Nuffield Trust - "Shifting the balance of care" - March 2017

The Nuffield Trust has published its own research into the credibility of the proposals to shift care into the community, the proposals which underlie Simon Stevens' "Five Year Forward View" (2014) and its implementation in the 44 regional "Sustainability and Transformation Plans" (STPs) (2016).

The Nuffield Trust  "Shifting the balance of care: Great Expectations" was published in March 2017.

I have selected two key messages from the report:

....• Nonetheless, in the context of long-term trends of rising demand, our analysis suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise. A significant shift in care will require additional supporting facilities in the community, appropriate workforce and strong analytical capacity. These are frequently lacking and rely heavily on additional investment, which is not available.

.....• While out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope.

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Open letter to Jeremy Hunt from Dr Louise Irvine - NHA candidate in South West Surrey constituency at the General Election

The facts don’t lie, and nor do I – An open letter to Jeremy Hunt MP

Dear Mr Hunt

On Thursday night, in your acceptance speech, you accused me of “falsehoods”.

In your words, you accuse me of lying about “both our record with the NHS and also our motives”. You were clearly rattled that over 12,000 people in South West Surrey showed their concern for the NHS and voted for someone who questioned your record, but that is what democracy is all about – holding the government to account.

The truth is that I haven’t lied for the simple reason that I haven’t needed to. The facts speak for themselves.

When I talked about your record, I drew out many facts:

  • The number of people lying on trolleys waiting more than 4 hours to be admitted to a hospital bed increased from 387,737 in 2015/16 to 560,108 in 2016/17 – that’s a 45% increase in one year. I’m sure I don’t need to remind you that a trolley is one of the least safe places to be in the health care system or of the three patients who died in Worcestershire hospital on trolleys during last winter’s crisis?[i] The British Red Cross described it as a “humanitarian crisis.
  • Ambulance response times, especially for the most urgent calls, are the worst since records began. The national target of reaching 75% of Category A calls within eight minutes has not been met for 32 consecutive months. [ii]
  • Mental health services are struggling. Suicide is the commonest cause of death in boys age 5-16 yet children’s mental health services can’t cope with the volume of referrals and often there is not a single mental health bed anywhere in the country due to cuts to mental health provision. [iii]
  • Performance against the 6-week cancer treatment target and the 18-week elective treatment target are deteriorating. [iv]
  • Infant mortality is rising for the first time in years, having been rising for poorer children for a decade. [v]
  • The Royal Society of Medicine attributed the 30,000 excess deaths in the winter of 2015 to cuts to health and social care. [vi]
  • The NHS has fallen further down international league tables of mortality due to treatable causes. [vii]

None of these is a lie.

I also talked about the increasing privatisation for the NHS and your quote that “I am not privatising the NHS”. Was it a lie when I pointed out that the percentage of Dept of Health budget spent on for-profit providers rose by 25% in two years? [viii]

Perhaps it was my comments about funding that you felt were untrue. I said that the NHS had been underfunded and that future plans in the manifesto were insufficient. In fact, it was your government that was rebuked by the health select committee (including two Conservative MPs) for claiming that you’d be spending an extra £10 billion a year on NHS by 2020.[ix] They pointed out that a large proportion of this was taken from public health and doctor and nurse training budgets. Moving money around within a service to appear more generous than you actually are is fundamentally dishonest. [x]

In fact, your claim that you will be spending an extra £10bn per annum by 2020 compared with 2015 turns out to be only a £4.5 bn increase. This amounts to a 1.1% annual rise each year in the decade from 2010 -2020[xi], the biggest funding squeeze in NHS history and not even half of the 2.7% per annum forecast growth in need over that period, according to the NHS chief executive.[xii] As for the future, Prof Anita Charlesworth of the Health Foundation says that the promised extra funding for the NHS in the Conservative manifesto is far less than the NHS needs.[xiii]

