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COVID-19 Defend the NHS Privatisation TTIS

Public Health and Primary Care

In January 2019, Doctors in Unite issued proposals relating to public health and primary care. This document has now been revised.

In the light of COVID-19 the authors believe that if these proposals had been implemented before the pandemic struck then the UK would have been able to respond much more quickly to the need and would have been in a much stronger position to plan and deploy local responses.

The government has allocated significant resources into protecting the front line of the NHS at the level of hospital services, with particular investment in the building of Nightingale hospitals. However, it has put almost no additional resources into primary care or community services to deal with COVID-19.

We believe that strengthening primary care and community services as laid out in our paper would mitigate the effects of COVID-19 for five main reasons:

1. Those working in primary care should look after populations and communities as well as individuals and their families. Dual training and accreditation for GPs and nurses in public health and primary care is essential. Neighbourhood public health leads would co-ordinate appropriate local responses to a pandemic, for example, by supporting people at home with COVID-19, isolating them and contact tracing in ethnically and culturally appropriate ways.

2. Primary Care Networks of GP practices should be funded to provide care home and appropriate domiciliary care during the pandemic. Community organisations should be integrated with primary care, which during theCOVID-19 lockdown could deliver food, medicines and other essential items as well as provide support for isolation, loneliness and respond to mental health issues.

3. We support a social prescribing model, which in normal times encourages patients to go out, meet people, socialise and stay active; during a pandemic this is necessarily amended, and patients are asked to stay in and not meet people, but to still socialise, keep in touch with others and remain active.

4. We develop the idea of local democracy through Neighbourhood Health Committees which would organise appropriate medical, psychological and social care, led by public health leads working seamlessly with directors of public health who have authority and independence which has been devolved from central control.

5. We propose professionally independent public health advocacy so that the people can trust the advice and information they receive.

Read the full paper here

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commissioning Defend the NHS Government Policy Local Authority Privatisation

Matt Hancock offered to auction his football shirt for the NHS – we need proper funding, not charity gimmicks

Doctors in Unite would like to remind the Secretary of State for Health and Social Care that the NHS is not a charity but a government funded health service, set up in 1948 with the specific intention to remove health care from the precarious state of reliance on income or beneficence.

Matt Hancock has his hands on the levers of government, he should be using his time and influence to bring investment in the NHS and Social Care up to the levels needed to redress the years of systematic underfunding, fragmentation and privatisation which have contributed hugely to the failures we now see in the government’s ability to cope with the challenges of COVID-19, not trivialising matters by suggesting that all of the problems can be solved with the sale of a football shirt.

Dr Jackie Applebee is the chair of Doctors in Unite

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COVID-19 Defend the NHS Government Guidelines Privatisation

Government ineptitude has undoubtedly led to many unnecessary deaths – they must be held to account

Richard Horton, respected editor of the medical journal ‘the Lancet’, aptly summed up the current pandemic in the following words: “Coronavirus is the greatest global science policy failure in a generation. Austerity blunted the ambition and commitment of government to protect its people. The objective was to diminish the size and role of the state. The result was to leave the country fatally weakened”. China implemented a lockdown in Hubei province on 23rd January in response to a new and severe respiratory infection. One week later the World Health Organisation declared a global emergency in recognition of what had become a worldwide pandemic. It then took nearly two months for the UK government to grasp the seriousness of the problem and to implement social distancing and isolation. This delay has led to many unnecessary deaths.

Despite there being core public health principles of “test, isolate and contact trace” in response to an epidemic, this process has not been implemented in the UK. There was talk of ‘herd immunity’ as an alternative strategy, but scientists then pointed out this could mean hundreds of thousands of deaths before the infection was under control. A panicked government decided to abandon its irrational belief in ‘British exceptionalism’ and on 23rd March instituted a lock down of sorts, with people encouraged to stay at home, and most businesses closed down. News footage still showed London underground packed with people and construction workers as key workers were expected to turn up for work as usual.

Unrecognised dangers included the risk to the elderly living in care homes together with their carers, the risk to bus drivers and other key workers with public-facing roles in the community.  The fact that many workers on zero hours contracts and those outsourced from the NHS and not entitled to sick pay would be forced to continue to go to work even if ill. Sick and elderly patients were discharged to care homes only to spread infection without having been tested for the virus, and outrageously, ‘do not attempt cardio-pulmonary resuscitation’ orders proliferated for pensioners and those with learning difficulties or disabilities often without discussion. The official death toll has gone up to above 20,000 – but these are confirmed deaths in hospital and there may be at least as many again in the community without a definitive diagnosis.

