The NHS reforms- what they mean on the ground

Having been essentially ignored by most of the media for the past 18 months, the NHS reforms are all over the news in the last few days. The TV coverage has been mainly awful, chiefly consisting of proponents of the changes popping up to tell us how marvellous it’s all going to be. This reached a nadir for me last night when BBC South’s evening bulletin revealed that they couldn’t find a doctor to talk on camera in opposition to the plans. Now, given that every time doctors have been polled on these changes they have overwhelmingly rejected them, either the government have done an unprecedented job of persuading my famously stubborn profession, or people are too intimidated to speak out. This, at the same time that Jeremy Hunt is talking about absolute protection for whistle-blowers, sent a chill down my spine.

So I thought it might be helpful to describe the possible effect of these reforms on my own, very tiny and insignificant part of this vast healthcare landscape, to illustrate the possible effects on the whole, and why *spoiler* I think they are a terribly bad thing.

I run a small clinic in south London for children with developmental problems. For various reasons, we’ve missed out on a lot of the previous reforms instituted by Labour, so the current wave of upheaval will have an especially big effect on us.

The current situation is this. We are the only publicly-funded service of our type locally. We are funded by a contract based on the approximate needs of our population (not enough, and less every year, we all have to do our bit). Any professional who is concerned about a child can write to us, and we select those most likely to benefit from our assessment to see.

We see the child and family for 90 minutes initially, listening to them, interacting with and assessing the child, and gathering a load of information about the family circumstances and the child’s function within the family. Then we put together a developmental profile of the child, including why some of the problems might have occurred, and, if it’s going to be helpful, suggest some diagnostic labels to investigate

We then produce a comprehensive report, with some suggestions for useful next steps. We link with other publicly-funded local agencies to share knowledge expertise and plan co-ordinated intervention.

None of this is clever, high-tech stuff. It’s just care, thoughtful analysis, and common sense. It seems to work OK

So what will change now that everything’s opened up?

First of all we might not be running the clinic for much longer. The local commissioners are being forced to put almost all services out to competitive tender. This has two effects. Firstly to keep our service going we’ll need to spend money that is needed for front-line care on paying someone to put together a bid for the work, not once, but repeatedly every few years.  Secondly, whatever the government’s flimflam, if a private service of ‘apparently equivalent’ quality comes in with a cut-price loss-leading bid for what we do the commissioners will be obliged to award them the contract. Recent legal analysis has confirmed that this is the case despite the cosmetic rewriting of the regulations.

Now obviously if our service were privatised, this would be bad for me, but would it be bad for families? It would if you could construct a service that looks like it will be of equivalent  quality to ours, but actually isn’t. Anyone who works in any public service knows how easy this is.

For instance, the current draft NICE quality standards for ADHD specify who does the assessment, but not, bizarrely, what is done. So you could easily save money by cutting down the face-to-face time and instead of finding out about a wide spread of the child’s function and circumstances, just get the family to fill out some questionnaires aimed at specific diagnoses that you are fishing for, for instance ADHD or autism, then wheel in a consultant to deliver the diagnosis and get the prescription pad out. 

It seems clear to me that this is inferior care- it’s impersonal, it treats children as points on a graph not people, but also it will both over-diagnose some conditions and miss other important aspects altogether.

So the care itself might go downhill, but be cheaper. You might think that’s a reasonable trade-off so far. But there’s more; under the new system services will be paid per assessment, so it makes no sense to choose those who would benefit most- it makes far more sense to see straightforward cases and find a reason why complex ones should go elsewhere. And believe me, it can be done.

Finally there are no mechanisms in the new system to ensure that different agencies co-operate, so if our service gets taken over by say, Virgin, the joint work we do with educational, mental health and therapy services will instantly disappear, which will lead to fragmentation and duplication of work.

So in my little corner we are likely to see more financially-driven impersonal care directed not to areas of need but to where profits can be made. This will look great to a management consultant looking narrowly at our service’s efficiency, but it won’t look great to patients, and because of the fragmentation and duplication, it will be a less efficient use of public money.