Maybe you are accusing me of lying when I draw attention to NHS staff shortages and the disgraceful way you treat NHS staff:

  • In 2015, Health Education England calculated that the NHS had 30,000 fewer full-time equivalent nurses than needed – equivalent to nearly one in 10 positions.[xiv]
  • You have imposed a draconian pay cap on nurses meaning their pay will have been cut by 12% by 2020[xv]
  • You have removed the bursary for student nurses, meaning many people who want to train to become a nurse can’t afford to do so[xvi]
  • You have treated nurses and junior doctors with contempt. Record numbers are taking time off with stress because they fear that patients aren’t receiving the care they need[xvii] and 50% of nurses are considering leaving the profession because of this[xviii]
  • In the recent NHS staff survey, 47% said current staffing levels were insufficient to allow them to do their job properly and 59% reported working unpaid overtime each week.[xix]
  • Since your announcement in 2015 of 5,000 more GPs by 2020 we actually have fewer GPs now than two years ago! [xx]

In the election campaign I stated that your performance as Health Secretary is destroying the NHS, demoralising staff and risking patient safety. As you can see from the above, this is absolutely true.

Finally, you accused me of lying about your motives. I have no idea what your motives are for destroying our NHS, but I have tried to give you the benefit of the doubt.

I have assumed that you are doing it deliberately – in order to run it down and provide an excuse for privatisation.

If I were you I’d accept that interpretation, because the alternative is that this has all been caused by your sheer incompetence.

Patients and NHS staff deserve better than this. The NHS is a great organisation and provides excellent care to most people most of the time, thanks to its dedicated and hardworking staff. But it is cracking at the seams and sometimes failing, due to the many pressures it is under. I am motivated by the desire to defend the NHS and raise the alarm about the dangers it faces from a continuation of Conservative policies. And as long as you are health secretary I will continue to hold you to account for what you are doing to the NHS.

 

Dr Louise Irvine

[i] https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity

[ii] http://www.qualitywatch.org.uk/indicator/ae-waiting-times

[iii] https://www.theguardian.com/society/2016/jul/04/nhs-child-mental-health-services-anxiety-depression

[iv] http://www.qualitywatch.org.uk/latest-data/combined-performance-summary-march-2017

[v] http://www.bmj.com/content/357/bmj.j2258

[vi] https://www.rsm.ac.uk/about-us/media-information/2017-media-releases/new-analysis-links-30000-excess-deaths-in-2015-to-cuts-in-health-and-social-care.aspx

[vii] http://www.telegraph.co.uk/news/2017/05/18/nhs-care-among-worst-europe

[viii] https://www.bma.org.uk/collective-voice/influence/key-negotiations/nhs-funding/privatisation-report

[ix] https://www.theguardian.com/society/2016/oct/30/theresa-mays-claim-on-health-funding-not-true-say-mps

[x] https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget

[xi] https://www.england.nhs.uk/wp-content/uploads/2016/05/fyfv-tech-note-090516.pdf

[xii] https://www.theguardian.com/society/2017/apr/29/nhs-nurses-pay-cut-12-per-cent-over-decade

[xiii] https://www.theguardian.com/society/2016/jul/21/nhs-bursaries-for-student-nurses-will-end-in-2017-government-confirms

[xiv] http://www.mirror.co.uk/news/uk-news/national-hell-service-landmark-nurses-10053340

[xv] https://www.nursingtimes.net/news/reviews-and-reports/critical-reasons-behind-nurses-leaving-profession-laid-bare/7016295.article

[xvi] http://www.telegraph.co.uk/news/2017/05/23/number-gps-has-fallen-since-nhs-launched-5-year-rescue-plan/

PFI/PPP Buyouts, Bailouts, Terminations and Major Problem Contracts

Further reading: Prof Allyson Pollock and David Price: "PFI and the National Health Service in England" June 2013

 

https://www.european-services-strategy.org.uk/wp-content/uploads/2017/02/pfi-ppp-buyouts-bailouts-and-terminations.pdf