In the meantime, countries like Singapore, South Korea, New Zealand and Germany, which rapidly instituted widespread testing and contact tracing were demonstrating a much lower number of cases and deaths. While the UK government kept promising more testing, numbers grew painfully slowly. Centres specially created to test key staff were set up by the accountancy firm Deloitte, given the contract without it going out to tender under obscure legislation passed in 2015. As usual, reports of problems with lost samples and mis-communication of results followed, just as the privatisation of NHS logistics caused problems with distribution of personal protective equipment (PPE). Despite repeated reassurance from government ministers that stocks of PPE were available, this turned out not to be the case as week after week front line staff complained of being sent to war without the necessary armour. Around 132 NHS and care staff have now died from the disease and will be remembered along with many others on International Workers’ Memorial Day.

Worse still for government credibility were details of the unpublished Cygnus report from a 2016 pandemic planning exercise, and more from the 2019 National Security Risk Assessment, both showing that the government knew full well of the major risk posed by the likelihood of a new pandemic, and the need to stockpile PPE and equipment such as ventilators for intensive care, yet did nothing. As one commentator remarked: “We have been paying for a third-party fire and theft policy for a pandemic, not a comprehensive one. We have been caught out”.

Things which have assisted the pandemic response include the fact that we still have a ‘national’ health service and brilliant staff with a public service ethos. Things that have hindered the response include government reforms over recent years promoting marketisation, fragmentation, privatisation and outsourcing. NHS England has rightly taken over commissioning functions from Clinical Commissioning Groups, and government has wiped away the £14 billion hospital overspend to let Trusts focus attention on doing what was necessary to fight the infection. The small private sector capacity was harnessed to assist the NHS. However, the huge PFI debt millstones remain in place, and private hospitals are only too happy to be subsidised to the tune of £2.3 million/day through block contracts- one of the businesses that will not now go under in the coming recession.

The hostile environment aimed at those migrants with uncertain immigration status not only meant the end to universal health care under the NHS, but now fear of being reported to the home office or financially charged will undermines planned contact tracing. This charging needs to be abolished now, as does the yearly surcharge of £625 for members of NHS staff coming from abroad, and each of their family members.

Government policies left the NHS in a weak starting position, with over 100,000 staff vacancies, cuts in bed numbers of 17,000 since 2010, and near the bottom of the European league table in relation to intensive care beds (half as many as Italy and around one fifth of those in Germany). The government will be constructing a narrative portraying themselves as victims of a natural disaster, doing their best in impossible circumstances and leading us all to victory in the war against Covid-19; in this they will be aided by large sections of the media.

Trade unionists must make sure that ministerial incompetence, arrogance and callous disregard for human life are not forgotten and there is a holding to account. When the pandemic is over, we cannot go back to how things were before. We need to take the public with us in demanding a return to NHS founding principles, a publicly funded, managed and delivered health service with democratic control, linked to a national social care service. Renationalisation of the NHS; proper funding; an end to PFI, the Health and Social Care Act and the Long-Term Plan for the NHS; and an end to outsourcing and privatisation. We are witnessing a tragedy unfold and a government scandal of momentous incompetence. The right lessons must be learned.

Dr John Puntis is co-chair of the campaign group Keep Our NHS Public.

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COVID-19 Defend the NHS DiU and Unite H&S at work Hospitals and IPC Privatisation

Doctors in Unite statement on payouts for those who die in service with COVID-19

It is an insult for the government to claim that a life assurance pay out of £60,000 to the families of a health or social care worker who dies of COVID-19 in any way compensates for the loss of life.

Despite their protestations that they “will do whatever it takes”, this again shows the scant regard the government has for frontline workers.

It follows the abject failure to ensure that staff are properly protected at work, and a testing and contract tracing regimen that is too little, too late. The government has now neglected to correct historic inequalities in the provision of death in service benefits.

On April 27th Matt Hancock announced the £60,000 payout. But the conditions that go with it are an insult to those who are lost and those left behind.

One of the criteria is that the deceased must have been in work within two weeks of developing symptoms.

We do not yet know enough about COVID-19 to be able to confidently state that the longest period from exposure to symptoms is fourteen days.

Many health and social care workers do not qualify for full death in service benefits. These include people who have opted out of the NHS pension scheme due to an inability to afford contributions, or because their jobs have been outsourced to the private sector. 

GP locums who die on a day they are not in work, and retired health and social care workers who have generously returned to work during the pandemic are also not eligible for the full amount.

Widowers will also only receive a pension based on their spouses membership of the pension scheme after 6th April 1988.

Families of those with less than two years membership of the pension scheme will receive no short term pension or long term adult dependants/child’s pension.

Full death in service benefits should extend to all health and social care workers regardless of bureaucratic caveats. The criteria that the deceased must have been in work two weeks before developing symptoms should be dropped.

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COVID-19 Defend the NHS Hospitals and IPC Privatisation TTIS

For-profit companies have no place administering retirees return to the NHS

We deplore the involvement of Capita in the administration of retired doctors’ return to the NHS workforce. Reported delays of over two weeks to inclusion back on the performers’ list, while NHS 111 remains overwhelmed, are unacceptable. Valuable, willing expertise is being underused at a time of national crisis. Inexperienced call handlers are being recruited at £5.82 per hour and given as little as 90 minutes training.  Senior support is badly needed.

