National Health Service
Defend your #NHS: Rally in support of the NHS, March 4TH 2017, featuring speeches from Jeremy Corbyn and John McDonnell.
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Rally in support of the NHS, featuring speeches from Jeremy Corbyn and John McDonnell.
For more information visit:
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CAROLINE MOLLOY 13 November 2015
The government is setting out what it will tell the NHS to do for the next five years (the ‘mandate’) – and there are lots of worrying signals. Here’s our response – you’ve 10 days if you’d like to respond, too.
You probably won’t have noticed, but you’ve got just ten days to comment on the only bit of democracy left in the NHS. It’s the NHS mandate – ie, what the government tells the NHS to do for the next 5 years.
Pretty important, huh?
As the introduction to the mandate consultation explains:
“The mandate to NHS England sets the Government’s objectives for NHS England, as well as its budget. In doing so, the mandate sets direction for the NHS, and helps ensure the NHS is accountable to Parliament and the public… This consultation document sets out, at a high level, how the Government proposes to set the mandate to NHS England for this Parliament.”
The mandate is what Jeremy Hunt talks about whenever he’s accused of no longer having any proper responsibility or political accountability for securing a comprehensive NHS service, since the 2012 Act.
At the end of October, the government quietly put the mandate aims and objectives out to consultation for 4 weeks. Healthwatch England (the national body that is supposed to give patients a voice in the NHS) only circulated it to local Healthwatch groups yesterday, which is when it came to OurNHS’s attention. The deadline is 23 November.
Here’s what OurNHS has just submitted. I’ve written a fair few consultation responses in my life, and this is probably the grumpiest I’ve ever done. So do feel free to use any of this – but you may wish to tone down the grumpiness and make your response more formal!
Bear in mind, ‘high level’, in this context, means the government’s document contains lots of vague, aspirational sounding stuff – so you have to read through it carefully for clues about what kind of policies it might open the door to…
OurNHS’s response to the NHS mandate consultation
- It is very worrying that the word ‘comprehensive‘ doesn’t appear in the document once, which seems a pretty major omission given this document is supposed to summarise what our NHS will do in future…
- It is worrying – particularly given the current fraught relationship between government and NHS staff, and the exodus of the skilled staff that are the backbone of the NHS – that the document mentions ‘staff’ only once (in the context of a commitment to continue the flawed friends and family test) – and doesn’t mention doctors or nurses once.
- It is worrying that the document does not say anything that would rule out an increase in health co-payments (ie patient charges), given that voices within government such as health minister Lord Prior have been floating the consideration of such charges.It does state that the mandate will focus on “the changes needed to ensure that free healthcare is always there whenever people need it most.” But hang on – why do we need that last word, ‘most’? Are we creating a mandate for unelected people to decide when people need free healthcare ‘most’ – and when we may be charged for previously free healthcare?
- It is worrying the document does not say anything that would rule out large groups of people being prevented from accessing NHS services on account of (clinically unrelated) lifestyle choices/diseases, as Devon attempted to dolast year. Government ministers criticised Devon – Eric Pickles said the plan was “not the kind of Britain I recognise” – but if these are not to be crocodile tears, government needs to make sure no other cash-strapped local health bosses try the same plan.
- It is worrying that the document commits the NHS to ‘maximise income’, without saying how, exactly. NHS hospitals are already increasing their private patients, meaning fewer beds and longer waits for people without means to pay. The mandate should not be encouraging this practice – the supposed safeguards we were promised in 2012 are clearly insufficient.
- As for setting the NHS an objective to ‘minimise costs’ – well, there isn’t an NHS hospital in the land that is not already desperately trying to do that! Indeed, as hospitals’ duties to provide mandatory services are whittled away, and again in the absence of an overarching duty to provide comprehensive health services across England, we are told by governors that many hospitals are discussing how they can shed unprofitable procedures and patients. This must be stopped – not encouraged.