ESSU Research Report No 9, Dexter Whitfield - Published February 2017

Details 11 buyouts, 20 terminations and 43 projects with major problems, plus many bailouts, accounting for 28% of PFI/PPP contracts by capital value. The public cost of buyouts, bailouts, terminations and major problem contracts is £27,902m, when combined with the additional cost of private finance, interest rate swaps and higher PFI transaction costs. This could have built 1,520 new secondary schools for 1,975,000 pupils, 64% of 11-17 year old pupils in England. The UK’s 6.8% ratio of buyout and terminated contracts is higher than the 5.4% average of World Bank projects in developing countries for terminated contracts. This ESSU Research Report explains the causes and fundamental flaws in the PFI/PPP model.

Databases of buyouts, terminations and major problem contracts.

"Neoliberalism and the state-business partnership: the PFI/PPP model

PFI/PPP projects are a product of neoliberalism. The Design, Build, Finance and Operate (DBFO) model has increased the commodification and financialisation of public infrastructure to provide new opportunities for accumulation; created new markets for finance capital, construction and facilities management companies, consultants and lawyers; reduced the role of the state; and ultimately widened the potential for privatisation of buildings, transport and utility networks and public services.

Incomplete and complex contracts

A large and complex contract is at the centre of every PFI/PPP project. A standard draft contract is amended and developed as procurement proceeds up to the point of financial closure. The final contract or project agreement can range from a few hundred to several thousand pages. But no matter how comprehensive they are, virtually all contracts are incomplete in practice (Hart, 2003), because they cannot predict future events and changing economic and social needs. Tirole (1999) identifies three reasons for incomplete contracts:

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The NHS budget and how it has changed

From the King's Fund, updated 12th May 2017:  https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget

 

Department of Health budget (in real terms at 2017/18 prices)

Source: Department of Health annual report and accounts 2015/16; Central government supply estimates 2016-17, supplementary estimates and new estimates – Feb 2017; HM Treasury GDP deflators at market prices, and money GDP March 2017 (Quarterly national accounts, March 2017)

Planned spending for the Department of Health in England is approximately £123.7 billion in 2017/18 (at 2017/18 prices).

In the 2015 Spending Review the government announced that funding for the Department of Health would increase to £133.1 billion (or £126.5 billion at 2017/18 prices after adjusting for inflation) by 2020/21. The increase in health spending between 2015/16 and 2020/21 is less than the government has claimed, mainly because ministers have chosen to highlight the funding provided to NHS England only, rather than the Department of Health’s total budget.

Though NHS funding is continuing to grow, the rate of growth is slowing considerably compared to historical trends. The Department of Health budget will grow by 1.1 per cent in real terms between 2009/10 and 2020/21. This is far below the long-term average increases in health spending of approximately 4 per cent a year (in real terms) since the NHS was established.

Looking ahead, between 2017/18 and 2019/20 the Department of Health budget will increase by just 0.6 per cent on average each year in real terms. This will place increasing pressure on the NHS, as demand for services is continuing to grow.

 

10 charts that show why the NHS is in trouble

Nick Triggle, Health Correspondent - BBC News website 7th February 2017

Although this article is now four months old, it is still a useful summary of the overall problems besetting the NHS and social care in the UK.

What it does not address is (1) the impact of wasteful marketisation and (2) the massive reorganisation called "Sustainability and Transformation Plans" which the Conservative government and CEO Simon Stevens are currently promoting.

The charts are:

 

1. We spend more on the NHS than ever before

2. A bigger proportion of public spending goes on health

3. Key A&E targets are being missed

4. The UK's population is ageing

5. Care for older people costs much more

6. Increases in NHS spending have slowed

7. The UK spends a lower proportion on health than other EU countries

8. Demand for A&E is rising

9. Fewer older people are getting help with social care

10. Much more is spent on front-line healthcare than social care

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