Capita’s record in providing NHS services is a poor one. Their contract for cervical screening has already been removed after nearly 50,000 women were denied vital information. They should never have been offered this new role.

The 2012 Health and Social Care Act enshrined competition in the business of the NHS. Fragmentation and deterioration of services quickly followed, as the newly involved private sector cut costs to increase profits. 

The NHS has been subjected to systematic under-funding for over a decade. The average increase in the NHS budget before 2010 was 3.7%. Since the Conservatives came to power it has been only 1.4%. This lags behind inflation, and leaves no room to treat a growing population or invest in modern medical technologies.

This is brought to sharp focus by our response to coronavirus. Our health and social care services are struggling with a shortage of staff, beds, ventilators and personal protective equipment. Public health organisations cannot conduct the widespread testing needed to inform any meaningful preparations for an end to the lockdown.

Retired health workers began their careers in a very different NHS; one that was comprehensive, universal, and properly publicly funded. Our much applauded health service now deserves restoration to these founding principles.

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COVID-19 Defend the NHS KONP and other campaigns

The only future for the NHS after COVID-19 is a return to its founding principles

The COVID-19 pandemic illustrates the vital importance of a comprehensive, publicly funded and universal health service. The choices we make during this crisis will shape the future of the NHS and our wider society.

We are already limited by poor decisions made before the virus struck. The Conservative’s ‘hostile environment’ policy, where people with a precarious immigration status risk deportation or destitution if they seek NHS services, means there may now be considerable apprehension to access necessary care. Though coronavirus treatment is exempt from charging for those without documentation, this message is likely to be lost.

When more beds were needed, rather than requisition private hospitals the government struck a deal where beds are rented for £300 each, per day. This amounts to a public sector bail out of private hospitals that the NHS should never have to pay. These beds could be utilised in the public interest; instead they are rented at public expense.

The government then wrote off £13.4bn of NHS debt. It is disingenuous to call this debt. It represents money that has been rightly spent on patient care, and the government’s actions acknowledge this with a trick of accounting. It is also only a fraction of the shortfall in NHS funding over the last ten years of austerity.

A sincere approach to the NHS’ debt would be to cancel Private Finance Initiative payments. £2bn was paid in 2016/17 in PFI debts, and repayments will continue every year until 2050. This lost wealth represents around 2% of the annual NHS budget. It could be reinvested to improve the nation’s health but instead vanishes into private hands. The same is true for private buildings used for NHS services. There is an opportunity to return these to the ownership of the public they serve.

Fragmentation, cuts and creeping privatisation have all contributed to the difficulties in our response the pandemic. More than 17,000 beds have been cut from the 144,455 that existed in 2010. The UK has a lower number of critical care beds per person than Italy, France, Spain, Germany, the USA, Japan, or South Korea. Years of underfunding led us to this moment. The PPE distribution fiasco shows the inability of the private sector to provide the service needed. Cutting warehouse capacity in order to prioritise profit means private distribution companies cannot now supply health and social care workers with the person protective equipment they need.

The hundreds of billions of pounds made instantaneously available in response to coronavirus shows the transformative power of the state to provide a crucial safety net for all of us. We can afford a far fairer society than the one we became accustomed to. Rapid changes to manufacturing capacity to produce ventilators, dialysis machines, PPE and other socially useful products demonstrates that an economy based on public ownership, planning and democratic control could meet the needs of people across the world, unlike the chaotic response of the free market.When this crisis eventually subsides, the public must not be made to pay. We must not return to more austerity.

We also cannot emerge from this pandemic and continue to ignore the harm caused by environmental destruction. The delayed, incomplete initial response to coronavirus echoes our apprehension to face the challenge presented by climate change. We should confront the runaway economic expansion that created the conditions for previous, current, and perhaps future outbreaks. We have an opportunity to live within our planetary means.

We could recreate our health and social care systems based on need not profit. We could choose to reduce inequality permanently. The reset button on society has been pushed – what happens next is up to all of us.

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commissioning COVID-19 Defend the NHS Government Guidelines Government Policy Privatisation

Despite coronavirus and clapping, the Tories remain hostile to a public NHS

In recent weeks we have among others seen Boris Johnson, Matt Hancock and members of the Royal family (all of whom it’s safe to guess have never used the NHS) joining in the public applause for key workers. Additionally, there have been a number of structural changes and commitments to increased funding that make it feel as if the strengths of a truly public National Health Service are now being acknowledged, together with an implied criticism of many of the reforms of the last near decade.