- It is worrying that there is no commitment to sufficient funding through the fairest and most efficient system (which the evidence shows, is public funding through progressive taxation).
Of course, we recognise that this gaping hole is inherent in the ‘mandate’ system set out in the 2012 Act, with its greatly narrowed political accountability. We want to put on record how unsatisfactory it is, to be ‘consulted’ on a document that is separated from the political and financial settlement in this way, and which blithely states we have to wait for the Spending Review to see if any of the commitments are actually deliverable.
- We also feel concerned about the heavy emphasis on self-care/self-management of patients own care. Given the lack of commitment to proper funding and a comprehensive system, we fear this opens the door to excusing reductions in the amount of care patients are entitled to receive on the NHS.
- We also feel particularly concerned about the related heavy emphasis on so called ‘person-centred’ care without any proper explanation of what this nice sounding buzzword means, beyond patients being “empowered” to “make meaningful choices”. We fear that – given Simon Stevens commitment to personal health budgets – ‘person-centred’ may be interpreted as treating patients as consumers, shopping around with their personal health budgets. Such a system we see as little different to the Thatcherite voucher schemes of old, and similarly likely to lead to cost caps for patients and devastated budgets/planning for NHS providers. There is a paucity of independent evidence for the benefits of personal health budgets, per se – and some evidence that they are dangerous even at an individual, short-term sweetened level.
- It is also worrying that the proposed mandate green-lights the continuedmerging of NHS and local authority spend. The impacts of expenditure through this route to date have not been sufficiently assessed, and the Public Accounts Committee found much money had been wasted. We also have serious concerns about the pace of, and lack of accountability of, the delivery of some of this merging of expenditure, through devolution, vanguards, ‘success regimes’, and personal budget roll-out. The mandate is worryingly silent on the implications of all of these – despite the fact the Kings Fund has just raised serious concerns that the NHS cannot cope with devolution on top of its other challenges.
- It is very worrying that there is a green light given to a vague commitment to ‘harness digital and online technology‘. This is misleadingly implied to be mostly about patient access to records online. In fact there is a mushrooming of initiatives (and expenditure) where not just admin, but patient careis increasingly delivered through digital means. Once again, there is a paucity of evidence for the benefits of much of this ‘digital health’ and a surplus of magical thinking about its benefits.
For example, NHS England’s recent submission to the Department of Health for the spending review (as reported in Digital Health) was full of claims that remote monitoring equipment “has the potential” to reduce length of stay, and that in primary care tele/web consultation “may lead to substantial benefits” (my emphasis). The summary of the Department of Health’s submission (in a heavily McKinsey influenced presentation) also states that “While it is envisaged that data transparency may (my emphasis) have benefits for patient care direct evidence for economic impact has not been found.” And in primary prevention it admits that there is “relative scarcity of longitudinal studies linking digital programmes to encourage healthy living to long term impact”. In integrated care and screening it admitted the evidence for telehealth was “mixed”.
- Indeed it is very worrying indeed that the word ‘evidence’ doesn’t appear in this document about what should drive the NHS – not once.
The Kings Fund have raised similar concerns, particularly in relation to mental health, where they said this week that ‘trusts have embarked on large-scale transformation programmes aimed at shifting demand away from acute services towards recovery-based care and self-management. This has seen a move away from evidence-based services in favour of care pathways and models of care for which the evidence is often limited. There has also been little formal evaluation of the impact of these changes.’ The Kings Fund characterised this as a ‘leap in the dark’ approach with highly deleterious consequences for the quality of patient care.
We need a mandate that stops the toys for boys / creative destruction /disruptors and heretics / leap in the dark approach, and returns to a proper, evidence-based approach to health care improvements.
Lastly, we have an allergic reaction to phrases like this:
“We propose to set an objective for NHS England to support the transformation of out-of-hospital care using whole system approaches to ensure people get the right care in the right place at the right time.”
