Social Justice. Equality. Enterprise.

New Fears for NHS after Coalition agree to Reforms


NHS reforms hide 'new threats', warns leading Lib Dem

The Guardian, 18 June 2011

Evan Harris predicts another MP rebellion, claiming the Tories want to bring in 'privatisation through another route'

A leading Liberal Democrat has warned there are "new threats" hidden within the reworked NHS plans that have been drawn up for the coalition.

The former MP Dr Evan Harris, who led the first Lib Dem rebellion which forced the government to "pause" its reforms and think again, has told the Guardian he can't rule out another Lib Dem rebellion if the coalition doesn't move to ameliorate three new problems in its proposals.

Harris has concerns regarding competition, commissioning of private firms, and the level of responsibility for the NHS held by the health secretary.

On Tuesday last week the group of professionals assigned to working out the compromise – the Future Forum – delivered their report, and the government is due to issue its response on Monday.

Harris believes "there are new threats to the NHS emerging as the Conservatives appear to try to bring in competition and privatisation through another route".

He hopes the government will register they agree with his concerns when they issue their formal response on Monday.

The former party health spokesman is speaking about the health reforms to 250 Liberal Democrat activists at the Social Liberal Forum (SLF) conference "Liberalism, Equality and the State" – a group that represents social democrats within the Lib Dems that have increasingly been concerned at the direction the coalition is taking.

Lib Dems say there remain ways in which they can register their unhappiness if concerns are not reflected in the government's response. The bill is only due to enter the House of Lords just after the autumn party conference season, and a rebellion when their party convenes for its conference could see amendments put down in the Lords.

Harris is a vice-chair of the Lib Dems Federal Policy Committee and a former health spokesman for the party. He spearheaded the rebellion at the Lib dem's party conference in March when activists voted in favour of deputy leader Nick Clegg blocking the coalition's reform plans.

He told the Guardian: "Liberal Democrats and healthcare professionals have largely succeeded in preventing Monitor [the proposed independent regulator] being used to marketise the health service but there's a real danger the new health bill, or the government's 'instructions' to the NHS Commissioning Board will force competition on local health services through a different route."

Harris highlighted the danger of essential NHS services being undermined by large numbers of cases, and the income that goes with them being farmed out, to private or third sector providers leaving an A&E, or intensive care unit unviable.

"The NHS doesn't need any favours on a level playing field but in the end it has to provide these emergencies and rescue services and it can't do that in a free market."

A second area identified by Harris was the potential for clinical commissioning groups to outsource most work to private companies with vested interests, beyond the scope of full public scrutiny.

"Commissioning healthcare is a key public function and we need to use the skills and experience of public health doctors and existing NHS staff to do it, rather than sharp-suited executives from private companies with their own agendas of simply making money."

Harris is also concerned that the government is still only placing a responsibility on to the secretary of state of the "duty to promote" rather than the stronger duty to "provide or secure the provision of" a comprehensive NHS service.

Harris said he had received advice from public interest lawyer Peter Roderick demonstrating that was now in doubt.

"If the government doesn't want the secretary of state to have a duty to provide a comprehensive NHS then they should say so and see it voted down by the Liberal Democrats. If they accept that the secretary of state cannot shrink from that responsibility they should make it clear."

Party grandees business secretary Vince Cable, deputy party leader Simon Hughes and energy secretary Chris Huhne will all address the SLF conference. Before the SLF's battle over the NHS the group was regarded by party managers as obscure, but it has now grown significantly in stature. It is expected attendees at the conference will discuss the pace of deficit reduction, with a proportion of Lib Dems feeling it needs to be recalibrated. Harris's comments came as Labour attacked plans by a GP commissioner in Leicester to ration NHS care.

Shadow health minister Liz Kendall highlighted comments left on website Conservative Home in which Dr Teck Khong said: "The government must not flinch from setting out an explicit list of services available and excluded from state provision."