Taking over CCGs

On March 23rd it was announced that NHS England was taking on extensive special powers normally held by clinical commissioning groups to support efforts in the face of coronavirus. Dr. Tony O’Sullivan (co-chair of Keep Our NHS Public) commented on the NHS England website: “at this time of national tragedy, we should remember the function of a national health service and how politicians and the seismic restructuring policies in the Long Term Plan have weakened the NHS. I hope that this ends the fragmentation into 42 separate commissioning units and integrated care systems. How wrong that strategy has been. As we welcome some steps towards the re-integration of the NHS in our hour of need, let us not forget the follies that weakened it and that have put NHS staff and the public at risk. We need the NHS to go forward as a single coordinated public service, there for everyone in time of ‘war’ and nurtured once again in post-COVID-19 peacetime.”

Taking over the private sector?

These special powers will be in place until at least the end of 2020, and one of the principal reasons for them was to gain access to independent sector beds. Taking over the independent sector in times of national need is to be applauded. Spain for example has just requisitioned its large private sector. In stark contrast, however, the UK government is paying private hospitals £300 per bed per day. Business analysts have observed that this is a huge boost to independent hospitals. A private hospital working on an NHS tariff at 100% capacity is far better than conducting private medical insurance work at 50% capacity.

Abolishing debt?

The government announced that from April 1st it would “write-off” £13bn of historic debt across the NHS. In recent years financially struggling trusts have been routinely forced to seek emergency bailout loans from the Department of Health and Social Care. Last year, trusts’ total debts reached £14bn, of which £10bn was related to emergency loans. While Matt Hancock declared this a “landmark step” made by himself to help the NHS COVID-19 response, the plans had in fact already been discussed at a January meeting called by NHS England and NHS Improvement, and had been under consideration for at least 20 months. 

As tax expert Richard Murphy explains, the government has not written off hospital debt. “All it did was make a book-keeping adjustment. What it actually did was allow NHS trusts to record the sums they had spent for the populations they served as having been funded by central government when previously the government were claiming they had overspent.”

John Lister writing for the KONP website also noted that “it’s like a gang of burglars seeking gratitude after handing back some of the jewels they have stolen. £13.4bn averages to a refund of just £1.3bn per year for the last ten years – far less than the real terms cuts that have been imposed by the virtual freeze on funding while the population and its health needs have grown.” It would be much more valuable to the NHS if the government were to write off the huge outstanding payments for new buildings paid for through the Private Finance Initiative, but strangely, Rishi Sunak does not seem to be stepping forward with this proposal.

Xenophobia is alive and well

Before the pandemic, the UK had only 4100 critical care beds, 6.6/100,000 population compared with Germany’s 29.2. An urgent need to find more ventilators was identified at the start of the outbreak, yet Downing Street chose not to participate in an EU scheme to source such vital equipment, leading to the charge of putting “brexit over breathing”. The government’s attempts to justify this through claims of having accidentally missed a deadline due to communication errors were quickly exposed as groundless by EU officials.

Despite the need for both trust and a unified response to the crisis by members of the public, it is notable that the hostile environment in the NHS has not been lifted. As one member of KONP writing in the British Medical Journal observed, “it is simply not good enough for the UK to add the novel coronavirus to its list of exemptions from charges, which few people will know. To tackle this epidemic and protect everyone’s health, all barriers to accessing NHS treatment – including charges and reporting of debt to the Home Office – should be suspended immediately.”

References to COVID-19 as the ‘Chinese virus’ and promising a reckoning with China after the pandemic are diversions of attention from the failings of our government ministers. Zoonoses (infectious diseases that spread from animals to humans) are linked to climate change and intensive farming methods among other things, and are destined to be a recurrent event. Michael Gove would do well to reflect that not long ago Bovine Spongioform Encephalopathy resulted in the slaughter of 4.4 million cows in the UK and was responsible for variant Creutzfeldt-Jakob disease in humans. The World Health Organisation has warned against use of the term ‘Chinese virus’ saying that it could lead to racial profiling against Asians when “there is no blame in this”. In the UK we have already seen reports of Asian people being physically attacked in the street. 

What next?

Writing in the nineteenth century in his book The Housing Question, Frederick Engels made a highly relevant comment on the self-interest that motivates those who are in control of society through virtue of their wealth and position. “Capitalist rule cannot allow itself the pleasure of creating epidemic diseases among the working class with impunity; the consequences fall back on it and the angel of death rages in its ranks as ruthlessly as in the ranks of the workers.” 

Having said that, the competence of the ruling elite in preventing and controlling epidemics is always in doubt, since their desire for profit is in opposition to any inclination to spend money on public services until it is too late. Thus an opportunity to avert a crisis is lost, and a pandemic that could have been limited if planning advice had been implemented and intervention had been timely must instead run its miserable course. We have known for the past 13 years, for example, that a pandemic at least as lethal as coronavirus represented an ever present major threat.