Banalities do not improve un-evidenced policies.
In summary, our view is that the mandate’s aims and objectives need to be driven by the NHS values the public understand (and hold dear).
These are not buzzwords like ‘transformation’, but values that actually mean something to patients – a service that is comprehensive, universal, staffed with sufficient skilled and properly rewarded staff, run ethically, and underpinned by proper evidence.
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Why you need to support the junior doctors: An open letter to members of the British public about the junior doctor crisis.
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Junior Doctors Leeds Demo Nov 2015 (c) Luke Farley
This letter has been written by A&E consultant Dr Rob Galloway.
“I am writing for your help in trying to stop the unprecedented damage happening to the NHS. Please read, share, like, tweet and tell your friends.
As someone who has the privilege of working for the NHS as an A&E doctor I see first hand what is happening. Please trust the real doctors and not the spin-doctors.
The NHS is on its knees and unless things change, it may not survive. It has been attacked, part privatised, demoralised and starved of funds.
We have tried to highlight what is going on; through the media, marches, speeches and endless tweets and Facebook posts. But it is not working. Things are getting worse and the NHS, which we all care so much about, may soon no longer be able to care for us.
The only thing which might save it is if the British public no longer just accept what is happening – but start to fight back. This is above party politics. This is about what we want our society to be. Fight back for the greatest safety net we have – the knowledge that if you live in the UK if we get sick, then we will be looked after: an envy throughout the world.
The NHS was born on the 5th July 1948. Heroes from World War Two, no longer wanted to accept a society where if you were rich you would prosper and if you were poor you were left to suffer. It was born in a period of great austerity but money was found because health and welfare was made a priority above all else.
The pictured letter was sent through the door of every citizen. The opening lines were:
“It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child – can use any part of it. “
This promise is one we may soon not be able to keep.
The NHS has its problems and needs reform. But its ethos was what made it great; patients before profits, co-operation instead of competition. But the last few years has seen a determined effort to undermine all that is good about the NHS – its socialised system of working for the good of our patients.
The government has started a process of privatisation. Billions have been wasted on re-organisations and competition and contracting out of services to the private sector which have destabilised the hospitals we all use. Despite this, the NHS kept going because of the skills and commitment of its staff.
So to deliver the politically and ideologically driven plan of reducing the size of the state and selling off the NHS to the private sector – the government has started to attack the staff. Destroy the staff, you damage the NHS. A damaged NHS is one which the public would go along with privatising.
If this happens, things will become like the USA where they spend double what we spend on health care , but the money is wasted on profit, bureaucracy and excessive wages and the standards of care are so much lower than in the UK, especially for the poor.
Why are they doing this? It has been their plan all along. Because they do not believe in the concepts of the NHS. They believe in individuals floating or sinking. Jeremy Hunt even co-authored a book on this 10 years ago in which the authors said the NHS is “no longer relevant in the 21st Century.”
The new contracts they are proposing for junior doctors will mean an exodus of doctors from the NHS. Without these doctors, standards of care will fall, waiting times will rise and patients will die.
They have said this is about 7 day working. They are lying. The new contract will harm 7 day working. How do you improve care at weekends if you stop giving people the incentive to work in jobs with lots of out of hours work by saying evenings and Saturdays are normal working hours?
They have also lied by saying there will be an 11% pay rise. Junior Doctors salaries have a large component made up of supplements because they work so many nights, weekends and evenings. If you cut these payments by 30% and increase basic pay by 11% that is not a pay rise.
And you can tell they are lying by simple maths my 6 year old can do. They have said that everyone will get an 11% basic pay rise but the pay envelope will not rise.
So we need the British public’s help: you need to understand what is happening because there is so much misinformation and lies out there spun by the politicians and propagated by sections of the press.
