansley, Conservative Party press release, 11 July 2007). In a speech at the Royal College of Pathologists on 2 November 2009, Cameron said: "With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS." The coalition went on to launch the biggest top-down reorganisation of the service in its history.

Jan 2013 : Poor performance by SERCO
A report in the Guardian describes how SERCO, who had won the contract for the out-of-hours GP service in Cornwall presnted false data to the NHS on 252 separate occasions.

Nov 2012 : Broxtowe Save The NHS - Public Meeting
The newly formed “Broxtowe - Save Our NHS” group had a public meeting recently regarding the effects of the 2012 Health and Social Care Bill. There were three main speakers, and some of their points are outlined below.

Nick Palmer (former Labour MP for Broxtowe)
Nick began his talk by pointing out that when Labour entered office in 1997 the average waiting time for a hip replacement was 2yrs, and that patients were routinely told that they could instead have the same operation, by the same surgeon (!!!) privately within 2 months.

During Labours time in office, waiting times dropped dramatically. And the result of this was that fewer patients went private and the private healthcare companies lost a lot of business.

Nick went on to describe the three types of privatisation that he felt were now underway.

Privatisation of Provision - the fees that the government pays for each specific medical provision (from a hip operation to open heart surgery) are loaded in favour of the easier procedures that private companies prefer to undertake. In contrast, the fees for complex surgery do not cover costs. Traditionally, NHS hospitals could use the surplus from the easy operations to cover the losses in the complex ones - but with the easy operations being stripped out and handed to private companies this will no longer be possible. And as a result, NHS trusts will find themselves at much greater risk of going bust.

Privatisation of Patients - the amount of private work the NHS is allowed to perform was increased in theSocial Care Bill from the previous limit of around 5% to 49%. Supporters of the Bill claim that this money will go straight back into the NHS but Nick was concerned that NHS managers- under intense financial pressure - would use the money not for general care but to build more money-making private facilities - sending us back to the situation that existed in 1997.

Privatisation of Preventative Care - Unbelievably, the new Clinical Commissioning Groups (CCG’s) do not have any responsibility for preventative health care, so this is being landed on councils, who do not have the funding or the expertise to undertake this work. To call this shortsighted seems something of an understatement. Nick pointed out that the Nye Bevin, the architect of the NHS, said at its inception that it was about prevention as well as cure.

So what is to be done? Nick felt that it was not necessarily wise to simply dismantle the whole Bill, should Labour be elected at the next election, and that there were two specific areas that, if addressed, would alleviate most of the damage that the Bill was doing. Firstly, that the financial pressure on hospital managers should stop and secondly the existing NHS provision should be given priority in any tendering competition.

The doctor said that some of the objectives that Landsley stated for the Bill (such as clinicians input into service provision) were things that doctors were happy to do for free - it did not need legisalation. What needed legislation were the elements of the Bill that enabled privatisation.

Dr Chopra felt that this profit motive was having adverse effects for the NHS, saying that GP practices run by private companies sometimes had only one permanent doctor, with the rest being made up of locums. This saved money but provided a poorer quality of service for the patient. Another example given was that of the report into Winterbourne View Hospital, were patients were ill treated, with Dr Chopra stating that the investigation into the abuse there identified the profit motive as being a factor (BFTF has found a link to the report (see here) and it states that “Castlebeck Ltd appears to have made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment andrehabilitation “)

ATOS won a contract for performing “Benefit Tests” and then promptly subcontracted the work back to the Lanarkshire NHS - presumably after taking a profit.

An extra-short version of recent interview wwith Prof Ian Shaw for the time poor / attention span challenged out there (long version here). Prof Ian Shaw is the Professor of Health Policy at the University of Nottingham’s School of Sociology and Social Policy, and is also (amongst other things) a Non-Executive Director of NHS Nottingham City Primary Care Trust.

BFTF: How can people find out more about what the directors of the NHS are doing?

Ian Shaw : The best thing to do at the moment, because we are in a period of transition, moving from PCTs being in charge of the buying and selling of health services. . .to the clinical commissioning groups doing it. If you google “NHS Nottingham City” you’ll get the website with both the CCG and the PCT and all the board papers are on there, published at least a week in advance and the public is welcome to ask questions which are read out in board and to attend the board meetings as well.

BFTF: You have a very interesting blog and one of the posts was about the “Kidderminster Effect” and how competition doesn’t always pan out to be a good thing. Can you give a little more information on this?

Ian Shaw : Kidderminster was a district general hospital, a bit like the QMC only a lot smaller, in Worcestershire. And Worcestershire had [but didn't really need] three district general hospitals serving around 526,000 people. . .so they decided to beef up two and close Kidderminster.And they did it BADLY. They didn’t tell people WHY they needed to close Kidderminster. . . it wasn’t explained to the doctors in the communities, they just decided to do it. And it was a misunderstanding about who owns the NHS. The managers thought they owned it. They don’t - the people own it.

BFTF: Moving on a little to talk about competition. On the one hand superficially you can understand it, people are competing, they’ll try harder. But then you think about within an organisation - suppose you have an engineering company with five engineers - if they are all each keeping their good practice to themselves, they are hoarding their secrets, they don’t want to co-operate with the other engineers - that company isn’t going to last very long. How do those two drivers relate to the NHS?

