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Health & NHS

Lansley’s NHS reorganisation Bill goes back into intensive care

On Wednesday (February 8) the coalition government’s Health and Social Care Bill reappears in the House of Lords for its report stage.  The government have tabled 136 amendments described as ‘concessions’ – but calls to stop the Bill are growing.

However, stopping the Bill is problematic.  Prior to parliamentary approval, the Secretary of State for Health, Andrew Lansley has driven ahead with changes which would be hard to reverse.

In our area, NHS Wiltshire (the primary care trust or PCT) is already being split into three Clinical Commissioning Groups (CCGs) which are run mainly by GPs.  The North East Wiltshire CCG (or NEW) covers the area from Ramsbury to Corsham.

In other areas these CCGs are already (before they’ve been fully approved) setting budgets and commissioning health care. Doctors in Wiltshire took a little longer to decide how to divide the county up, but members of the three CCGs are now working with the PCT and executive directors of the PCT are assisting the CCGs with governance issues.

The PCT itself has made the 45 per cent savings in admin costs that Lansley demanded and from March 1 will be ‘clustered’ with the Bath and North East Somerset (BANES) PCT.  The regulations have been changed so these ‘clustered’ PCTs can merge their budgets – it’s not yet clear how far the Wiltshire-BANES ‘cluster’ will be a merger.
The merged or ‘clustered’ PCTs will only last till 31 March 2013.  They are not statutory bodies, but they could be taken to judicial review over decisions they take.

Further up the chain, the south west strategic health authority has already merged to become part of NHS South of England – stretching from Dover to the Isles of Scilly.

To get a new view of the coalition government’s reorganisation of the NHS, Marlborough News Online contacted Dr Huw Williams who was a partner in a Trowbridge surgery for twenty-nine years.  He retired two years ago and now works two or three days a week at the surgery mainly in its specialist cardiology unit which he helped set up.

As he is not part of a CCG Dr Williams can give his views on the Bill as an experienced yet  disinterested doctor.

Dr Williams’ main fear is that there is no evidence that the new system for commissioning will work: “I’m against GPs being given a lot of commissioning – I don’t think they’re any good at it. No one’s suggested getting train drivers to run a city’s transport system. Just because GPs are near to the patient it doesn’t mean they’re expert at commissioning services.  It’s a delusion.”

He looks back to the experiment of practice-based fundholding, when some doctors showed responsible corporatism while others proved very poor at controlling funds and some “rogue doctors” flourished: “Commissioning groups with a hundred GPs? No way they’re all going to agree – let alone behave in a sensible way.”

Dr Williams is worried by the “inevitable conflicts of interest” as many GPs will be providers of services at the same time as they commission services – whether it’s Dr Williams’ cardiology unit or a surgery that rents space to therapists.

One of the things he fears most is political interference: “Left to the politicians you’ll get examples of people misunderstanding the difference between needs and wants.  It’ll be decision-making by decibel – he who bangs the desk loudest gets results.”

However, he does think that part of the trouble the government now faces has come from the concessions Mr Lansley has made after his Bill was first paused for alterations and then savaged by the Lords.  It was “tokenism”, he says, to add one hospital doctor and one nurse onto each CCG: “What on earth is she or he going to be doing? It’s a bit of a dog’s dinner.”

However, Dr Williams says that once you’ve decided on a way to operate, “The more you dilute the less chance you have of getting people involved who can make a difference.”

Government ministers have dismissed the recent high decibel opposition from GPs – from both the doctors’ union, the BMA and from the Royal College of GPs.  They do not seem to realise that many of the concessions they make to the plans simply alienate GPs.

As Marlborough News Online has been reporting (see items in August 2011 and this month), GPs do not like the way the initial promise of power to commission has been eroded with more and more bodies and duties inserted into the system to look over their shoulders and monitor them.

On the other hand, as Dr Williams puts it, “patients’ expectations have been raised” by such promises as “No decision about me without me” which was at the heart of the White Paper and is being strengthened in government amendments to be debated this week in the House of Lords.

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Disability Living Allowance: a PERSONAL VIEW of government cuts

The coalition government are pushing through Parliament reforms to the Disability Living Allowance. They want to take 500,000 people off this benefit by 2015 and cut the costs of assisting the most seriously disabled by twenty per cent.
Max Preston is a freelance journalist who lives in Lockeridge.  A recent graduate of Leeds University’s broadcast journalism programme, he uses a wheelchair due to cerebral palsy and currently receives Disability Living Allowance. This is his personal view.

When the Tory-Lib Dem coalition took office in 2010, I – unlike a great many of my generation – held out some degree of hope.  Under Labour, dealing with the various implementing entities for disability-related policy had been an unnecessarily bureaucratic chore made all the worse by startlingly frequent passive aggression on the part of their administrators.