Public opinion matters. There may well be a strike by junior doctors. During the strike consultants like me will be doing what we can to make things safe. No one wants the strike – especially not the doctors. They have said they will negotiate with the government as long as the government say they will not impose a contract. That can only be fair – but the government refuses. A strike will be the fault of the government.
If the doctors strike, it would be to protect the NHS and not to harm it. Protect if by forcing the government into a climb down so that they do not bring in these disastrous policies which will lead to so much damage to the NHS.
But it is bigger than just this issue. We, as a society, must think about our priorities. Do we starve the NHS of resources whilst having tax cuts for millionaires and multinational businesses? Do we value and protect the bankers and speculators who have harmed this country so much or do we value and protect the doctors and nurses who heal the country?
We must start to fight back. Do what ever you can to let people know what is happening. Campaign on the street, pubs and ballot box. Even if we win the junior doctor battle and even if Mr Hunt is forced to resign, that is only the first war in a generational battle for the NHS .
Remember what Nye Bevan said on the day the NHS was founded,
“The NHS will last as long at there are the folk with the with faith to fight for it”.
We, as members of the British public, need to have the faith and we need to fight for it.
If we don’t, the NHS which our grandparents so proudly formed, will no longer be there for our children. They may never forgive us.
Dr Rob Galloway, A&E Consultant
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MARK BOOTHROYD 19 October 2015
This Saturday’s doctors’ march could be the start of a vital NHS-wide fight-back against cuts and demoralisation. The alternative is frightening.
Over fifteen thousands of doctors marched down Whitehall this weekend, in protest at the imposition of a new contract. The contract sets a dangerous norm which could be applied to other NHS staff. It permits longer working hours, including til 10pm on Saturday as ‘normal’, and slower pay progression for part-time workers (disproportionately women).
These signs of opposition from doctors are much needed. Staff morale is being crushed. Workloads are spiralling as a further £22bn budget cut by 2020 is imposed. A quarter of staff report management bullying as pressure is piled on to meet targets. Running short of staff, management turn to expensive private agency firms, who have increased their costs to the NHS from £1.8 billion in to £3.3 billion in just three years.
Unable to do the best for their patients, doctors and other health workers are voting with their feet. Six in ten GPs are considering retiring early. Many junior doctors are changing careers altogether, or considering emigration. NHS staff who remain, finding themselves on shifts working alongside agency staff earning two to three times their salary, may question why they continue in NHS jobs with permanently frozen pay, the constant threat of job cuts and management deaf and dumb to their complaints. They may be tempted by agency work with its flexibility, improved pay and freedom to move away from the wards and departments with the worst conditions.
The logical government response would be to increase pay and invest in more permanent staff to improve working conditions and hold on to existing NHS employees.
Instead, the Department of Health’s crude solution is simply to cap agency spending, saying they want it reduced from current levels (as high as 8% of some Trust’s budgets) to 3%.
And if – when – hospitals hit their capped spending limit and find they now have dangerous levels of unfilled shifts?
Well, the government’s NHS regulators have also written to hospital bosses effectively granting them permission to reduce nursing numbers on wards. The letter states that the 1:8 [nurse:patient] ratio developed by NICE is “a guide not a requirement“ and that it “should not be unthinkingly adhered to”.
Yet copious evidence shows harm begins to occur if nurses are made to look after more than seven patients at once. Over 40% of NHS nurses are caring for more than eight patients per shift.
Of course, patients will only be exposed to this if they’re lucky enough to get into hospital. The number of overnight stay NHS beds has fallen from 144,455 in 2010 to 131,820 in 2015. Hospitals often end up discharging patients inappropriately early to free up beds for the sickest. The NHS own guidance states any hospital with more than 85% bed occupancy is liable to face problems with emergency and elective admissions. In the last quarter of 2014/5 bed occupancy was 90.7%. Patients wait for hours on trolleys in A&E, or in the back of ambulances, as hospitals struggle to find beds to admit them.