At the same time we can be sure that history will be busily rewritten in order to exculpate ministers and make sure any temporary steps towards ‘nationalisation’ of services are quickly reversed. There may even be calls to continue the restrictions on civil liberty for much longer than the medical situation necessitates. 

Charles Moore (former editor of the Daily Telegraph, where he was Boris Johnson’s exasperated boss) is jockeying for position in this vanguard, explaining to readers that it is in fact deficiencies in the public sector that has brought the country to lockdown. In a sense Moore is correct, but for the wrong reasons. It is the underfunding and weakening of the NHS at the hands of the Tories that has made it much less able to deal with the current crisis, making lockdown even more crucial in order to limit demand. We can also expect to hear from other ideologues about how our small and parasitic private sector came to the rescue of the NHS in its time of need.

However much the Tories are now clapping for our NHS, we must remember that they are fundamentally opposed to public services, and will soon forget their panic and revert to form. A former Tory insider, now disillusioned with the world view that anything funded by the state is wrong (except of course infrastructure that furthers the interests of the rich), has written a tell-all piece stating as much.

Our job as health campaigners is to now make sure the right lessons are learned during the coming weeks and months. We need to keep the Tories on the hook, and harness the public anger which will no doubt grow over time. We must rally the vast majority of society around our vision of a health and social care service that exemplifies a more just, equal and caring society. 

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.

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COVID-19 Defend the NHS DiU and Unite DiU Policy Statements Unite Leader statements

COVID-19: Response from Doctors in Unite

The threat posed by COVID-19 demands a united national response across the UK. As well as protecting individual and public health, the burden of maintaining public resilience must be shared equally, on a pooled basis across society.

In response to COVID-19, Doctors in Unite urges the government to:

  • Extend day-one sick pay to those on zero hours contracts, in the ‘gig-economy’ and to the self-employed.
  • Ensure that workers are not under pressure to attend work while they are unwell and may inadvertently pass on the disease, both financially and in regards to staffing.
  • Allow the NHS to requisite private health care facilities to accommodate effective COVID-19 treatment and quarantine provision if needed.

Trades Union Congress General Secretary Frances O’Grady has said:

“Employers have a duty of care to support workers affected by coronavirus. No one should have to worry about making ends meet if they have to self-isolate or if they fall ill. They should be able to focus on getting better.”

The government issued a statement on 4th March, explaining that statutory sick pay (SSP) would be available from day one, and that “there is a range of support in place for those who do not receive Statutory Sick Pay, including Universal Credit and contributory Employment and Support Allowance (ESA).”

This solution is not sufficient for the three million people in the UK on self-employment contracts plus the two million workers who do not earn enough (£94.25 per week) to claim SSP. In order to claim, these workers would need to enrol for Universal Credit which can take up to five weeks for payment. The alternative is ESA which requires claimants to have built up two to three years of National Insurance contributions.

Doctors in Unite endorses the position adopted by the Socialist Health Association which strongly supports the TUC, and urges that this scheme is extended to those workers who currently do not qualify for SSP.

Employers should make up SSP to the average pay of workers to ensure they are under absolutely no financial pressure to attend work while they are unwell and may inadvertently pass on the disease. This must apply not only when patients are ill but also when people are laid off work for public health reasons, even if they themselves are not actually unwell. 

This is an area where the government must step in, as many sectors (e.g. retail, hospitality, or care providers) which interact most with the public may not have the financial resilience to weather the storm created by COVID-19.

Should the coronavirus outbreak spread significantly everyone will be expected to respond by putting the interests of the community first. Undoubtedly workers will volunteer long hours and take on exceptional responsibilities. This will increase the risk of errors, which will need to be balanced against the risk of failure to treat patients in a mass outbreak. We urge professional bodies to be aware of this.

Our NHS must be in a position to requisition private health care facilities where it will increase local health capacity or facilitate quarantine provision.

As the trade union for medical doctors, Doctors in Unite congratulates our colleague trade unions and Labour leaders for engaging with the government and employers, to ensure that these steps are taken as a matter of urgency in the national interest.

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Defend the NHS Independent Care Sector Privatisation

Rationing in the NHS

Given the chronic underfunding of the NHS, it is no surprise that rationing appeals to commissioners as a way of limiting expenditure. However, this goes against the NHS Constitution, which establishes that “the NHS provides a comprehensive service, available to all” and “access to NHS services is based on clinical need, not an individual’s ability to pay”. It is therefore approached in a covert manner.

The most obvious form of rationing is the waiting list: between March 2013 and November 2018, the number of people still waiting for their treatment grew from 2.7 million to 4.2 million, and the number waiting more than 18 weeks grew from 153,000 to 528,000. Exceptional funding requests, originally used to limit cosmetic and fertility treatment, have expanded into areas including hip and knee surgery as Clinical Commissioning Groups seek to limit patient access. Bristol, North Somerset and Gloucestershire CCG now lists 104 restricted treatments. GPs are no longer able to decide when a patient should be referred for a consultant opinion. In many situations, rationing has been disguised as “addressing unwarranted variation”, “evidence based medicine”, and even “patient choice”.