It is still beyond me as to quite why I – with a diagnosis of quadriplegic cerebral palsy (CP) confining me to a wheelchair for life – needed to check in with these people on at least a semi-annual basis to reassure them that I was, indeed, still profoundly disabled and really-rather-put-out-about-it. Having said that, the Department of Work and Pensions (DWP)  themselves have been – more often than not – courteous, helpful and disarmingly cognisant of how much of a pain-in-the-backside it is to have to deal with their paperwork.

After the election, I had hoped that the Lib Dems would provide a moderating influence on disability-related policy by offering a counterweight to Tory right-wingers, that efforts to cut back red tape would not be made merely for their own sake, and that David Cameron’s empathy thanks to his experiences with his own late son, Ivan (whose degree of CP was far more severe than mine), would win the day. Thus far, my optimism has not borne fruit.

Among other things, I use Disability Living Allowance (DLA) to fund a specially-adapted car which is driven for me to hospital appointments, grocery shopping excursions and – perhaps most importantly for a recent graduate – job interviews. In fact, it also pays for part of my food bills, as eating healthily (and therefore more expensively) is absolutely crucial for someone with as sedentary a lifestyle as mine.

Without DLA, I could not have gone to university and laid the foundations for what I hope will be a productive and fulfilling career in journalism. 

Whilst I understand that the government wishes to substantially reduce the number of people in receipt of this type of benefit, a far more sensible course was suggested in the House of Lords by Baroness Tanni Grey-Thompson, formerly of Paralympic fame and now a steadfast crossbench advocate for the disabled.

In short, it was grossly irresponsible of peers to vote down her motion that DLA’s putative replacement – the Personal Independence Payment (or, unfortunately, PIP) – be extensively piloted before it is launched.

In its quest to make what are admittedly necessary cuts across many facets of British life, the government has lost sight of perhaps its most fundamental mandate, one to which every government is beholden: to take care of the most-vulnerable among us first. To invoke what is probably a well-worn cliché: this is not an issue of left-and-right, but of right-and-wrong.

People do abuse DLA, but this attempt to stamp out such wrongdoing appears to cut first and ask questions later, simply in order to appease the need for overall fiscal stability.

The coalition’s most fundamental mistake with regard to benefits policy precisely and dangerously mirrors that of recent Labour governments. Namely, there appears to be a presumption of guilt – that you’re trying to get one over on them – rather than innocence.

That mind-set starts from an unhelpful, even noxious place that makes staff unnecessarily hostile, gives recipients an unduly guilty conscience and renders politicians apathetic at best and cold-hearted at worst.

Admittedly, with a condition as severe as mine, one would like to believe that any reduction in my own benefits would be minimal. But having lost the support of even The Daily Mail on this issue, Messrs. Cameron and Clegg must pause to consider what they want their legacy to be.

They had an opportunity to take a commendable, non-partisan moral stand, just as they did alongside Joanna Lumley and the Ghurkhas, even as Gordon Brown refused to join them – and they have inexcusably failed to do so. Now, the DWP will have to screw up PIP before they can put it right, and hundreds of thousands of already disadvantaged people will find themselves even more marginalised and overburdened as a result.

It is worth remembering that while his premature death was undoubtedly a tragedy, Ivan Cameron was a child of privilege, and the support system that his parents rightly placed around him would have always ensured him the best-possible standard of care... because they could afford it.

The Prime Minister has, in the past, earnestly put himself forward as someone with first-hand experience of dealing with the travails of disability. As it stands, however, he has entirely abrogated the responsibility due to his own son’s memory - and he should be ashamed.

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Are Wiltshire hospital meals REALLY the most expensive?

On Wednesday morning (January 11) the Daily Telegraph’s front page, lead story was headlined: “Hospitals feed patients on 90p a meal, official figures show.”  The story was also given wide publicity as one of the morning paper front pages shown on the previous night’s ITV News at Ten.

The newspaper’s report – using figures from Andrew Lansley’s Department of Health – highlighted Wiltshire NHS as spending more on food and drink per patient per day than any other primary care trust. But was the report accurate?

Picking up the headline, the Telegraph said that “the lowest spender was Western Sussex Hospital Trust which was listed as paying £2.57 a day to feed each patient” – presumably that is where their 90p came from – rounded up for headline purposes from 86p. The Telegraph then wrote that “several other trusts spent less than £1 on each meal”.
 
Quite how that justified using ‘hospitals’ in the plural for the headline is not clear.  Nor is it clear why the headline used the present tense when the figures were for 2010-2011 – that’s up to the end of March 2011.
 
However, there is a major problem with the figures.  They were not collected to any standard formula.  This means that some of the costs quoted were for ingredients only and others included the costs of buying, storing, cooking and delivering the meals.
 
The Telegraph did approach Western Sussex hospitals who explained that their figure only covered ingredients.  If they had included “the total cost of sourcing, preparing, cooking and serving food and drink” their figure would have been about £8 per patient per day.
 
That was not enough to get the Telegraph to change their misleading headline.
 
