NHS for Sale: Myths, Lies & Deception (17 page)

to create a single, clear and authoritative, democratic voice for local people that will monitor and scrutinise local health and social care services and plans for future developments, but also champion patient complaints.

Of course, one other important player behind the scenes of CCGs, in addition to the control exercised by NHS England, is the shadowy network of ‘commissioning support units’, some of which are clearly steering the CCGs towards greater and wider moves to put services out to tender. These bodies too are beyond any public scrutiny or accountability, and it seems likely that many of them would be privatised if the Tories win the next election: they are all due to be put out to tender by 2016.

The whole sorry history of the erosion of the public voice since the late 1990s has been accelerated dramatically by the HSC Act and the cash pressures of the coalition’s freeze on spending.

All this further exposes the cynical deception of Andrew Lansley’s plagiarised promise that patients and public would be far more involved: ‘nothing about me without me’. In fact almost every decision is now less likely than ever to be taken with any regard for the views and voice of patients, local communities or health professionals. The proliferation of commercial secrecy, from the very top right down to local commissioners and competing NHS trusts, means local people are even less likely to be aware of issues on which they might expect a say, and journalists find it harder than before to access information on controversial issues to inform their news audience.

The government’s real agenda is opening up wider private sector involvement, replacing NHS providers with social enterprises and prioritising competition over cooperation, collaboration and quality of patient care. This is incompatible with democratic accountability and a strong independent
voice for the public in influencing decisions. For people to take control, we need to dismantle the market and return the NHS to its founding values and purpose, allowing professionals to work together to address the health needs of local communities rather than tend the balance sheets of big business.

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A policy which the IMF has now decided was a big mistake – see Mayeda, A. 2014. ‘IMF’s Post-Crisis Austerity Call Mistaken, Watchdog Says’, Bloomberg, 4 November 2014:
http://www.bloomberg.com/news/2014-11-04/imf-s-post-crisis-austerity-call-mistaken-watchdog-says.html?hootPostID=913aee1114adb25290ac384f63ae0f80
.

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Hammersmith Hospital and Central Middlesex A&E departments, which have since closed, and virtually all acute and in-patient services as well as A&E at Charing Cross and Ealing Hospitals.

The NHS will become more transparent under proposals set out by the Health Secretary.
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Press release from Department of Health and Andrew Lansley, October 2011

There was plenty of rhetoric about accountability and transparency in the period during the passage of the Health and Social Care Bill but an examination of the small print revealed that the reality would be different. There was an early indication of Lansley’s real attitude to transparency when he refused to publish the risk register (which looked at the potential dangers if the Bill passed) despite having been ordered to do so by the Information Commissioner.

Clause 1 of the Bill ends the duty of the Secretary of State for health to ‘secure or provide’ a universal and comprehensive health service in England. This was a line in the sand for Lansley who was determined to make this change. The HSC Act has resulted in confused lines of accountability and a situation where a Secretary of State for health can criticise the NHS without offering solutions or acknowledging responsibility for problems arising from government policy.

Many features of the HSC Act conspire against transparency in the NHS. New bodies created by the Act do not have to
meet in public or publish their minutes. There are different standards for the private sector delivering NHS care – they are protected by ‘commercial confidentiality’. Information about their costs, profits and outcomes is unavailable and even parliamentary bodies struggle to find out the basic facts needed to assess their performance. Private companies are not subject to freedom of information requests. Despite promises to vet private companies bidding for NHS contracts there is no central register of ‘Any Qualified Providers’, nor any plan to establish one. Contrary to Lansley’s promise the NHS is now considerably less transparent and accountable than it was before the HSC Act came into force.

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Within a few weeks of the 2010 election, in a Department of Health press release on the White Paper ‘Equity and Excellence – Liberating the NHS’,
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Lansley made clear that in his new structure, the Secretary of State would no longer be in charge and therefore accountable for the NHS:

But I want to be clear – while the NHS will no longer be accountable to ministers or the Department for its performance in these areas, it will be very much accountable to the patients and public it serves.
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Few people listening would have immediately drawn the conclusion from this that the very first clause of the HSC Bill (now the Act) would take the step of scrapping the Secretary of State’s duty to provide universal and comprehensive health care, but of course it did.

A few days later, in a keynote policy speech to the NHS Confederation conference on 24 June 2010, Lansley claimed his White Paper, soon to be the Bill, represented a step towards transparency. He declared: ‘I will set out what the Secretary of State is and is not responsible for, and where the Secretary of State is not responsible, I will set out who is.’
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Lansley’s NHS Confederation speech also included a rousing commitment to ‘democratic accountability’. He promised that:

For the first time the voice of the public will be heard across commissioning, the public health service and social care. In these straitened financial times this accountability for how we use taxpayers’ money is even more important.

Despite Lansley’s fine phrases the ‘voice of the public’ has never been more marginalised than it has been since the HSC Act took effect (see
Chapter 6
). Not only did Lansley want to duck his own responsibility to steer the NHS, but he was also determined that the public would have no chance to hold commissioners or providers to account either.

Of course Lansley was not the first to offer a false prospect of transparency while in reality reducing the level of public accountability for local services and NHS bodies. But by opening up the NHS to greater involvement with the private sector, the HSC Act also meant the further surrender of public sector values and potential for accountability, in favour of the secretive approach that is common in the private sector.

New Labour was obsessed with transforming the NHS from a public service into a purchaser of care from a competitive market for healthcare services. This and the resultant increasing use of private sector providers alienated many of its supporters in the years from 2000. New Labour ministers also shrouded whole new areas which once were in the public domain under a dense cloud of ‘commercial confidentiality’ – including competitive tenders, the contracts for Independent Sector Treatment Centres and outsourced diagnostic services, and the details of contracts for new hospitals built under PFI.