Simon Stevens, The World Economic Forum, and McKinsey

A 2012 report from the World Economic Forum (based on work led by Simon Stevens, then head of United Health’s Global Division and now Chief Executive of NHS England) focused on economically challenged health care systems and how to “help existing models become sustainable”. One proposal was to “ration access to care… for example, restricting coverage, imposing cash-limited budgets and allowing waiting lists to rise, or reducing the scope of services covered”. The Five Year Forward View of October 2014 which Sustainability and Transformation Partnerships are now set to implement is drawn directly from the WEF’s diagnosis of, and prescription for, the healthcare crisis.

The WEF report was produced in association with management consultancy firm McKinsey, who in 2009 advised the Department of Health on “how commissioners might achieve world class NHS productivity”. Their presentation outlined the potential for savings by decommissioning procedures of “limited clinical benefit”. These included tonsillectomy, back pain, grommets, trigger finger, Dupuytren’s contracture, knee washouts, dilatation & curettage, minor skin surgery, aesthetic surgery of various types, knee surgery, hip surgery, and cataract removal. Nearly all of these procedures are to be found in the Croydon list, NHS England’s 17 Evidence Based Interventions, and the shopping lists of self funding NHS patients.

The obsession with unwarranted variation

Even before McKinsey’s work, in 2007 the London Health Observatory explored the potential savings that might be realised if treatment access criteria could be standardised for certain procedures – the Croydon list. This focus on variation has been continued under the strapline of getting it right first time, or GIRFT, “designed to improve the quality of care within the NHS by reducing unwarranted variations… as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings”. NHS RightCare is also concerned with variation in outcomes between CCGs. RightCare has been implicated in unjustified proposals to cut hip and knee replacement surgery, and its methodology has been strongly criticised. The vey real difficulties of measuring “unwarranted variation” are discussed by the King’s Fund. Their report contains a pertinent quote from Professor Al Mulley, Managing Director for Global Health Care Delivery Science at The Dartmouth Institute for Health Policy and Clinical Practice:

“If all variation were bad, solutions would be easy. The difficulty is in reducing the bad variation, which reflects the limits of professional knowledge and failures in its application, while preserving the good variation that makes care patient centred. When we fail, we provide services to patients who don’t need or wouldn’t choose them while we withhold the same services from people who do or would”.

17 Evidence Based Interventions

Variation was also central to the 2018 NHS England consultation and subsequent recommendations to commissioners, 17 Evidence Based Interventions. This identified four generally unwarranted procedures that should almost never be done, and 13 warranted procedures where considerable reduction in activity was anticipated through standardising access criteria. The 13 procedures are breast reduction, removal of benign skin lesions, grommets for glue ear in children, tonsillectomy, haemorrhoid surgery, hysterectomy, chalazia removal, arthroscopic shoulder decompression, carpal tunnel syndrome release, Dupuytren’s contracture release, ganglion excision, trigger finger release and varicose vein surgery.

Where there were already existing NICE guidelines, NHS England recommendations generally conformed with them. But where there was no NICE guidance, NHS England is generally restrictive (regarding skin lesions, breast reduction surgery and ganglion removal). It seems likely that CCGs and referring GPs will consider many of these treatments as to some extent off limits, making it more difficult for patients (including those who actually meet NHS England criteria) to access treatments. While arguably the four “unwarranted” procedures are of little clinical benefit, restricting the other 13 is likely to deprive some patients of valuable interventions.

NHS England argued that the main cause for variation was doctors failing to observe accepted evidence based guidelines, despite the absence of such guidance for some of the procedures. Consequently, it was necessary to introduce economic levers to force providers to reduce activity by threat of non-payment for work done. The title of the consultation was meant to convey the impression that a rigorous review of relevant evidence underlies the recommendations. However, the methodology used is not transparent (unlike NICE) and does not conform with accepted standards for guideline development. It seems more likely that the authors started by drawing conclusions, and then sought supporting evidence from a selective review of the literature. Although both relevant Royal Colleges and NICE were consulted (and appear on the front of the consultation document), they distance themselves from the recommendations made (with the exception of the uncritical Academy of Medical Royal Colleges). NICE explained that “this work was undertaken by NHS England rather than NICE. It would be inappropriate for us to comment on the validity of this work and the subsequent published guidance”.

What underlies variation?