The Telegraph also assumed that you can simply divide the daily cost by three to get a per meal cost. But breakfasts generally cost considerably less than the main meal of the day and suppers will cost a sum in between that for breakfast and the day’s main meal.
 
Apart from the figure for West Sussex, another figure caught the eye: Wiltshire NHS was spending £22.31 per day per patient – the highest.  This was computed including all the additional costs like cleaning the canteen and providing meals for visitors and the catering staff’s employment costs.
 
But even this figure has no relevance at all to the present situation.  Wiltshire NHS has not provided a single hospital meal since June 2011 when – on government instructions – its community hospitals were handed over to be run by the Great Western Hospitals Foundation Trust.  And GWH told Marlborough News Online that the current figure for its community hospitals – including Savernake Hospital – would be closer to £15 per patient per day for ingredients and preparation.
 
The £22.31 and £15 figures really only emphasise how very expensive it is to run small community hospitals spread across a huge county, when the large acute hospitals can buy ingredients and services in bulk and therefore so much more cheaply.
 
In the latest assessment of hospital food, GWH was rated as “excellent” and for the record the 2010-2011 figures showed GWH’s daily costs for food and drink per patient at £5.50.
 
Responding to the report, the director of the GWH department that provides food and drink, Mark Bagnall, said: “We put a lot of effort into providing patients with a choice of high quality, nutritious food and prepare almost 580,000 meals a year at the Great Western Hospital.  No one wants to be in hospital in the first place so it is important that patients receive the food they need to recover.”
 
And he emphasised the differences size made to the cost of meals: “With such a large number of meals being produced we can achieve large economies of scale which means we can produce good food at a lower cost than some smaller organisations and our current average spend per patient per day is around £6.00 - which is broadly in line with many other Trusts of this size.”
 
The figures, issued through the NHS Information Centre, appeared in an agency story (Press Association or PA) timed at 02.49 am on Wednesday morning (January 11).  But the Telegraph headline was shown on television at about 10.25 pm the previous evening. And the Telegraph’s journalist had had time to include extra research and comment.
 
So it seems likely the figures were leaked to the Telegraph well ahead of the PA story.  Both the Telegraph and PA stories included long quotes from the health minister, Simon Burns.
 
What’s the game?
 
A clue comes in the Telegraph’s own story: “Government sources said last night that concern about the poor state of nutrition in some hospitals had prompted David Cameron’s warning last week about declining basic standards of care in the NHS.”  So this, it appears, was designed to support the prime minister’s campaign.
 
Or perhaps this was an attempt to deflect attention away from health secretary Andrew Lansley’s problems over the faulty breast implants crisis.  This issue has forced him to criticise the private health sector – to which he is about to hand over large parts of the NHS.  And also means he has to extend regulation and its attendant bureaucracy.

Alternatively, this could simply be part of the coalition government’s longer term plan to destabilise the NHS and so make it easier to justify its costly reorganisation and the surreptitious moves toward privatisation.
  
The Department of Health has pointed out that the money hospitals are spending on food has gone up over the past five years.  The average per patient per day in 2005-2006 was £6.53 and in 2010-2011 it was £8.58 - which somewhat undermines the Telegraph's headline.
  
Marlborough News Online is making enquiries to find out why this information was published at this time and in such misleading form.

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Meet the man whose company runs Savernake Hospital’s financing contract

Doubts and anxieties about Savernake Hospital’s private funding initiative (PFI) have been raised by Devizes MP Claire Perry and local campaigners – both about the size of its burden on the area’s health services and its future amidst the wholesale reconfiguration of the NHS.  And some local people have expressed worries about what might become of the hospital itself.

In addition, the whole value of PFIs in building new infrastructure has been called into question at Westminster – in Parliament and within the Treasury.  And this just as the Chancellor of the Exchequer announces that he wants to get more private funding into building to help fire-up the stagnating economy.


Who better to go to for the facts (as opposed to the political rhetoric) about Savernake’s PFI and PFIs in general than Alan Birch, the group managing director of Semperian PPP Investment Partners, the largest public private partnership infrastructure fund in Europe.  Semperian owns and manages the Savernake PFI contract – and also the much bigger one for the Great Western Hospital.

Semperian’s annual bill for the Savernake Hospital PFI (known as the ‘unitary charge’) is £938,000 for the financial year 2011-2012 – paid by NHS Wiltshire, our Primary Care Trust (PCT.)  This cost is partially offset by rental payments from the other health authorities that provide services at Savernake.

And for the Great Western Hospital the unitary charge this year is £18.7 million – paid by Great Western Hospitals NHS Foundation Trust .

Alan Birch agreed to meet Marlborough News Online at the company’s regional offices in Bath. The group own and run over a hundred PFI projects. They are secondary investors in the PFI market.  They do not start projects and build hospitals, schools, army training facilities, roads and so on, they do buy up projects that have been successfully completed and then run them.

