"At what cost? Paying the price for the (internal) market in the English NHS" by Prof Calum Paton

This is a paper published by the Centre for Health and the Public Interest in February 2014: a seminal and excoriating indictment of the "evidence-free" policies of successive Governments in England.

Calum Paton is now Professor of Public Policy at Keele University, where he has been Professor of Health.


1. Extreme financial pressure upon the English NHS for the foreseeable future makes avoidance of waste imperative. The 'market' in the NHS is a major source of waste.Creating and maintaining markets has incurred huge direct costs and significant 'opportunity costs' – money which could have spent upon patient care and clinical re-design.

2. Not only has evidence to justify 'market reforms' to the English NHS from 1990 to the present-day been absent, but the recent Health and Social Care Act of 2012 actually ignores, or even inverts, evidence which suggests that 'commissioning' by GPs in local markets characterised by separate 'purchasers' and 'providers' is costly and of dubious effectiveness. The only reasonable conclusion is that that market policy is based upon ideological dogma, pressure from commercial interests or both.

3. It has been argued that the only way in which hospitals and other service providers can be reimbursed in a timely manner for their workload, and given the incentive to increase workload and productivity, is through the operation of market forces. This is simply untrue and based on a re-writing of history.

4. The recurrent, annual costs of the market can be estimated (conservatively) at £4.5 billion.

5. The one-off, start-up costs of the various phases of the market (1991-97; 2001-2007; 2010 to date) have run into billions of pounds, with (again, conservative) estimates of the most recent market initiatives under New Labour and then the Coalition government comprising £3 billion each.

6. This paper sets out how the wider costs of the market have included both opportunities foregone and likely harm to the system.

7. Possible benefits from the market are hotly contested in the research community and – even if one grants the benefits claimed by supporters of the market – very small when set against the costs.

8. It would take ideological chutzpah of the most irresponsible sort to suggest that the answer to the failure of the market so far is 'more market'. The paper suggests why.

9. It is possible to have patient choice and high-quality health-care without the market. The paper suggests how.

Submission to the People's Inquiry into London's NHS - commission chaired by Michael Mansfield QC




Submission to The People’s Enquiry into London’s NHS

December 2014



Save Our Hospitals (SOH) has been campaigning, together with other groups in NW London, against the proposals in Shaping a Healthier Future for over 2 years. As well as campaigning, every week, in the London Borough of Hammersmith and Fulham, we have attended CCG meetings, Imperial Board meetings, Healthwatch and have had two formal meetings of our officers with the CEO of Imperial, Dr Tracey Batten, and several of her senior officers. (We have attached our reports on these meetings to this submission as Appendix A and Appendix B). Week by week we are told of how concerned people are at the proposals and how angry they feel that their needs are not being taken into account.


Read more ...

"Liberating" the NHS: source and destination of the Lansley reforms (Reynolds, Lister, Scott-Samuel and McKee) August 2011

For the background to the 2012 Health and Social Care Act please read "Liberating the NHS: Source and destination of the Lansley reforms" by Dr Lucy Reynolds, Dr John Lister, Dr Alex Scott-Samuel and Professor Martin McKee, 29th August 2011



A & E waiting times week ending 30th November 2014: worst ever!


The tone of this e-mail is a little "tongue-in-cheek" - but the statistics quoted are unfortunately all too true.

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Date: 5 December 2014 at 17:30
Subject: Worst Again
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Dr Spencer,


It is reported that you have gone on the £120,000 junket to America.  I continue to hope not.  Quite what you would have expected to discover there after you spent over £3.5 million on McKinsey's advice for Shaping a 'Healthier' Future it is hard to imagine.  I look forward to a full and costed report of the findings.


Many people feel that your time would have been better spent in dealing with the increasing A&E crisis in NW London.  'Crisis' has ceased to be the appropriate word;  it is a catastrophe.


It now almost goes without saying that in the week ending 30 November London North West Healthcare was the worst Trust in the country for Type-1 waits at 65.7%, over 5 percentage points worse than the next.   And it was the 14th worst for 'All attendances', out of some 280.