A large component of variation among providers for the 17 interventions relates to treatment access policies, devised by Primary Care Trusts and then CCGs, which are increasingly at odds with NICE guidance. This is not acknowledged by NHS England, yet it becomes obvious on accessing their own website. For example, when searching NHS England for breast reduction surgery we find the following statement: “some CCGs do not fund breast reduction surgery at all, and others fund it selectively if you fulfil certain criteria”. If the evidence based criteria for treatment access from the 17 interventions consultation process were strictly imposed, while projected activity in some CCG would fall, in others it would have to rise. It is striking that in the tables published by NHS England estimating the possible effect of the recommendations, nowhere is there an increase in activity. This exposes the sham of these recommendations – they are neither national, nor evidence based.

Consequences

17 Evidence Based Interventions introduces a mindset in which the public accepts that it is justifiable for some treatments (currently those seen as largely cosmetic, and therefore a soft touch) to no longer be provided by the NHS. NHS England promises that many more procedures will be added to the list in due course. As there is no intention on the part of NHS England to advise CCGs to follow national guidance and commission services where they currently do not, this source of variation is not effectively addressed. The website Ration Watch shows that many CCGs are already routinely restricting access to treatments including hip and knee replacement, hernia repair, and cataract removal, and are simply ignoring NICE guidance.

NHS Clinical Commissioners, the national body representing CCGs, describes this state of affairs as a regrettable but often unavoidable consequence of the systemic financial pressures on the health service, confirming that financial concerns are the underlying driving force for such forms of rationing. Further undermining of the force of NHS England guidance is the fact that many restricted treatments are being made available to NHS patients at a price – the so called self funding patient.

Simply using the term ‘evidence based’ does not legitimise a policy unless the methodology underlying recommendations is both transparent and scientifically robust. It should then be left to doctors to implement guidance after taking into account the individual needs and preferences of a patient (the real essence of evidence based medicine), rather than them being forced to follow a course of action imposed through economic sanctions. As NICE always states: “When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service”. It is ironic that NHS England pays lip service to a “new national ambition to embed personalised care across England so that shared decision making between patients and clinicians becomes the norm”.

Variation in the NHS is a topic deserving of scientific scrutiny, but as the King’s Fund points out, the patient must remain at the centre. “A key focus will need to be to tackle clinical decisions… with patients as a way of driving out unwarranted, and promoting warranted, variation”. Some treatment access policies are now being written for CCGs by shadowy Clinical Commissioning Support Units. CCGs should be openly challenged on how such policies have been developed and in whose interests they operate. They must be asked to justify their rejection of NICE guidance where this exists. The claim of being evidence based requires scrutiny, and may well prove unfounded when examined carefully.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite. A longer version of this article was presented at a Doctors in Unite meeting in September 2019.

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Defend the NHS

‘Groundhog day’ in the NHS means death and despair for thousands

Recent performance figures show that it is groundhog day once again in the NHS. A series of unwelcome events (missed targets) recur in exactly the same way. But behind these statistics are human stories of unnecessary suffering, that shame those politicians who have tenaciously supported the failed Tory policies of the past ten years.

A classic model of an organisation’s defenses against failure is a series of barriers represented as slices of Swiss cheese. The holes in the slices are weaknesses in individual parts of the system, and are continually varying in size and position across the slices. When a hole in each slice momentarily aligns, a hazard passes through all of the slices leading to a failure.

Patients are now tumbling through the huge holes in primary care, ambulance services, A&E, and social care every minute. If patients cannot be discharged because of inadequate social care, bed occupancy rises. A&E is then filled with those needing admission but with nowhere to go, and the new specialty of ‘corridor nursing’ is created. Since A&E is packed with patients, waiting times for assessment and treatment increase and the four hours target becomes even more elusive. Meanwhile, ambulances are unable to handover sick patients and queue outside instead of being able to respond promptly to further call outs.

While NHS England SitRep reports give some of the picture, the first publication from the Royal College of Emergency Medicine’s (RCEM) 2019-20 Winter Flow Project indicates that existing data does not always reflect the true scale of the problem. RCEM figures show that in the first week of December, over 5,000 patients waited for longer than 12 hours in the Emergency Departments of 50 Trusts and Boards across the UK – equivalent to a third of the acute beds in England. From the beginning of October 2019 over 38,000 patients had waited longer than 12 hours for a bed at sampled sites across the UK – yet data from NHS England reported that in England alone, a total of only 13,025 patients experienced waits over 12 hours since 2011-12.

The reason for the difference is that the RCEM correctly counts 12 hour waits from the moment a patient arrives in A&E – which is how it is measured in Wales, Scotland and Northern Ireland – but the NHS officially only records 12 hour waits from when doctors make a decision to admit the patient.

Data (as yet unpublished) by former RCEM vice-president Dr Chris Moulton, and former RCEM president Dr Cliff Mann, was widely reported in the press last December. Their study analysed the care received by more than four million people who attended A&E in England over the past three years. The findings indicated that 960 out of 79,228 patients who had to wait around six hours died as a direct result of the delay. One in every 83 people who have a six hour or longer wait to be admitted will die due to the delay in them starting specialist care.