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New' NHS reforms a lot like the old reforms

Left Foot Forward, 21 June 2011


By Andrew George MP (Liberal Democrats, St Ives)

For those who, like I, had strongly criticised the government's Health and Social Care Bill and campaigned against the government's plans, the unprecedented "pause” and "listening exercise” was an encouraging success. Then the Future Forum report represented a welcome step forward.

However, what is emerging from the government's response is disappointing. It leaves many of the previous concerns - about the risk of a marketised NHS, a missed opportunity to better streamline health and social care and a lack of accountability - still unresolved.

Whether it is the intention of ministers or not is unclear, but it seems that the government will perpetuate rather than resolve the risk posed by the private sector to core NHS services.

In particular:

• Although, as before, Monitor will not "promote” competition, the new NHS Commissioning Board will have an enhanced role in driving competition;

• The proposals weaken the ability of commissioners to treat core NHS services as their "preferred provider”;

• It enhances the opportunities for private sector providers as "choice” gains pre-eminence over integration; and

• Although commissioning bodies will not be able to delegate their responsibility for commissioning decisions to private companies, all other aspects of their role in managing and delivering those decisions can be.

In addition, some of the core issues which helped to persuade the government to "pause” are still not resolved.

The government's proposals do not:

• Go far enough in strengthening the ability of clinical commissioning groups to better coordinate health and social care; and

• Enhance democratic accountability.

1. NHS Commissioning Board driving competition

The NHS Commissioning Board will be given a mandate by the secretary of state to "set clear expectations about offering patients the choice: a ‘choice mandate'”.

The NHS constitution has seven key principles – comprehensivity, equal access based on need, safe/effective care, to reflect needs and preferences of patients and carers, integration, cost-effectiveness and accountability. Integration is given an at least equal status with that of patient "preferences” (i.e. choice).

It seems that while we have successfully stripped Monitor of its proposed power to impose competition, it appears to have been smuggled into the NHS Commissioning Board's remit.

2. NHS as preferred provider

The government's response to the Future Forum states that it will "prevent current or future ministers, the NHS Commissioning Board or Monitor from having a deliberate policy of favouring the private sector over existing state providers – or vice versa”.

The reference to "vice versa” ditches the possibility of preferred provider status applying to NHS services and hospitals. It also potentially contradicts the claim of ensuring the integration of services and the ability of, for example, NHS hospitals to provide a range of specialities, case volume and income to run safely emergency, complex and A&E services.

3. Choice over integration

Choice will now have a "mandate” whereas integration will not. HealthWatch will be told to establish a Citizens Panel to look at "choice and competition” whereas there will be no such instruction for integration, etc.

4. Private commissioners

The government's proposals for Clinical Commissioning Groups seeks to reassure by stating that these will be "public bodies” and will not have the power to "delegate their statutory responsibility for commissioning decisions to private companies or contractors”.
So, the decisions may not be delegated, but everything else could be.

5. Integration of Health and Social Care

The government's proposals only require the NHS Commissioning Board to have "taken properly into account” objections from Health and Wellbeing Boards regarding the boundaries of Clinical Commissioning Groups. Objections on the grounds that there is insufficient coterminosity between health and social care would not in itself be sufficient to stop any proposed Clinical Commissioning Group proposals from proceeding.

6. Lack of democratic accountability

There is no further enhanced role for Health and Wellbeing Boards, nor for elected representatives on commissioning groups.

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Government accused of trying to rush through botched NHS plans

Daily Mirror, 22 June 2011

DAVID Cameron was accused of trying to rush through the Government's botched NHS reforms without real scrutiny.

The PM was forced to water down Andrew Lansley's original blueprint, and now the Government wants to steamroll the Bill through Parliament with just a fraction of MPs debating it.

The Commons Health Select Committee will get only 10 days to look over 60 of the Bill's 300 clauses – meaning 80% of them will not be scrutinised fairly.