And the running of them is where things get complicated.  Aside from the capital investment and consequent interest payments, the contracts include two types of facility management: hard (which includes maintenance, replacement of equipment and of plant like boilers or switchboards) and soft (which includes facilities involving staff like catering and security.) Alan Birch says that the average proportion for Semperian PFIs that is spent on hard and soft facilities management accounts for between forty and forty-five per cent of the unitary charge.  Many of these services will be contracted out and, to maintain value for money, are put out to tender every three or five years and the unitary charge is then adjusted to ensure the taxpayer only pays the market rate for these services.


At Savernake Semperian are only responsible for ‘hard services’ – maintenance of the fabric and upkeep and replacement of hospital equipment and services like heating and lighting.

At Great Western Hospital Semperian are responsible for both hard and soft services, which includes estate management and life cycle maintenance works; catering for patients, staff, employees and visitors; portering, mail delivery, cleaning, security services, the switchboard and a 24/7 customer help desk.  It also buys the hospital’s utilities and manages the shop.

The scale of Semperian’s involvement through these soft services in the everyday life of hospitals is staggering.  At one Manchester hospital they manage ‘soft services’ valued at £17 million a year.

 








Turning to the ‘hard services’, during school holidays, Alan Birch’s project managers can be organising £70 million of maintenance work at their PFI schools – making sure they’re finished so the schools can re-open.  If they can’t re-open Semperian won’t get paid its unitary charge.  

 

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At Savernake, they’ll soon begin replacing the windows in the old, Gilbert Scott buildings with top-of-the-range double glazed windows. That’s one of the great advantages of PFIs: the companies are obliged to keep the buildings’ fabric and services up to scratch and at the end of the contract, deliver the hospital, free of charges, back to the PCT, well maintained and achieving the same output standards as on day one – but, of course, with up to date materials and technology.

Conversely, for PFI hospitals one of the disadvantages raised by critics is that over thirty years of a PFI contract patterns of health care and budgets will change and a hospital risks becoming something of a costly white elephant.  But that’s not Alan’s experience.

He explained how Semperian had developed a simple way to vary buildings so they can be continually changed and adapted to meet the changing needs of health care policy.  And it’s up to the primary care or hospital trust to ensure the buildings are configured and occupied properly.
 






Alan Birch started his career as an apprentice plumber with British Rail at Edge Hill in Liverpool.  By the time he was twenty-three he had become a manager and was given the job of preparing the Liverpool area’s maintenance organisation for privatisation.

He has been involved in PFI from the outset, negotiated the very first PFI projects for education and worked his way through every level of management until he reached his current position.  Now aged 41, whilst his family home remains in Wigan, he works from London during the week.

He certainly knows a great deal about making economies and running a tight and efficient ship.  Along the way he has, he says quite openly, worked very hard and been rewarded very well.  He even joked he could retire and live modestly in Wigan: “But I choose to work because I like what I do.”

He likes working in the social infrastructure sector, and he likes being able to make a good return for his investors, almost all of which are public sector pension funds or UK corporates that the government has a material stake in.  That return is generally eight to nine per cent. He likes seeing the returns generated by Semperian fed back into the public sector via pension funds – forming a virtuous circle.

So he’s a little disconcerted that PFIs have suddenly become a political football.  He wonders whether if they had been named PPPs – public private partnerships – rather than PFIs, the current political squall would have arisen.  Especially as the public sector is unable to raise the money and politicians are saying how much our infrastructure needs updating.

 

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He was a little troubled when at a committee hearing, one MP failed to understand the difference between Semperian’s parent or holding company being registered in Jersey and resident in the UK.  It’s resident in the UK so it pays UK taxes like any equivalent UK company.


It is registered in Jersey so it can attract foreign investors who do not then get taxed twice on their dividends That’s in accordance with international tax treaties and is agreed by British tax authorities.
Both the Treasury and the Treasury Select Committee have been looking at ways to save money on PFIs. From a pilot scheme, the Treasury reckons it’s possible to save “around five per cent of the annual unitary charges”. 


 

The bulk of these savings will come from soft facilities management on which Alan Birch says “We don’t make a single penny and never will, all these savings are passed directly to the owners of the buildings.”  

He explains that as soft services rely on people, the savings will come from lower wages now that nationally pay increases have fallen so far behind inflation.  The November figures showed the pay of British workers up just 0.4 per cent on November 2010 while inflation is above five per cent.

There are other ways to save small parts of the unitary charges.  For example Semperian now pays Savernake’s gas and electricity bills.  This is a simple way to save money as Semperian with all its projects can bulk buy energy at far greater discounts than a small group of primary care trusts.  At Savernake this will save between £15,000 and £20,000 a year.

_________

PFIs were born in November 1992 when Norman Lamont announced “ways to increase the scope for private financing of capital projects.”   And the Conservatives’ 1997 election manifesto promised to use PFIs “to unleash a new flow of investment funds into the modernisation of the NHS.”