PFI contracts and the process through which the final deal was negotiated have always been and remain especially opaque. In some cases – even where local union reps have battled for years to invoke their rights to see the finished text of PFI contracts under the Freedom of Information Act – they have been handed only heavily redacted versions, often missing the very sections of most interest to them.
⁵

While they were happy from time to time to take opportunist pot shots at secrecy under Labour, the Tories in government have been more than willing to behave in exactly the same way. The coalition government made clear from early on that they would pick and choose what information would be released not only to the wider public, but even to MPs deciding major policy changes.

One of the early, unresolved battles around the HSC Bill concerned Lansley’s dogged refusal to publish a ‘risk register’ compiled by Department of Health civil servants, exploring the potential dangers in the Bill and its implementation. Lansley defied not only the Labour opposition but also the Information Commissioner, who ruled that it was ‘unjustified’ to keep the register from MPs before they decided whether or not to support the huge Bill and its various clauses.
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Lansley refused to budge, and the document was (and still is) withheld from everyone including MPs who, perhaps shockingly, voted by a majority that they were happy to decide on the Bill in ignorance of the warnings it contained.

In May 2012, just after the Bill completed its progress through Parliament, the Department of Health pronounced that the risk register would definitely not be published.
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Instead a laundered ‘review’ of the Transition Risk Register was eventually published.
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The register itself was eventually leaked to a few, including commentator Roy Lilley.
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One fascinating example of a complete lack of transparency was the major report from McKinsey that was commissioned by Labour ministers in 2009 (in the aftermath of the banking
crash), some elements of which leaked out to the health service trade press.
¹⁰
In it McKinsey consultants put forward ideas for steps to bridge the widening gap between an NHS budget that would no longer be growing in real terms and the rising demand for services.

In place of a proper, evidence-based and fully argued report, McKinsey produced a set of 124 largely unconnected Powerpoint slides (with no accompanying narrative or evaluation of the strengths and weaknesses of the various proposals). McKinsey argued that by 2015 the cumulative spending gap could be as high as £20bn – and then set out a series of increasingly speculative and largely unexplained ideas on how to generate up to £20bn of ‘cost savings’.

The McKinsey document set out a wide range of proposals, but lacked any narrative explanation of how such measures were supposed to be implemented, or what any possible downsides and unintended consequences might be if they were. The evidence for most of their proposals was seriously deficient, or lacking altogether. But as news of the report leaked out in dribs and drabs, Labour ministers responded not only by denying that any of it was policy, and trying to distance themselves from having commissioned it – they refused point blank to publish it.

Lansley, then shadow health secretary, made great play of this in the run-up to the election, challenging and ridiculing Labour’s secrecy. Indeed one of Lansley’s first actions, once installed as Health Secretary in 2010, was to publish the McKinsey report, as he had promised.

However Lansley was also determined to enforce the £20bn savings target at the centre of the McKinsey plan. So denouncing and publishing the document turned out to be simply a prelude to Lansley effectively compelling almost
all commissioners and many NHS trusts to adopt some of McKinsey’s key proposals, and implement them in the quest for cost savings.

Since this one grand gesture of transparency (at the expense of the former government), the doors have swung completely shut once more. The drive towards greater secrecy has been resumed, taken to new levels by the fragmentation and attempts to foster competition set out in the HSC Act.

Labour’s suppression of the McKinsey proposals was most likely based on the document’s potentially explosive content – not least the threat to over 100,000 NHS jobs – although it may also have been partly due to embarrassment at the poor quality of the report they had paid for, which was little more than a string of unsupported assertions.

Eerily foreshadowing the Five Year Forward View document produced in October 2014 by NHS England chief executive Simon Stevens,
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the McKinsey suggestions began by insisting that heroic increases in productivity could be achieved – 15-22 per cent over three to five years, equivalent to £13-£20bn.
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But McKinsey went further: part of their £20bn target involved a 10 per cent reduction in staff – and a reduction in medical school training places to avert a surplus of doctors. Older GPs and community nursing staff would be offered early retirement. Staff who remained would be pressed to work more intensively, although how they could do that and maintain proper records and exchange information with
colleagues was not explained. The plans also demanded a concerted effort to push through hospital reconfigurations.

The drive for savings was broken down into eight main headings, including squeezing more ‘productivity’ out of acute hospitals (partly by reducing the tariff on which they would be paid for patient care) along with productivity savings from community and mental health services. There should be a programme of ‘estates optimisation’ – selling off ‘spare’ land and buildings.

Under ‘optimising spending’ came four pages of detailed suggestions on which treatments and operations the McKinsey team considered to offer ‘no or limited clinical benefit’, which many patients should therefore no longer be offered on the NHS – including some hip and knee replacements. Other types of treatment included on their list were tonsillectomy, back pain injections and fusion, grommets, hernia operations, varicose veins, minor skin surgery, cataract surgery and wisdom teeth extraction.

An expanded version of the document commissioned for NHS London included some added gems, such as the suggestion of cutting primary care consultation time by 33 per cent (from a target 12 minutes per patient to just 8) which McKinsey claimed could ‘save’ £570m.
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While the authors may have accurately calculated this potential (notional) cash saving, they appear to have devoted no attention at all to a risk analysis of this policy, or considerations of quality from the patient and GP points of view. Obviously if cash savings are the sole objective, cutting GP consultation times by 60, 80 or even 100 per cent could increase the savings much further – although with more drastic and obvious impact on patient care.