Shadow Health Secretary John Healey said it was "rushed and reckless” to deny the House of Commons its "proper role”.

He added: "NHS patients and staff have seen a wasted year of confusion and incompetence.

"It's clear today this will continue, with the NHS set to be more deeply mired in complex bureaucracy and wasted costs for years to come. The way the ­Government is treating the health service is a disgrace.”

Labour MP Grahame Morris, who sits on the Health Select Committee, added: "The Health Bill is in chaos because this government thought it could steamroll the largest ever NHS shake-up though Parliament.”

Mr Cameron defended the limit, calling 10 days a ­"significant amount” of time.

This came as he was forced to clarify a statement rejecting the Mirror's revelation that one of his advisers had called for the NHS to be "shown no mercy”.

The PM initially said he had "never heard” of Mark Britnell, but a Freedom of Information request revealed the pair had met in 2007. Downing Street said: "They may have been in the same room four years ago, but Mr Cameron has no memory of it.”

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Mental health services in crisis over staff shortages

The Guardian, 20 June 2011

Exclusive: Royal College of Psychiatrists warns society will be overwhelmed if ministers fail to fill gap

Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, says British doctors are not training as psychiatrists and those from abroad cannot fill the gap.

Overcrowded and understaffed psychiatric wards are leaving patients fearful for their safety and unable to make proper recoveries, according to a damning assessment of Britain's mental health service by its lead professional body.

Professor Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, told the Guardian that widespread failures in inpatient care for mentally ill people meant many hospital wards did not meet acceptable standards and discharged back into society sick people who remained a risk to themselves and others.

Bhugra blamed the problem partly on a "dangerous vacuum" created because British doctors are not training as psychiatrists, while visa restrictions mean doctors from abroad can no longer fill the gap.

"Society will be overwhelmed by the demand of those in need if government doesn't act now," he said in an interview.

A survey by the royal college found that 544 consultants' posts in the UK – 14% of the total – are either unfilled or filled by a locum. In addition, 209 consultants intend to retire or resign soon, a situation exacerbated by the government's cap on immigration from outside the EU.

"This is a huge, a massive problem," said Bhugra. "We will be left with a dangerous vacuum of help for people with mental health disorders or will be forced to get special dispensation from the government to recruit heavily from countries who can ill afford to lose their mental health professionals."

His warnings are supported by a study to be published next week in which the royal college describes how about half of patients – mostly women – report feeling unsafe in many of worst-performing hospital trusts. The report also says:

  • Average bed occupancy rates in English inpatient units are much higher than the 85% standard, with some wards running at 120% occupancy.
  • Access to psychological therapies falls far short of acceptable standards recommended by the National Institute for Health and Clinical Excellence and other health bodies.
  • Daily one-to-one contact with nursing staff is less than that accepted as being conducive to recovery.
  • Outreach links into the community are insufficient in two-thirds of the wards inspected by the royal college's centre for quality improvement.

Bhugra said the failure of wards on the 85% bed occupancy rate was particularly troubling. The report reveals that more than half of all adult general wards run at more than 100% occupancy, with 16% meeting the required target. Just 21% of acute wards meet the 85% target.

"Very high bed occupancy militates against quality and safety of inpatient care," Bhugra said. "It is a main driver of inpatient care standards. [High bed occupancy] can result in patients becoming more distressed and unwell, and likely to need more longterm care.

"Given the continued reduction in bed numbers and increased community care over the past decade, inpatient units have become places for crisis stabilisation and are likely to admit only those individuals who are the most disturbed, distressed or unwell. For such people especially, as they are unable to make the choice to leave, the ward is their home."

The report also reveals that wards are failing to provide separate sleeping and toilet facilities for men and women, despite gender-segregated accommodation having been government policy for a decade. Just 85% of wards have segregated sleeping accommodation and less than 60% have separate lounges. "This remains an intractable problem," said Bhugra.