Labour won that election and made PFIs their own. Records show that 101 of the 135 new NHS hospitals built between 1997 and 2009 were funded using PFI. The 2010 coalition agreement confirmed its future use of PFIs.  And as at March 2011 sixty-one new PFI projects were being procured – with a total investment value of £7 billion.

Alan Birch does admit that at the beginning a few companies succeeded in making some big short term gains on projects mainly because there was a flood of money into the PFI market.  However, since the credit crisis private sector borrowing costs have tripled and sometimes public bodies can get funds more cheaply than PFI projects allow – especially now with interest rates at rock bottom levels.

An example is Semperian’s sale of two of its PFI projects to Transport for London (TfL) which is a government body with a triple-A rating and is unique in that it can raise its own external funds.  The two PFI projects are extensions to the Docklands Light Railway – the Woolwich and Arsenal links both run by Semperian companies.  

According to TfL this will save some £250 million over the length of the contract.  TfL can make this work because it does, of course, have its own maintenance teams ready to go.

Alan explained:  “On these two PFI projects Semperian could not match the cost of borrowing TfL could find, so the only pragmatic thing to do was to sell them the companies and let them realise the savings. But this is an exception. The fact is public sector funding is not normally available and so private finance is required.”

Private finance is more expensive than public finance, but if the latter is not available because a government won’t allow more borrowing, then it is not a question of comparison, more a realisation of the true costs of renewing our social infrastructure.

One of the FAQs about PFIs is why the unitary charges for NHS projects rise each year by inflation (RPI.)  This money is used to repay the capital toward the end of the contract. It means that unitary charges start lower and are paid for by matching RPI increases in funding to the PCT or hospital trust.  

However, during the current period of austerity and the reduction in NHS funding, the inflation linked unitary charge is being seen as a burden, but the inflation element is needed to repay capital raised to fund the building of the hospital.

Stirring the political storm swirling around PFIs, conservative MPs have implied that the last government simply ‘threw money’ at projects.  But a look at the Treasury’s role in the development of PFIs shows that contracts have evolved and become tighter since the days of the Major government.  The current standard contract - ‘Standardisation of PFI Contracts Version 4’ (“SoPC4” for those who need to know) – was published in March 2007 and is still in use.

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Savernake being extended and refurbished under PFI in 2004
Two things are certain: without the PFI Savernake would never have been extended and renovated.  It was re-built within budget and on time.  Its PFI contract means that far from saddling our grandchildren with a debt, they will, in 2035, inherit a hospital even more modern and as well-maintained as it was on day one of its new existence, and with renewed services and equipment.

Alan Birch says that discussions with the government about PFIs in the reorganised NHS have been going on for several months.  He thinks that Great Western Hospital will be the best people to hold the Savernake Hospital PFI contract after the PCT is abolished in 2013.

GWH now manage most parts of Savernake Hospital and its fabric. And Semperian’s full-time GWH manager also looks after Savernake.
 











This would seem to be a perfect fit as Great Western Hospitals NHS Foundation Trust took over Wiltshire’s community health staff – and community hospitals – from the PCT in June this year.

Alan Birch has comfort for those who fear Savernake Hospital might simply disappear when Wiltshire’s primary care trust disappears.  The contract has a clause which means that “upon the Trust ceasing to exist”, the contract is passed automatically to its “successor” organisation which may include “any person to whom the Secretary of State [for Health] in exercising his statutory powers…transfers the property, rights and obligations of the Trust under this Agreement”.


FACTS CHECK:

  • Semperian PPP Investment Partners is a £1.3 billion company.  It is one quarter owned by the Transport for London pension fund.  Its other shareholders are similar institutions.
  • The money to rebuild and extend Savernake was lent at 6.98 per cent a year.
  • PFI keeps debt off the government’s books. The national debt would increase by at least £35 billion if all PFI liabilities were included.
  • By May 1997, seventy PFI schemes were in the NHS pipeline.
  • In the NHS at present there are £2.9 billion of PFI projects under construction and another £1.4 billion worth in the preparation or procurement stage.
  • The Treasury estimates that when all Department of Health PFI projects are taken into account the annual unitary charges will add up to over £1.5 billion for 2011-2012.

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Wiltshire health matters: behind the headlines - checking the health of our NHS

Nationally the NHS has come in for some dreadful headlines in recent weeks.  Indeed it’s quite hard to keep up with the flow of reports and statistics – both official and unofficial.

Late on Monday evening (October 17)  the Guardian’s  main online headline ran: “Revealed: how NHS cuts are really affecting the young, old and infirm – Services slashed affect patients on frontline such as pregnant women and elderly despite assurances they would be protected.”

Leaving aside the headlines about the passage through Parliament of the coalition government’s Health and Social Care Bill and the dire warnings from some of its critics and from health professionals, we can dig through the data behind the headlines to run a quick health check on some of our local health care provision.