Ian Shaw : There is what’s happened historically and there is what is going to happen in the future - so I’ll handle those separately.

What has happened in the past is that going back to 1997 . . . at that time there were people waiting for nine months on waiting lists - and that wasn’t uncommon so what the NHS did was say, here are some more resources, we want more facilities but also, if you can use the private sector sensibly where there are large queues to take the pressure until this new money in the NHS can build capacity then that is a sensible way to do it.

A&E Department, QMC, Nottingham

So that was the situation before the introduction of the NHS and Community Care Bill. The situation after its introduction, which is now, is that all significant contracts are going to have to be put on open tender. That means that the private sector can compete with your local community NHS service for example or your out-of-hours doctors service to compete for that service. They will compete on costs and on quality and it is up to the primary care trust at the moment, CCG’s soon, to procure those services through a contracting procedure and monitor them once the contract has been done.

BFTF: How does European competition law and the wish to balance cost and quality affect how decisions might be made?

Ian Shaw : If - IF - the contract continues to be based on quality so that it is the same quality going across and what you are doing is competing on quality then that is not necessarily a bad thing. . . It’s get into difficult waters if you start competing price, if you compete on price you are goinf to be driving the quality levels down. Competition has got to be done on quality and at the moment the safeguard is still there for competition to be done on quality but it’s literally a very small safeguard. . .

BFTF: You have mentioned a House of Commons report that stated that transaction costs were 14% of NHS total costs, but that there was no evidence that these transactions delivered 14% more productivity. Could you just elaborate on that a little bit?

Ian Shaw : This was the House of Commons select committee report in 2009, which showed 14% of the total budget going transaction costs - they buying and selling of goods and services in the market, the contracting and the monitoring of these contracts . . .and there was no evidence at all that this was creating 14% of added value in terms of productivity or quality. . . . A big worry for me is that the level of management costs in these new commissioning groups is capped so it is going to be challenging to do all of the monitoring of the contracts, the quality assurance that they are going to have to do with increased numbers of providers.

BFTF: Can ordinary citizens challenge their local Conservative or Lib Dem parties or the Dept of Health and say “Can you assure me, as a Citizen, that these contacts are going to be monitored adequately?”

Ian Shaw : . . The big thing is the Health and Wellbeing boards which are set up by local authority area and decide the health and social care strategy for the communities which they serve. The elected representatives, councillors, form a large group on that board so that the attitudes of the councillors are REALLY important for how this is going to role out within a locality.

Harltey Road Medical Centre, Nottingham
BFTF: Why am I hearing these clearly defined points from you? Why didn’t I hear it on the news? Why didn’t I hear it from the MPs?

Ian Shaw : That is a long argument. Twitter has been alive with criticism over the BBC particularly on their reporting of the NHS reforms and particularly the protests against the NHS reforms. There is not one single Royal College or Union which has not stood up to these reforms. They are trying to impose reforms on the NHS when all the Royal Colleges and unions are against it. . . Al Jazeera covered the NHS protests far better than the BBC. . .

BFTF: One other point about the Bill, perhaps a bit of a technical point, but one that is often mentioned is that the Bill allows Trusts to take up to 49% of private work [compared to a 3% cap before]. What is the concern here?

Ian Shaw : The concern is two fold. Firstly, most of the big NHS Trusts are working at full capacity anyway, so where are they going to get 49% of free space to bring in private patients. . . And the second thing is, why on earth would someone want to go privately when they can have things done free, to a good quality, in a timely manner within the NHS where they also have choice.

BFTF: Before we wind up the interview, is there any key message you want to get across to the public.?

Ian Shaw : There is concern about the direction of travel of the NHS. . . I am concerned that the “free at the point of use” bit - which is there now, it’s there with these new reforms but I think it might be under threat in the future. Bevan said that the NHS would be there so long as people defend it and I think that people need to be aware that it needs defending.

BFTF: Do you think it might go the way of dentistry has gone?

Ian Shaw : Well that is one of the scenarios on under this direction of travel. You might get the basic service free but they might say, “well, you’re in a bed, we’re changing your sheets, we are going to charge you hotel fees and we’re feeding you so we are going to charge you for food”. You can see the ways in which a cash starved service might keep to the letter of free-at-the-point-of-use but actually the add-ons become very expensive and in the US almost half of all bankruptcies are because they cannot afford to pay their medical bills and I would hate to see Britain move to that situation - nobody is suggesting that they are moving to that situation at the moment but I think that really we need to be alert to the possibilities that the direction of travel is moving.
NHS Flag, QMC, Nottingham

Image Sources: All BFTF's own.

Mar 2012 : This is what is wrong with the NHS Bill
A Tweet pointed BFTF towards the site of Prof Allyson Pollock (professor of public health research and policy at Queen Mary, University of London). Allyson, with the help of others, has compiled a series of briefing papers on the Bill. And it is worth noting thatthe bill's proposals were not discussed during the 2010 general election campaign, nor were they contained in the Conservative – Liberal Democrat coalition agreement.
In contrast, here is an article by Baroness Warsi, outlining the Conservative perspective.

And here is a blog post that tries hard to be as even handed as possible.