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.
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?
As the coalition government’s plans to bring radical change to the NHS advance by fits and starts, it’s now clear how Wiltshire will be divided into the newly termed “Clinical Commissioning Groups” (CCGs) – which just a month ago were called “GP Consortia”. These groups will be given most of the county’s NHS budget which is currently administered by the Primary Care Trust (PCT) – in our case by Wiltshire NHS which is due to be abolished after April 2013.
At the start of the government’s reform process, Dr Helen Kingston (pictured left) wrote the application for what were then five Wiltshire GP consortia to start the process toward official formation. Now she has told Marlborough News Online that there will be just three CCGs in Wiltshire.
The Marlborough Medical Practice will be part of the CCG that brings together the East Kennet (Marlborough, Great Bedwyn, Burbage, Pewsey and Ramsbury practices) and the North Wiltshire areas. It stretches from Corsham in the west to Ramsbury in the east, south to Pewsey and north to the border with Swindon. It will take in a population of about 167,000 out of Wiltshire NHS’ total of 455,450 people.
[The other two CCGs are Sarum – the south and south-east of the county based in Salisbury. And the CCG temporarily known as WWYKD – pronounced ‘wicked’ – which includes west Wiltshire, Yatton Keynell and Devizes. Dr Kingston is joint chairman of this CCG.]
Dr Kingston, who studied at King’s College, Cambridge, and trained in Oxford and Bath, qualified as a GP in 1990. She’s a partner in the Frome Medical Practice which has a branch surgery in Warminster. And she’s now working with lead doctors in the three groups on some Wiltshire-wide plans.
Dr Kingston acknowledges that there is a ‘tension’ between the demands stressed in the government’s health White Paper that the new structures to deliver the modernised NHS must be local and the whole service ‘patient centred’, and the tight state of the public finances. She says there’s a difficult balance between being small and ticking the ‘local’ box and the need to find economies of scale to achieve the huge and obligatory savings within the NHS.
With that in mind, the three Wiltshire CCGs are moving towards setting up an ‘over-arching’ organisation to provide essential management and administrative back-up right across the county. Some will undoubtedly say this looks like the ghost of the PCT.
Others will whisper that it might even mean that eventually there will be just one CCG for all Wiltshire. And that would not look good for a government that has made so much of its drive towards localism – pushing decision-making further down the democratic ladder.
Dr Kingston takes a positive view of the coalition government’s response to the parliamentary ‘pause’ and ‘listening process’ that followed the trenchant criticism – from within the health service and from outside – of Health Secretary Andrew Lansley’s original plans. She’s especially pleased with the new attitude toward managers - no longer seen as a “waste of space”.
She also backs the switch from the reliance on competition towards more “co-operation and coordination” to find the best ways to treat patients and improve care. The ‘year zero’ approach of the White Paper has gone: “Lots of good things are happening already [in the NHS] – let’s not throw the baby out with the bath water.”
However she does admit that the drawn out uncertainty amongst so many NHS employees is not good: “We need the new order put in place so we’re not distracted.” And she explains that the silence on the changes from the groups isn’t because people at local level “haven’t made up their minds, the structures haven’t been decided centrally yet”.
The process of these reforms has been slowed considerably – perhaps Andrew Lansley (pictured left) thinks of it as another over-long waiting time for treatment. And the new governance requirements for the CCGs are putting extra layers into the structure – in Dr Kingston’s words “frameworks and frameworks within the frameworks.”
“If the governance arrangements become very complex – it would drive us towards a larger grouping – because the infrastructure and expertise to manage it would need to be of a higher calibre and the resources for that would become too costly for small groupings.”
There’s that hint again that in the future they might need to be a single CCG for Wiltshire – the ghostly PCT walking abroad again.
But she fully acknowledges that, even when reinforced by boards that will include a hospital doctor, a registered nurse and two lay members, the new groupings of GPs will be responsible for such huge sums of taxpayers money that they must be seen to be properly set-up and accountable.
The Wiltshire’s CCGs’ next hurdle is for their business plans, accountability and governance structures to be signed off by the PCT at its July board meeting. If the PCT is satisfied they will become ‘interim CCGs’.
Final authorisation can only come in 2012 once the new NHS Commissioning Board comes into existence and has its say on what the government calls the groups’ “skills, competences and behaviours to do their job well. Skills that they will need to be able to commission high quality care within their allotted resources” [from ‘Government response to the Future Forum report’ – 3.93.]
There are now a lot of people whose official job – never mind the journalists, politicians and busy-bodies – will be to peer over the GPs’ shoulders and make sure they’re doing the job properly. And then, of course, there’s the public, the patients.
The government’s new plans for the CCGs put a tremendous onus on them to involve “patients and the public in their commissioning decisions”: “Clinical commissioning groups will be required to consult on their annual commissioning plans to ensure proper opportunities for public input…[and] will have to involve the public on any changes that affect patient services, not just those with ‘significant’ impact.” [from ‘Government response…’ - 4.41.] (That would certainly include any future changes to the use of Savernake Hospital.)
Dr Kingston is determined to have proper consultation processes in place: “Most people will be happy if there’s transparency. We have to explain prioritisation and then be consistent. We have to have very careful communications with the public.”
“People would get understandably cross if they thought they’d get a different treatment in a neighbouring practice. This involves consulting people before decisions are taken.” And for consultation she wants a reference group of the public in her area to include a “broad range of ages, geography, jobs and a balance of the sexes.”