Waiting for treatment

August’s figures for the time taken from referral to treatment showed a rise in the number of patients waiting longer than the all-important recommended maximum ‘waiting time’.  Across England there was a forty-eight per cent rise in patients waiting more than eighteen weeks to be treated in hospital: “Sharp rise in NHS patients waiting more than 18 weeks for care”.

Nationally the average waiting time for those completing referral to treatment in August was 8.1 weeks for those admitted to hospital and 4.1 weeks for those who did not need to be admitted to hospital.

For NHS Wiltshire patients admitted to hospital, the average (median) waiting time from referral to treatment was 10.9 weeks – only eight PCTs recorded longer waiting times.  But the percentage of NHS Wiltshire patients admitted to hospital and treated within the eighteen week target was a respectable 93.5 per cent against the national average of 90.4 per cent.

For those not admitted the average (median) waiting time was 4.8 weeks with 97.7 per cent completing referral to treatment within the eighteen week ceiling.

For Great Western Hospital the average (median) waiting time between referral and treatment for patients admitted to hospital was above the national average at 12.7 weeks. Yet the average (median) waiting time from referral to treatment for those not needing hospital admission was 3.6 weeks – well below the national average.

And 98.1 per cent of non-admissions were treated within the eighteen week limit – against the national average of 97.3 per cent.

Care of the elderly by hospitals

Some of the most alarming and outraged headlines concerned the Care Quality Commission’s (CQC) report on the care of the elderly in hospitals.  Based on unannounced inspections in April this year, this looked at two elements of that care - patient dignity and nutrition.  The report did not look into the elderly’s medical treatment.

The headlines were damning: “Treatment of the elderly is a national disgrace” (The Independent.)  Under the headline “Our nurses must go back to basics”, the Mirror’s veteran columnist, Paul Routledge, said: “Making nursing a graduate profession has been a medical success and a caring disaster.”

The Great Western Hospital was among those criticised in the report – but not as harshly as were some hospitals. For the full story and GWH’s response, read Marlborough News Online here.

While the CQC’s national report was very worrying indeed, there was also worrying news about the capability of the CQC to monitor care properly.  While the coalition government has cut the CQC’s budget by about one third, its remit has been widened to include GP’s premises and it currently has about two hundred staff vacancies.

The wait for diagnostic tests

August’s monthly data from the Department of Health showed a growing number of people in England were not getting one of the fifteen key tests - like scans and gastroscopies – within the NHS’s recommended six week waiting time: “Patients waiting too long for NHS scans”.

NHS Wiltshire scored well in this data even though  August’s figures are liable to reflect appointments postponed because of holidays and specialists on leave.  Out of a total of 4,427 tests in the fifteen categories, nineteen were performed beyond the six week wait and three were beyond thirteen weeks.  Some of those may have been based on rogue data recorded by the first time use of new software.

To take one of the more common diagnostic tests as an example: out of 1,633 non-obstetric ultra sound tests commissioned by NHS Wiltshire, 1,233 were completed within four weeks and none ran over the six week waiting time.

The NHS’s budget

On October 7, NHS managers called on the government to be more honest about the financial challenges facing the NHS in England.  They fear that the public will hear the government’s claim to have increased spending in real terms and not understand when cuts have to be made.

The Primary Care Trusts are facing cuts to their staff, huge savings and the intricacies of the government’s developing and changing restructuring plans.

When in April a Marlborough News Online writer challenged Devizes MP Claire Perry’s upbeat press release  – “Claire Perry welcomes £19 million extra for NHS in Wiltshire” – the Conservative Research Department did finally agree that the increase over inflation was “marginal”.

In fact it was 0.1 per cent.  To call the 0.1 per cent an increase at all increase was optimistic based as it was on an inflation figure of 2.9 per cent with a 3 per cent funding increase.  That was what the promised ‘real terms’ increase meant.

Even with pay freezes and job losses, the NHS has to cope with the steep increases in fuel and energy costs and other inflationary pressures.  At the same time, NHS Wiltshire has to meet its share of the national target of £20billion in savings and to pay off the debt inherited from its predecessor care trusts.

And lurking in the background is the Health Secretary’s forthcoming ruling on the changed emphasis of the government’s competition rules that may wipe out much more than that ‘marginal’ increase in Wiltshire NHS’s 2011-2012 budget.

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Jeff James talks about his resignation, Savernake Hospital, the NHS’s future and his own future

Jeff James’ resignation last month as Chief Executive of two primary care trusts (PCTs) – Wiltshire and Bath & North East Somerset (BANES) – came as a great shock to his colleagues and friends.  He had been with Wiltshire NHS since it was formed in 2006 and was appointed to BANES this year.

As part of the government’s major reorganisation of the NHS, Wiltshire and BANES were ‘clustered’ together to save money and make way for the abolition of PCTs in 2013 when the GP-led Clinical Commissioning Groups (CCGs) and Wiltshire Council take over.  During the ‘clustering’ process, the team he had built at NHS Wiltshire saw many redundancies as costs were saved.