And that week the North West London Sector was the worst in the country, if it were taken as an 'Area Team' of its own – which it could easily be, given its size and activity levels.  As you know, there are 25 Teams including London and NW London was 6.9 percentage points lower than the worst of those for Type-1s, at 79.9%.  Against the 95% target for 'All attendances' it was the worst again, managing 91.2% compared with 96.5% for the rest of London.


So, instead of swanning off to the States, all you had to do was to talk to your colleagues in London to find out how to run A&E services.  30% of all London Type-1 waits occurred in the area under your supervision.  So, when you said 'We think there are many other factors going on across London,' you failed to point out that you were attracting more than your fair share of whatever you think these might be.


There again, I am not aware that any other London Sector has decided to axe 2 of its central A&Es, reduce bed capacity (until the recent frantic reversals) and invite ambulance crews to telephone for an appointment to deliver a casualty to a 'Major Hospital'.


Your position is increasingly untenable.


Colin Standfield


Imperial board meeting 26th November 2014 Key Points

Project diamond predicted income at risk, if they don't get both components 


P 8


Bill Shields " He believed the Trust would still receive £7.2M for Project Diamond but not necessarily £10M for market forces which would see the Trust reduce its surplus from £11.2M to £1.2M". 


Jolly to USA (we found at meeting it is organised by McKinsey's)


"North West London CCG are paying for an international integrated care study tour from 29th November to 6th December to the US which will be attended by the CEO. Visits in Boston, New York, Baltimore and Richmond will be to innovative organisations who are renowned for excellent community care, integrated care and partnership models. Invitees to the tour include chief executives from acute and community providers and commissioners in the North West London sector. A report will be made to the next Trust Board meeting on the learning and outcomes of the visit."


Poorer financial performance than predicted


"The Trust’s financial position for the month was a surplus of £1.8m which is an adverse variance of £1.6m in month. The Year to Date (YTD) surplus of £0.8m represents an adverse variance against plan of £8.0m. Pay expenditure shows an adverse YTD variance of £18.9m as a result of under-achievement of CIPs, which are behind plan by £12.1m (53%) and the higher than planned bank and agency staff. Significant work is underway to look at our rostering practices across the Trust".


Complaints increasing


"There was an increase in volume of formal and PALS complaints in October."


Increase in length of stay for unplanned admissions in October


"the non-elective length of stay measure worsened in October to above the threshold of less than 4.5 days, to 4.9 days."


Reduction in theatre utilisation


from 77% to 74% in October.


Unpredicted variance in A&E attendances leading to longer waiting times

p 31

Following the closure of the Hammersmith Emergency Unit as planned. The subsequent number of attendances at

the St Mary Hospital and Charing Cross Hospital sites has been as expected from the modelling that took place

prior to the closure. However, there has been huge variance in the volumes of patients attending A&E, particularly

at St Mary’s Hospital.

Variations in attendances between days can be as high as 120. These unprecedented surges in activity have

resulted in the Trust failing to meet the 95 per cent four-hour waiting time standard.


Measures Imperial taken to improve A&E waiting times

p 31

" The focus for the Trust is to action a targeted response aimed at boosting resilience. There are a number of

initiatives now in place which will improve the waiting times.


Senior decision makers

The Trust has put in place additional GPs in the Urgent Care Centres, Emergency Nurse Practitioners, Intaking

Physicians, A&E consultants and management and nursing support. This will improve the pathway within the

emergency departments and reduce the time it takes for a clinical decision on the treatment options.


Physical capacity

The Trust has opened up extra capacity at St Mary’s hospital to accommodate an increase in medical admissions.

The Trust is also in the process of completing some estates work to accommodate additional ambulatory care and

Urgent Care Centre capacity at the Charing Cross.


Delays in Referral to treatment (RTT) targets missed

p 32

There is currently a national amnesty on delivery of the three RTT standards. This has been put in place and

agreed at a national and local level to allow Trusts to clear as many over 18 week patients as possible to add

resilience into the system going into the winter period. The Trust has put on additional capacity to treat long

waiters and therefore a dip in performance is expected. This applies to data submitted for performance in October

and November. In October, as planned, all three standards were under delivered. As well as putting extra capacity

in some challenged specialities to reduce the numbers of patients waiting over 18 weeks, there have been a

number of data quality challenges that the Trust has experienced since the implementation of a new patient

administration system in April 2014 (Cerner).