Several dozen psychiatric patients take their own lives while in NHS care every year. Mental health charities such as Rethink claim this shows that care needs to be improved and staffing levels boosted.

Rethink spokeswoman Rachel Whitehead said: "Psychiatric wards are not a therapeutic environment. Many people tell us they don't feel safe there and they are not getting access to the support and therapy they need. Supervision is also a problem, largely due to overstretched staff and wards which are over their occupancy levels."

Another research paper by the college, to be published next month, shows that the number of medical graduates who accepted an offer of psychiatry training posts in England and Wales fell from 184 in 2009 to 158 in 2010. Bhugra said "dangerously few" doctors train as psychiatrists because the specialism suffers from a poor reputation compared with other medical disciplines. "It is wrongly seen as less scientific," he said.

Professor Peter Jones, head of the neuroscience department at Cambridge University, admitted the lack of psychiatry applications was a "terrible state of affairs". He said the formation of specialist mental health trusts had made psychiatry "seem more remote from mainstream medicine". He also said stigma "is a huge problem for people with mental health disorders and trickles into professional lives."

Wards are also failing to provide structured therapeutic activities, the royal college report finds, with 35% of patients complaining of too little to do during weekdays, rising to 54% in the evenings and at weekends.

Bhugra said: "The value [of this] cannot be overestimated. A lack of regular activities can lead to boredom, frustration and inactivity, which not only impede recovery but also can instigate unsafe, violent and erratic behaviour. Inpatients may be experiencing paranoia, be easily over-stimulated and sometimes frightened and disorientated."

Bhugra criticised wards for falling short in standards of security, risk management, violence prevention and management, medicines and confidentiality.

The report highlights evidence revealing that in the worst-performing 20% of trusts, only 50-60% of patients said they felt safe. Overall, less than 45% said they "always" felt safe.

"The Care Quality Commission has found that unnecessary and excessive restrictions, and security measures are sometimes imposed on detained patients," said Bhugra. "Undue restrictions on a patient's autonomy compromise their personal dignity and rights as an individual. Such excessive restrictions are upsetting for the patient and can delay recovery.

"Safety and risk policies are in place to aid patient recovery. Unnecessary bureaucracy and rules can not only hamper a patient's recovery but possibly exacerbate their mental illness. Whether a person is detained or voluntarily admitted to hospital, general ethical standards that are adhered to in the community should, wherever possible, apply on the ward."

The report found just 52% of patients claimed to have "supportive", one-to-one meetings with staff for at least 15 minutes every day. In 20% of the worst-performing trusts, as few as 50% of patients felt they were given enough time with a psychiatrist and even fewer said they were given enough time with a nurse. Bhugra said every patient should have a one-to-one session with a relevant staff member once a day.

Bhugra also admitted deep worries about the drop in British medical graduates going on to train as psychiatrists. He said that government's cap on immigration from outside the European Union will make the problem much worse.

The Royal College's survey reported that 544 consultants posts in the UK are either unfilled or filled by a locum: 14% of all posts. In addtion, there are 209 consultants who intend to retire or resign in a short time.

"This is a huge, a massive problem," he said. "We will be left with a dangerous vacuum of help for people with mental health disorders or will be forced to get special dispensation from the government to recruit heavily from countries who can ill-affod to lose their mental health professionals."

A Department of Health spokesperson said: "Mental health is a cross-government priority. We published No Health Without Mental Health, our cross-government mental health outcomes strategy, to drive up standards in services and improve the nation's mental health. The strategy makes clear that mental health services should be just as important as physical health services such as those for cancer and heart disease.

"We have supported the Royal Colleges of GPs and Psychiatrists to develop advice and support for commissioning consortia to commission effective mental health services. The strategy emphasises the importance of improving quality and productivity across the system, while making efficiency savings that can be reinvested in the service to deliver quality improvements.

"In addition, we will invest around £400m over four years in psychological therapies for those who need them in all parts of England, expanding provision for the entire population."

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