Ambulance services themselves are under strain too. At least one in tenambulance posts are vacant in the UK. A third of paramedics have taken time off for stress, and over 80% have thought of leaving the job. The number of staff leaving the London Ambulance Service tripled between 2011 and 2014. Ambulance bosses are frantically recruiting from as far afield as Australia to attempt to fill vacancies. Response times have soared; every borough of London has failed to meet their target for Category A life threatening calls.
In the same time period, spending on private ambulance services grew by a staggering 1,000%.
As hospitals struggle under the pressure, no relief is found in primary care. GP funding has been squeezed from 10.33% of the NHS budget in 2004/5 to 8.39% in 2012/13. 500 GP practices have closed in the last five years, forcingthousands of patients to compete for places in dwindling numbers of surgeries. The number of doctors applying to be GPs has fallen 6%, and in Scotland one in three GP posts is vacant. Unable to get GP appointments, every minor ailment drives patients to seek treatment in A&E, putting more pressure on the system.
The privatisation of NHS Direct and its replacement with the 111 service does nothing to help. Untrained and inexperienced staff often refer in error, giving bad advice or sending patients to A&E unnecessarily, and some staff admit to having recommended decisions which lead to patient harm and even death.
Reduced funding leaves management with few choices. Those willing to stand up and oppose decisions detrimental to patient care risk being sacked. Many have been cowed into silence or converted to the NHS make-do-and-mend culture. The latest brainwave from NHS execs is for an army of volunteers to rescue the NHS. Indeed this already happened last winter, with the Red Cross and other organisations sending volunteers to help overstretched A&E departments.
This winter could be the breaking point. Everything is set for a perfect storm of insufficient capacity, overstretched budgets, critical under-staffing, rock bottom morale and inflexible government.
Is permanent crisis being normalised? It was May of this year before most hospitals were hitting their A&E targets again following the last winter crisis, and many staff reported no slackening of the workload, even during the warmer and quieter summer months. The government doesn’t appear to have published its winter plans for this year yet.
Meanwhile the public, having already endured 5 years of worsening NHS failures, may begin to run out of loyalty and support for the NHS.
It is only a matter of weeks until the winter influx of patients begins. To fail to act will put the lives of thousands of patients at risk through a completely avoidable crisis.
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Thousands of mental health patients are being put in danger due to an alarming shortfall in specialist nurses.
New figures show mental health services are under “serious pressure” because of a perfect storm of savage cuts to nurse training places at the same time as spiralling demand for care.
Experts last night (FRI) branded mental health services a “a car crash” and warned that Britain’s most vulnerable people were being “left to cope alone with self-harm and suicidal thoughts”.
As specialist mental health nurses leave the service, the number of trainees coming in to step into their shoes has fallen sharply as training places are cut.
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Mental health trusts in England have seen their budgets fall by more than 8% in real terms over the course of this parliament, figures suggest.
The reduction, worth almost £600m, was revealed through research by BBC News and the online journal Community Care.
At the same time, referrals to community mental health teams, which help people avoid being admitted to hospital, have risen nearly 20%.
Care minister Norman Lamb said budgets were “not the full picture”.
He added: “Mental health care is given through a range of services including the voluntary sector.”
‘More with less’
Using Freedom of Information requests, annual reports and other extensive research, BBC News and Community Care compared the budgets of mental health trusts in England in 2010-11 with this year, 2014-15.
Out of 56 trusts contacted, 43 responded – but not all provided data on all areas.
Taking changes to trust structures and contracts into account, analysis suggests trusts have suffered a real terms cut of 8.25% – the equivalent of stripping £598m from their budgets.
Some trusts like Pennine Care and Lincolnshire have seen funding increases, but most have suffered cuts – such as Leicestershire and West London which have seen above average losses.
Data from 34 trusts showed community mental health budgets were cut by 4.9% in real terms during this parliament.
And figures from 29 trusts indicate referrals to those services have increased by 18.5% over the same period.