Now think about scaling these changes up through the whole NHS. Depersonalised, financially driven care, fragmented services working against each other? Sound familiar at all?  Combine that with unprecedented savings demanded of all NHS services, and I hope you can see why so many of who work in the NHS fear that mid Staffs is only the beginning.

So what can we do? I’m at a low-point in my optimism about stopping this, I’m afraid. I suppose the Lords might vote down the competition regs on the 24th April, but with Labour going so very quiet on the subject in the last few months (no more Andy Burnham ‘i will repeal the bill, full stop’ tweets), I suspect we will need to wait for care to really disintegrate before the country wakes up and demands a sensible, integrated service run around patients, not finance.  



The Lewisham scandal: market failure and the NHS

Next week Jeremy Hunt will announce the closure of A&E and maternity services, in the face of a concerted campaign which culminated in today’s 20,000+ march. I don’t think he has any realistic choice but to do this, and here’s why..

When the Labour government turned hospitals into pseudo-companies and simultaneously saddled them with decades of debt via the PFI scheme which started in the 90s, they made it inevitable that some of these organisations would ‘fail’. 

By ‘fail’ I don’t mean that the hospitals would be bad or the care inadequate, just that for some of these hospitals their funding levels would not match their liabilities, especially with PFI added in. 

The failure of these organisations was put off by rising funding levels until recently, but now we’re here as the South London Healthcare (SLH) Trust has ‘gone into administration’. 

What does this mean? The hospitals haven’t closed, but the organisation is now overseen by a ‘special administrator’ to straighten out the finances. In the private sector a buyer would be sought and probably the business shrunk, closed, or merged into another. But this can’t happen to SLH- people would start dying fairly rapidly, and in its current state no-one would touch it with a bargepole financially.

The PFI liabilities can’t be changed, so the only other way to balance the books is to increase income. This, the administrator has suggested, can be achieved by removing acute services from Lewisham, so that more funding can flow to the SLH hospitals. They become viable financially and a private company, Circle say, is brought in to manage them.

Now I hope this is making sense from a money point of view. The problem is that it makes sod-all sense from a service perspective; there is no serious attempt to dress this up as of benefit to the service as a whole, or to the health of South Londoners. 

There has been an attempt to argue that poor management at SLH is the cause of the failure. Balls. SLH failed because it didn’t have a nice lucrative tertiary centre, and its two full general hospitals were both heavily indebted via PFI. Mistakes were made, of course, but mistakes are constantly made in all organisations (yes, even mine…). 

By the market logic that this government professes to swear by, SLH hospitals should be down-graded- after all, no-one asked Amazon to close its CD-selling department when HMV was in trouble. But of course this would make the hospitals permanently ‘unviable’. 

So we get the weird situation of Health Secretary who is avidly pro-privatisation and market forces recommending something utterly alien to capitalism- rewarding ‘failing’ organisations at the expense of ‘succeeding’ ones.

Because Lewisham Hospital is succeeding. It’s PFI debt is manageable (they do have one though), and, far more important, it’s clinical services are generally excellent. 

I hope it’s obvious by now that all this financial winning and losing is just a game that NHS organisations play- I see this all the time, from when in 2003 I was asked to record a patient’s admission as pneumonia rather that asthma because that payed more (I refused), to yesterday, when I learned about a trust who have built a state-of-the-art mental health facility… for other trusts’ patients. They all play this artificial system which determines funding, attracting the lucrative patients and contacts, neglecting those that don’t pay, and some lose that game. Although of course the only people who suffer are the patients, both in the ‘failing’ trusts, and throughout the NHS as this pointless financial roundabout has trebled admin costs.

So Jeremy Hunt has to decide the Lewisham loses its services. The alternative is to admit what a terrible, painful failure the NHS market experiment has been, and reverse the whole sorry process. And that’s never going to happen….. 

I’ve tried not to make this post personal, but I need to close by saying that Lewisham Hospital is where I started in Paediatrics, where I first kissed my wife, and where two of my children were born. It hurts me to see it brought low, but it hurts more to know that this will be the first of many such scandals.