Delay in cancer RTT and diagnostic waiting times


"In September the Trust achieved six of the eight cancer standards. The Trust under delivered on the 62-day first

treatment from GP referral standard. This was the result of a high number of patients being referred into the Trust

from other sites late in their pathways, plus a number of pathways being resolved after delays through the

summer period. The Trust also under delivered on the 31-day subsequent surgery standard as a result of a number

of delays caused by consultant absence over the summer period. It is expected that performance for both of these

standards will be recovered in Quarter 3.


The Trust continues to work with local providers to redesign their diagnostic pathways. This is to ensure that

patients are transferred to ICHT for treatment earlier in their pathways in order to reduce the number of shared

pathway breaches, the predominant cause of 62-day breaches for the Trust.


Diagnostic waiting times

The Trust has not yet submitted the data for the six week diagnostic standard (due for submission on Wednesday

19th November) but expects to under deliver on this standard in October. 


Cost Improvement Plans behind schedule by £12..1m 53%


"The main reasons for the YTD adverse variance are:


Cost Improvement Plans (CIPs) are behind plan by £12.1m (53%);


Staff pay costs are significantly higher than planned and with an increase in month, indicating that the

previously instigated controls and agreed financial recovery controls are not being implemented.


There is on-going dialogue with the TDA about the impact of the proposed Project Diamond funding reductions on

the Trust’s financial position in both current and future years. Any reductions in funding will mean that the Trust’s

I&E control total will have to reduce.


Vacancy rate increased fr om 12.59% and Bank & Agency increased to 11.9% in October.



Threat to emergency surgery at CX?


The committee received an oral update on the action plan for Emergency Surgery at Charing Cross noting that

Divisional colleagues were developing proposals for the end of December 2014 for a plan around investment

across the three levels of cover required for a 3-5 year period to sustain the Charing Cross Hospital emergency



p 222

"Dr Tracey Batten advised that a decision was required by the end of the calendar year as to whether emergency

surgery at Charing Cross Hospital was a sustainable service and if not how to ensure the service at Charing Cross

Hospital would be sustainable. Prof Jamil Mayet would produce a detailed action plan by the end of October 2014

and Dr Tracey Batten noted that a sustainable plan needed to be put in place for the next 5-6 years as the

Business Case would not be implemented until 2020.


Surgery & Cancer

Prof Jamil Mayet noted that elective surgery at Charing Cross had moved from a Consultant of the day model to

Consultant of the week. The recruitment of Junior Doctors remained difficult but the rota was being actively

managed although would become an issue in the middle of 2015 as the rotation procedure would change

with Junior Doctors being given community placements resulting in a loss to the Trust of 15 Junior Doctors which

would be mapped for discussion at ExCo. 


Call for less spin from Imperial (from a insider)

p 224

" Sir Gerald Acher stated that he had been very disappointed with the recent Trust press release which implied that the Trust

was doing well in the National Cancer Patient Experience Survey and suggested that the Trust needed to be open and clear

in its messages and not use "spin".


Bill Shields is frank about finance


"The month 5 figures indicated that there remained a year to date deficit despite improvement with issues around:


Increase in both temporary and permanent staff;


Increase in bank and agency and locum staff;


A lack of effective controls with ineffective delegation;


Capacity not returning to pre winter levels;


Issues with Cerner:


More money on implementation

Inability to collect activity data effectively


CIPs (which were the subject of a separate paper) being:


o Unrealistic;

o Based on income and not the contractual position;

o Undeliverable.


Plan to cut more beds


"He confirmed that there was already an outline plan in place which had started to be progressed and that there was a bed

reduction opportunity which could achieve another £0.5M saving."


Plan to identify non profitable services

p 237

"The Committee noted that the work would be likely to identify opportunities for services that were currently not profitable"