NHS for Sale: Myths, Lies & Deception (18 page)

It is easy to see why Labour might be especially keen to
keep these suggestions out of the public view, especially in the run-up to the forthcoming election. Andrew Lansley was equally determined, and much more successful, in the challenge of keeping his own plans – for a wholesale, top-down reorganisation of the NHS, and opening an ever-greater share of the NHS budget to potential private providers – out of sight until after the votes had been counted.

Clause 1 of the HSC Act ended the duty of the Secretary of State to secure or provide a universal and comprehensive health service in England. This responsibility was transferred to the body now known as NHS England. Lansley’s successor as Health Secretary, Jeremy Hunt, has taken full advantage of the new scope this has given him.

Released from any formal responsibility Hunt has repeatedly used his position to criticise the NHS whenever things go wrong, while doing nothing to address the resource constraints or inefficiencies imposed upon it by his own government. In this way the HSC Act can be seen as a way of ‘liberating’ not the NHS but ministers – to attack it whenever they feel it politic to do so.

Hunt clearly feels free to point the finger of blame for any problems either at the local commissioners and providers of services, or at NHS England, the new national commissioning board which is now theoretically responsible for commissioning – while the responsibility for frontline services remains firmly on the local NHS trust or Foundation Trust.

Lib Dem minister Norman Lamb has taken similar advantage of the separation of the NHS from parliamentary control, washing his hands of any responsibility for NHS England’s
decision to impose bigger cuts on mental health budgets than on acute hospitals.

Speaking to the NHS Confederation’s Mental Health Network,
¹³
Lamb criticised NHSE’s decision to impose a tariff reduction of 1.8 per cent in mental health contracts, compared with 1.5 per cent in acute care. He told delegates the decision was ‘flawed, not based on evidence and cannot be defended’. But then he dumped the problem straight back onto the mental health trusts, saying they should ‘fight’ with their commissioners over their contracts: ‘Do not accept a proposed settlement which results in mental health losing out.’

Since his Tory bosses have (with LibDem support) forced through legislation that puts all of the financial control in the hands of commissioners, and all of the problems in the court of the provider trusts, this is a cynical, hypocritical evasion.

However, Lamb’s outburst did at least confirm that the bold proposals of the Department of Health’s ‘Closing the Gap’ report,
¹⁴
launched by Lamb and Nick Clegg in January 2014 with the declared aim of working towards ‘parity of esteem’ between mental and physical health care, were not worth the paper they are written on. Having set up a dysfunctional system, Lib Dem ministers and Tories alike intend to stand back and blame the NHS as things go horribly wrong.

Now the Secretary of State is no longer responsible, in theory accountability for our health services runs through a variety of bureaucratic bodies. The Act established a new NHS Commissioning Board, now known as NHS England, which is responsible overall for the commissioning of primary care and specialist services, and for vetting the constitutions, setting the budgets and monitoring the decisions of all 211 local commissioners (Clinical Commissioning Groups).

The new regulator of the NHS is an expanded version of Monitor, which was set up by Labour in 2004 to regulate foundation trust hospitals. The regulator of quality and patient safety is the Care Quality Commission. On top of this there is the least well-known regulator of all, the Medicines and Healthcare products Regulatory Agency (MHRA) whose impotence was clearly demonstrated during the PIP breast implants scandal (see
Chapter 8
). However not one of these bodies, which are supposed to be the vehicle for accountability and transparency, is either accountable or transparent.

NHS England makes a great show of holding its board meetings not only in public but streamed on the Internet, but the agendas make clear that the meetings are dealing with only a small part of the business that passes through NHS England.

On a day-to-day basis much of the activity flows instead through NHS England’s network of Local Area Teams (LATs). These are the even more bureaucratic and secretive equivalent of the old strategic health authorities (SHAs). However, unlike the old SHAs, the LATs appear to have no formal structure of meetings, and offer no public access to board meetings or to board papers. They are ‘accountable’ only vertically upwards to NHS England and not at all downwards to the towns, cities and communities whose health services are subject to their decisions.

They may be obscure bodies to the public and health workers, but the LATs exercise real power over local services, shaping NHS England decisions over allocations to primary care and specialist services. Both of these face considerable
problems.

After years of steadily declining allocations of NHS resources to primary care,
¹⁵
planned revisions to the funding for GP services in deprived areas threatened to make significant numbers of GP practices unsustainable, effectively forcing their closure, until a last-minute change of policy.
¹⁶
GPs, led by the Royal College of General Practitioners, are campaigning for an increased share of the NHS budget to be allocated to primary care, which, according to NHS England
¹⁷
and the Royal College of General Practitioners,
¹⁸
handles around 90 per cent of all daily encounters with patients – for less than 9 per cent of the funding.

Meanwhile there have been continuing arguments over NHS England’s inept commissioning of mental health services, which led to them attempting to impose a tariff for secure forensic services which favoured poor quality private services over top quality and effective NHS care.
¹⁹
While a makeshift formula has so far been able to protect the NHS trusts that would have lost out on this formula, problems of desperate shortages of specialist inpatient services for Child and Adolescent Mental Health Services (CAMHS) have continued unabated, with some children transported up to 275 miles across the country in search of a bed. There are also serious shortages of appropriately-trained CAMHS staff, community based services, and intensive outreach teams, resulting in delays in discharging those patients who have managed to access services.
²⁰

As this chapter is completed comes news that in another abrupt retreat NHS England has been forced to abandon its silly plan to incentivise GPs to diagnose dementia in older patients with a ‘bounty’ of £50 for each diagnosis. The plan has been ‘ended before it even began’.
²¹

NHS England’s lack of local accountability and transparency, and the difficulty local communities and health professionals have in engaging with its far from accessible LATs have compounded these problems. They leave plenty of scope for further policy blunders and omissions in future, as the board attempts to rein in overspending of almost £400m in 2013-14.
²²

Similar problems of accountability and transparency apply to the workings of Monitor, which since the HSC Act is the overall regulator of the NHS, setting prices for NHS-funded care and compiling a register of 147 foundation trusts and 96 private providers who are licensed to deliver NHS-funded treatment.