Jeff James, who is 58, has worked in the NHS for thirty-one years – sixteen of them as a chief executive.  He was ordained priest in the Church of England in 2002.

Why did he resign?  Jeff James told Marlborough News Online that he had looked at the balance in his life between work, home and the church, and found it was not the balance he wanted. 

Why did he resign now?  “Now is as good a time as any.  If I didn’t change now, I’d have to wait till 2013.  Going now gives someone the chance to see through next year’s business plan and conclude the handover to the CCGs and the local authority.”

Did he resign because of the government’s reorganisation? No, but… “In 2013 the kind of job I’ve really enjoyed doing won’t exist.”  The fragmentation of the NHS means that no one will again have the whole canvas of health services to work with.  James now has national, regional and local responsibilities and is involved in almost every part of Wiltshire’s health service.

The Wiltshire PCT’s portfolio of responsibilities is being divided between the CCGs (in charge of some local commissioning), the yet-to-be-formed NHS Commissioning Board (in charge of specialist services), Wiltshire Council (public health and, through the new Health and Wellbeing Boards, strategy), Great Western Hospital (community health) and support services (Commissioning Support Services – CSUs, the latest out of the Department of Health’s copious store of acronyms, whose agenda is still be settled and which will ultimately be privatised.)

Jeff James would miss, for example, overseeing NHS Wiltshire’s work running the screening calls for Wiltshire, Swindon and Devon – work in which his team have become expert.

Savernake Hospital

In the Marlborough area, Jeff James is best known as the man who closed Savernake Hospital Minor Injuries Unit (MIU) and Day Hospital very soon after the community hospital had, at great cost, been expanded and renovated.  Why were they closed?

James says the decision was not specific to Marlborough and was brought about partly by costs and partly by a change in the model of service – creating a new balance between care at home and care in hospital. During his time at NHS Wiltshire he has pioneered the much admired Neighbourhood Teams bringing care and daily treatment to people in their homes.

James makes the point that consultation on the future of health care across Wiltshire had begun in 2005 - before he and NHS Wiltshire came on the scene. And that was also driven in part by costs. The Kennet and West Wiltshire PCT (K&WW) had run up an over-spend of £44 million by the end of 2005 and were on track to add another £24 million during 2006-2007.

The future of Savernake had been considered by the (then) Wiltshire Health Authority in 2002.  Then the issue was handed over to K&WW: “They were very optimistic about the money available, very optimistic about the clinical role of Savernake and not as aware as they might have been about the trends in hospital usage.”

Beds in community hospitals were becoming less busy.  More people were going home sooner after surgery. And community nursing and minor treatment in GPs surgeries was becoming the norm: “Gosh! How did anyone reach the conclusion that [upgrading Savernake] was the right thing to do.”

James and NHS Wiltshire’s Chairman, Tony Barron, have been criticised for the way they conducted the judicial review led by Val Compton which alleged the consultation on closing the MIU and Day Hospital was unfair and the decision unreasonable. Why, for instance, did they contest the cap on costs?  Each side had to pursue their ‘best interest’ and “The wider consequences in the NHS if we had lost would have set a pattern with serious financial consequences. We had a responsibility to conduct our case pretty vigorously.”

Both James and Barron have been the subject of some pretty fierce personal attacks.  During the 2010 general election campaign, the Devizes constituency’s independent conservative candidate pictured them as arrested criminals in American-type police mug-shots. And one campaigner greeted James’ resignation with a tweet: “The end of the road for Jeff James”.

“It’s part of the rough and tumble. When I first started in the NHS there was a committee, in the late 1980s chief execs and chairmen came along and we started to have a much more personal debate. Tony and I decided to make a lot of the running in the public debate – it was a style choice. If you are the person who is the accountable officer you can’t but be held responsible.”

“We don’t live in respectful or deferential times – that’s a good thing. But we can all wish there was a different tenor to the debate. The alternative is that you withdraw from the public.  Out of the public exchange you don’t get agreement, but by not doing it anonymously people may come to understand the reasoning.”

The NHS’ future

Jeff James sees some risks in the government’s new design for the NHS. He has made sure that as an organisation NHS Wiltshire has low costs – “mean management to fit austere economic times” – and the costs for the CCG’s will be higher.  (Wiltshire NHS costs £21 per head of its population, against an average of £35 for other PCTs in the region and a probable £25 for the CCGs.)

In the government’s Health and Social Care Bill, local authorities get more say in health services, running the new Health and Wellbeing Boards.  Might some of them flex their muscles and try to dominate the commissioning process? James admits there may be ‘tensions’. They may know the pain in closing a school: “Imagine how much more exquisite that pain would be if they were allocating health service resources” – closing a ward or a hospital.  And at least one person on the Boards will have to face re-election.

In Andrew Lansley’s new order “We’ll have three agendas: the local ‘popular’ agenda, the clinical agenda and the national political agenda – with the local agenda bumping into the national one.”

