Sunday, 10 April 2011

Read: 'The Plot Against the NHS'

Read The Plot Against the NHS which rather nicely details the progressive and deliberate destruction of the NHS under Labour and now the Tories:
Prices will rise. On the one hand, the cross-subsidisation that is practised inside NHS hospitals will come to an end as the less costly activities are taken out of them, forcing them to charge more for what remains. On the other hand, Monitor will have to ensure that prices are set so that all providers make a profit. To keep the NHS budget down, what is covered by the NHS will decrease. More and more treatments will be ‘decommissioned’ and will become ‘extras’, which you can have if pay for them. This is already happening in one particular way, thanks to another New Labour measure – personal budgets, or lump sums given to patients with chronic illnesses to buy their own care with. If you want more care than the lump sum will cover you can pay for more, if you can afford it. Inequality in health care will be restored.
If you were to ask me how I thought the NHS could be improved one of the things I would emphasise is that a fundamental priority is to ensure that people brought into hospital as emergencies are treated quickly and effectively - and this means moving away from a 9-5 culture (plus massively scaled down 'on-call' emergency staffing) towards 24hr care where consultant review and radiological investigations don't keep office hours.

However, government has never been very interested in emergency care, preferring to focus on the 9-5 routine elective operations because they are easy to count and put a price on - paying hospitals fixed tariffs for these. This emphasis has been such that most general hospitals are subsidising their emergency care with routine work like elective surgery or outpatient clinics. After all, it takes a huge number of doctors, nurses, and allied staff to provide even the scaled down 24hr emergency care we have now - getting some money back from this necessary excess capacity by providing elective care is paramount to make ends meet when the remuneration for the emergency care itself doesn't cover the costs.

Unfortunately the new model of health care, initiated under Labour, and now brought forward by the Tories, envisages that everything will be broken down into its constituent parts and tendered for by various private providers. The Independent Sector Treatment Centres were the start of this - and since elective work is subsidising the huge fixed costs of emergency care there is obviously profit to be made for those who agree to take the routine elective work but don't have the same emergency care commitments. If your patients get complications after your elective surgery and you can just ship them to an NHS hospital ITU without having to cover the cost of that care from the fixed tariff paid for that operation how can you fail to be making a profit over and above the NHS?

But providing A+E services and receiving unselected acutely ill patients needs more than just A+E staff, it needs the back up of general medics, general surgeons, orthopaedic surgeons, anaesthetists, paediatricians, gynaecologists, radiologists, physiotherapists, ward nurses etc so that once A&E have stabilised and triaged them someone else can actually treat them. That means, at a minimum, all the services of your average District General Hospital - you cannot hive off A&E as an isolated service.

So what will happen as the DGH revenue streams begin to dry up as more and more of the easy and profitable work is taken over by the private sector? Well since every hospital will now be part of a Foundation Trust they will either have to save money or go bust. Saving money entails cutting services below the already bare bones one we have now - probably a return to the trolleys-in-corridors NHS of the last Tory government - and the rationalisation of services to fewer and fewer centres*.

Competition isn't going to improve emergency medical care because there can be no market in it - already it is run at a loss because NHS hospitals can cross-subsidise from other revenue streams - they do this because they aren't run to make a profit, they are still, despite Payment By Results and other market 'reforms', trying to deliver good healthcare to the local population. When the NHS becomes just a franchise for private companies to compete for provision it will remain a monopoly provider of local emergency care (if you can't financially sustain one local A+E you're hardly going to open a competing one) so the best the market can deliver is a private company taking over the running of that A+E. But since they won't be able to cross-subsidise emergency care anymore - because other companies will already have cherry-picked the profitable elective work - there will be less money available and standards will have to fall.

We are moving inevitably to a two-tier NHS where private companies cream off large profits from over inflated centrally determined tariffs for simple elective services like outpatient work and routine operations while complex and difficult or emergency care is provided by an under-resourced remnant of the old public system.

* For some services, like complex poly-trauma, a rationalisation to fewer centres would improve outcomes as more specialist teams have better results - but this would only be a fortuitous unintended consequence under the Tory plans, and for many other conditions which require less super-specialist provision the extra travel time is likely to prove detrimental.


Zeno said...

I get more and more depressed every time I read your blog posts about the way the NHS is going.

Keep up the good work.

pj said...

I aim to please!