Similarly, 855 people died over the past three years because they waited about seven hours, as did 636 others who faced delays of at least 11 hours. The researchers concluded that the deaths were entirely and solely caused by the length of wait, and not by the patient’s condition. This is the first research worldwide to calibrate the risk of death for trolley patients by the number of hours waited. According to research seen by the Guardian, 5,449 people have lost their lives since 2016 as a direct result of waiting anywhere between six hours and 11 hours. Findings also showed that the chances of dying increased sharply the longer the wait, rising to one in 30 for patients whose admission is delayed for 11 hours.

John Kell, the head of policy at the Patients Association, said:

“These results are deeply shocking and very worrying. Patients are clearly suffering tragic consequences as well as loss of dignity and discomfort from spending far too long waiting on a trolley for care. This is as a direct result of sustained underfunding of the NHS and social care and ongoing shortage of hospital beds. Despite the unstinting efforts of NHS staff, patients can no longer be sure of receiving safe or dignified care if they need to be admitted to hospital. This is an entirely needless and completely unacceptable situation.”

Dr Nick Scriven, the former president of the Society for Acute Medicine, was also quoted in the Guardian as saying:

“The exact numbers in this study should be a sobering reminder to all that these risks are occurring in some hospitals on a daily basis and, apart from the obvious loss of dignity of being kept in a corridor, there are proven safety risks as well. The risks will continue until overcrowded hospitals have the beds and staff they need.”

The RCEM report also showed that only 69% of patients were seen within four hours across 50 hospitals, the worst performance in the five year history of the Winter Flow Project. This was in accord with NHS England SitRep data up to December 2019, with similarly shocking figures across a range of other indicators. In January 2020 only 82% of patients at all types of emergency departments were seen within four hours, against the target of 95%. Only one out of 118 major A&E departments that submitted performance data met the four hour target.

The total number of A&E attendances exceeded 2.1 million, about the same as 2018-19 despite efforts to redirect patients away from A&E. 100,578 patients spent more than four hours on a trolley from a decision to admit to actual admission – this is the highest since records began. 2,846 patients had a trolley wait of over 12 hours, which is more than four times higher than in January 2019.

Dying due to having to wait an unacceptable amount of time for emergency medical attention is not confined to those on trolleys. There have also been plenty of examples where patients have died in the back of ambulances queuing to access the hospital, or while waiting for an ambulance to arrive. In December, a 47-year-old woman from Cwmaman in south Wales suffered a cardiac arrest in hospital after having to wait 6 hours on the pavement for an ambulance.

The longer a patient waits, the higher the risk of complications and fatality. According to a BBC investigation, delays for 999 ambulance calls affect one in 16 emergency cases in England. While long waits for immediately life threatening cases were unusual, long waits for other emergencies were much more common, including patients suffering from heart attacks, serious injury, stroke, sepsis, major burns and fits. There were 385,000 waits of over an hour from January 2018 to September 2019, out of just over six million calls.

In November 2019 the British Medical Association analysed current performance data and trends, predicting that the NHS was on track to endure its worst ever winter as pressure on services intensified. It said that a lack of recovery from the summer, staff shortages exacerbated by pension tax legislation forcing senior doctors to work fewer shifts, and a focus on Brexit planning rather than winter preparedness risked creating a “perfect storm”.

It also warned that particularly cold weather and significant flu outbreaks could exacerbate these further, urging the NHS to increase its bed stock before winter. However, even if new, promised hospitals eventually materialise, these will not solve the bed crisis. The NHS is now haunted by the spectre of a coronavirus pandemic, with assurances from the Secretary of State for Health and Social Care that it is “well prepared” being met with some scepticism. Long waits in A&E clearly have the potential to increase the spread of the virus.

The NHS has lost 17,000 beds since 2010 as a result of cuts to services or mergers, leaving the health service with the lowest number of beds ever recorded. A&E doctor and member of Keep Our NHS Public Tom Gardiner says:

“Our A&E staff are working flat out in the face of an ever-increasing demand for services. Cuts affecting our hospitals, our GP surgeries and our social care system have led to a situation where vulnerable elderly patients are left waiting for hours on trollies. This is completely inappropriate and sadly I’m not surprised at this horrific new phenomenon of ‘trolley deaths’. It’s high time our politicians came and listened to the concerns of healthcare workers rather than going on the airwaves to promote yet more misleading pledges. Our patience is wearing thin.”

It is nothing short of a disgrace that this situation is repeatedly occurring in the sixth richest world economy with no sign of positive change. It is sadly a predictable consequence of trying to run a health service with a gross shortage of both beds and the people to staff them.

Only proper planning together with funding that takes account of inflation and increasing need will improve this shameful state of affairs. The government must recognise that their funding commitment will not be enough to reverse this situation, and crucially they must take sole responsibility for the abject failure encapsulated by these damning statistics.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.