Jeff James’ future

Once it’s decided when he will leave his posts (he can be held to six months’ notice), Jeff James wants to take some time off. “It’s a bit like deep-sea diving – after the pressure of the last few years, I need to decompress for a time – or I’ll get the bends.” 
Then he wants to divide his non-family time about 50-50 between work and the church, and would very much like to do more parish work.  Where will that be? “My wife comes from Cornwall and I’m from Wales – so we’ll see!”
Having watched Jeff James in action over the past six months for Marlborough News Online, I’ll bet he very soon gets a call from a university – his experience and analysis will be a great draw for them.  The university might be in Wales or it might be nearer to Cornwall.

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The government promised NHS patients more choice – it’s on its way

Just imagine it’s October 2012 and your left foot is really painful – as in keeping you awake at night.  In October 2011 it was your right foot that hurt and your doctor sent you to the local NHS hospital for treatment at its podiatry clinic (for foot health - more than chiropody.)

By October next year, your doctor might well offer you a choice for treatment for your left foot – by your local NHS hospital, by a charity, by a social enterprise group or by a commercial company.  Podiatry was one of the services the government wanted put in the fast lane to provide competition to the NHS and choice for the patient by October 2012.

When Health Secretary Andrew Lansley first launched the policy he called it “Any Willing Provider”.  It’s now somewhat more reassuringly called “Any Qualified Provider”. We are not re-entering the era of snake-oil salesmen.  But we are entering unknown territory.

The timescale is tight. NHS Wiltshire were told late in July that they had to complete consultation by the end of September on the government’s list of eight possible services. So on September 12 they held a Stakeholders’ Assembly - gathering about sixty-five local professionals, councillors, representatives of charities and patient groups and some of the doctors involved in the new commissioning groups to help select the first three or more services. 

After much discussion three services came to the top of the list: treatment of neck and back pain (physiotherapy plus), direct access diagnosis (blood tests and more) and memory clinics (for those in the earlier stages of conditions such as alzheimer’s.)  As it turned out, podiatry was one of the services least favoured to be part of the first round of setting up competitive providers – so your left foot’s safe with the NHS till well after October 2012.

Two other services – developmental disorders (ADHD and autistic spectrum conditions) and lymphodaema (swelling caused by lymph problems) – may come into the frame once more work has been done on how they could fit with related treatments and how to specify their work.

There are, of course, a great many hoops for any potential rival provider to go through. Are they a credible outfit – with financial stability, appropriate legal status and so on? Will they improve the service to patients?  Can they find the right staff? Can they respond to referrals from GPs fast enough? What about training?

One thing is certain: there will be no protection for any kind of provider - government policy focuses primarily on effecting choice.  This is a “very explicit political judgment on how to improve the NHS.”

All this will most likely bring added headaches for GPs and their colleagues in the new commissioning groups which will take over the budgets from the primary care trusts.  First it will make control of the budgets much more difficult – even precarious.  Secondly it may often face GPs with conflicts of interest.

Will they advise patients which treatment to choose when that choice may well affect the commissioning group’s bottom line?  We may well see the rise of “patient advisers” attached to surgeries to help patients choose.

Those advisers and the complexity of overseeing and checking the new providers, tracking fragmented sources of cost and keeping clear of the clutches of competition umpires, will all involve a host of backroom jobs – or, as the government likes to call them, bureaucrats. And this at a time when most of the savings from the coalition’s radical NHS restructuring are supposed to come from ‘cutting bureaucracy’.

And no one can foresee precisely how the new commissioning groups will be able to make these services a satisfactory part of continuing and integrated treatment of their patients.

GPs and commissioning groups will be open to scrutiny and public shaming by the competition tsars that want to give non-NHS providers every chance to succeed.  This is already happening with the choice of providers for elective surgery (such as hip replacements) – see Marlborough News Online’s earlier story.

There’s evidence already that social enterprises and charities will not get any favours in this process – in fact the risks in size and sustainability they bring to the NHS may doom them. 

The social enterprise, not-for-profit group Central Surrey Healthcare (CSH) has been running community health for a large area of Surrey since 2006.  Last year David Cameron presented them with the first ever Big Society award – a recognition that CSH’s 770 entrepreneurial nurses, therapists and other community staff have been providing quality care for less money.  Even the Cabinet Office said CSH are delivering substantial improvements in quality and efficiency.

But when CSH bid for a new £500milion contract to spread their work to more of Surrey’s patients, Surrey primary care trust decided to hand the contract to Assura Medical Limited (75% owned by Virgin.)  It seems the main reason was that CSH could not raise enough money for the necessary surety bond.

Has this decision put money before quality of service?  CSH’s own contract comes up for tender in the next twelve months.  The fear is the coalition government’s rules will favour another bid from a private, capital-rich company and dish the social enterprise workers.  

And bearing in mind the experience of the health workers of Surrey, will charities and social enterprises in Wiltshire be successful when they make smaller scale bids for services under the ‘Any Qualified Provider’ label?
 

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