The HSC Act also gave Monitor a contradictory brief, making it responsible both for ensuring ‘integration’ of services
and
for preventing ‘anti-competitive’ behaviour (i.e. promoting competition). Monitor has been criticised for using its powers to license Foundation Trusts as a way to scale back hospital and community services in England. This threatens to reduce NHS-funded care after 2016 (when new regulations come into force) to a ‘basic package of services equivalent to those that must be provided in the event of foundation trust failure’.
²³

Meanwhile the Commons Public Accounts Committee has expressed different concerns over Monitor and its ability to cope with its expanded brief. It points out that Monitor is hampered by a lack of clinical expertise and frontline NHS management experience. Just 21 of its 337 staff have an NHS operational background, and only seven are clinicians, meaning that 92 per cent of Monitor’s staff have no appropriate background for the role they are supposed
to play. By contrast no fewer than thirty people are employed on PR spin in Monitor’s huge department of ‘strategic communications’.
²⁴

Almost 20 per cent of Monitor’s £45m budget is spent hiring external management consultants to fill gaps in expertise and make up the numbers. Even with these staff, who do not assist in the development of in-house knowledge, Monitor is still 25 per cent short of the 450 staff it estimates are needed to fulfil its obligations properly. It is not clear who is accountable for regulating and scrutinising the work of this regulator.

One of the least transparent parts of the NHS has been the foundation trusts, many of which have eagerly exploited the ‘freedom’ to hold their regular meetings in secret and publish no board papers. The HSC Act offers them even more dubious ‘freedoms’, allowing them to raise up to half of their income from delivering private medicine to paying patients, or contracts with the private sector. The public have had no opportunity to express their views on these changes let alone vote on them; in fact most of the MPs nodding through the Bill that encouraged NHS hospitals to open more private beds and private clinics clearly had no idea what they were supporting.

Although the Act makes a token concession to some level of accountability by requiring a foundation trust to get support from its Board of Governors for such a policy, it is already clear that many foundations have forged ahead regardless, and expanded their private work substantially since the HSC Act became law.

Even if the governors were involved in some tokenistic level of discussion it is clear that these changes are taking place
with no engagement or transparency as far as the local public are concerned. By lifting restrictions on how much private money can be made in this way ordinary NHS patients cease to be the priority of some foundation trust managements, and become virtual second-class citizens compared with those with money to pay for their treatment.

The HSC Act has put the entire NHS at arm’s length from any democratic accountability, while at the same time opening the door for a growing range of services to be further distanced through contracts with ‘any qualified provider’.

Among Monitor’s obligations is the requirement to vet the private companies (‘qualified providers’) bidding for NHS contracts.
*
The Department of Health’s Operational Guidance to the NHS on ‘Extending Patient Choice of Provider’, published back in 2011 assured us that the ‘key principles’ of Any Qualified provider (AQP) were that: ‘Providers qualify and register to provide services via an assurance process that tests providers’ fitness to offer NHS-funded services … Competition is based on quality, not price.’
²⁵

However this is simply not happening. Shockingly neither Monitor nor the CQC currently holds or publishes any register of qualified providers. Monitor does not even bother to licence any organisation that has contracts with the NHS of less than £10m per year – thus excusing the vast majority of smaller ‘alternative’ providers and non-profit businesses from seeking any licence.

A call to Monitor by this author has confirmed that they have no register of AQP companies and organisations, nor
any plans to establish one. Indeed they would ‘love to know where there is a list’. Nor, it seems, is NHS England doing the job; they refer inquiries on to the Department of Health. The Department in turn appears to have decided to abandon its role in checking the credentials of would be private providers. It ceased to provide central support on this for commissioners as of 14 March 2014: ‘From 2014/15 onwards, qualification of providers will be entirely for commissioners to take forward with support from Commissioning Support Services, as required.’
²⁶

In the spring of 2014, the online ‘AQP Resource Centre’ was closed down as part of the Supply2Health website, which is also now defunct. Yet another responsibility has in this way been dumped back onto the local level by those supposed to be scrutinising and regulating NHS services. This opens a real possibility of a postcode lottery in which certain companies will be accepted as ‘qualified’ by some CCGs, but not by others, and where lessons learned in one location have no means of transmission to other potential commissioners. The system now makes it difficult even to develop the equivalent of the ‘Trip Advisor’ website which allows consumers (satisfied or not) to feed back on their experience of hotels, resorts and restaurants.

This is a long way from transparency, and leaves huge scope for companies delivering poor and inadequate care to secure and retain ‘qualified’ status. Unlike NHS trusts, private companies delivering NHS clinical and other services are not subject to the Freedom of Information Act, allowing them to hide a multitude of potential sins and omissions.

Meanwhile there are question marks over the definition of ‘qualified’ – and whether the qualifications are appropriate. In the spring of 2013, as Clinical Commissioning Groups
began to function in earnest, a search through the online lists of ‘any qualified providers’ revealed that a company known as ‘Minor Ops Ltd’ had been deemed qualified to deliver Adult Podiatry services in Darlington and County Durham. The company was given the contract as a parting shot by the Primary Care Trust.
²⁷
On closer inspection, four of the seven providers working under the label of ‘Minor Ops Ltd’ turn out to be optometrists or opticians – not the kind of specialists people with foot problems would normally expect to consult. The same company also operates on eyelids!