New decade, old enemies for NHS

Perhaps against the odds, 2009 turned out to be a successful year in which campaigning and pressure forced a significant retreat on controversial policies in the NHS. The pell-mell drive to privatise community and primary care services that had until recently been directly provided by primary care trusts appears to have been slowed, if not halted, although very few people in the wider electorate even knew that it was going on. The change of policy is a result of consistent trade union pressure on health ministers - although sadly not before services in Hull, Bromley and Kingston had been lined up for take-over by "social enterprises." Private and "non-profit" voluntary sector organisations that fancied carving themselves a generous slice of the £11 billion NHS budget for these services, and some of the senior managers lining up to take advantage of Lord Darzi's so-called "right to request" that an NHS unit be hived off as a "social enterprise," have been twitching with anger at Health Secretary Andy Burnham. The so-called co-operation and competition panel, set up as a sounding board for aggrieved private-sector punters to complain they have been treated unfairly, has apparently received complaints from various aggrieved parties bitter at Burnham's October declaration that the NHS should be the "preferred provider" unless all efforts to improve NHS services had failed.

But to his credit Burnham has not only stuck to his guns, apparently having won the support of Gordon Brown - he has even suggested he may review the working of the competition panel itself. NHS managers have been - in some cases reluctantly - dragged into line on the new policy. If only we could look forward to similar successes in this new year. But sadly, the new decade is opening with the NHS facing new and very serious threats. The new danger is the old enemy that the London Health Emergency was formed to fight back against in 1983 - cuts and closures. All the main political parties are agreed that massive cuts should be inflicted on health care, education and other public services - not because these services have failed in any way, but because of a huge private-sector failure. They are cutting health care in a bid to cover the colossal £175 billion costs of bailing out failed and irresponsible bankers. Of course the party leaders won't admit that they plan cuts in the NHS, least of all in the run-up to the general election in May. So each of them claims to be "protecting" front-line services by increasing funding in line with inflation - ignoring the fact that the NHS needs billions more in real terms each year to keep pace with the costs of a growing population, rising numbers of elderly and new drugs and technology. And even if front-line budgets were to be protected, many spending plans for the next few years already assume massive "efficiency" savings of up to 5 per cent a year, without any evidence that unprecedented savings on this scale can be achieved without cuts.

To make matters worse, much of the 5 per cent of the NHS which is not seen as "front line" - and therefore not protected - includes training and research budgets which are likely to be slashed. Even NHS chief executive David Nicholson admits that the coming cuts are "tougher than the NHS has ever had, through its history. And it's for a sustained period." The squeeze will hit hospital services hardest of all - with a four-year freeze on the "payment by results" tariff which determines hospital budgets, and a massive 70 per cent cut in funding for any additional A&E patients treated in excess of the 2008-9 caseload. A Health Service Journal analysis argues that by 2014 "savings on this scale could entail perhaps half a dozen general hospitals going to the wall in each Strategic Health Authority." Hardest hit will be hospitals with large fixed overhead costs - in particular those funded through the private finance initiative. But primary care trusts and strategic health authorities are also required to cut their management costs by 30 per cent - some might say not before time. They are even looking to cut the massive amount they are wasting each year on hiring costly private-sector management consultants. While NHS chiefs are already discussing these issues in secret, the plans are only beginning to emerge. NHS London is leading the charge, with cuts - based on a secret briefing by US-based private management consultants McKinsey - aimed at slashing up to £5 billion from the capital's £13 billion primary care trust budget by 2017.

NHS London has said quite openly that it wants primary care trusts to chop A&E caseloads by 60 per cent - diverting almost 2 million patients a year to unproven or as yet non-existent primary care "polysystems." This seems especially bizarre in the context of this winter of snow and swine flu, in which all of the existing A&E units are full to bursting and running well above target. NHS London also wants primary care trusts to cut hospital outpatient attendances by 55 per cent - diverting upwards of five million appointments to other "settings" such as polyclinics and health centres, where highly paid consultants would have to travel to see a fraction of the number they could see in a properly equipped hospital. Even on Lord Darzi's inadequate and outdated figures in 2007, these two changes would mean cutting well over £1 billion from London hospital budgets, forcing a drastic round of service cuts and closures. But primary care and mental health face cutbacks too. GPs have been caught up in the new cash squeeze and required for the first time ever to deliver efficiency savings, but NHS London also wants to slash staffing in "non-acute" services by 66 per cent - and even cut GP appointment times by 33 per cent. The list goes on and on. NHS London is frogmarching the capital's primary care trusts deep into unknown territory. Nobody anywhere has changed an established health-care system on this scale before, let alone at the breakneck speed it proposes, with virtually none of the alternative services that would be required even planned, let alone in place.

All of these potentially devastating cutbacks are based on the assumptions and assertions in the secret McKinsey document. In other words, there is absolutely no published evidence that these changes could even be achieved, or that they would save money, enhance efficiency or deliver acceptable levels of patient care. The few Darzi-style health centres that have been established so far are not only much more expensive than the average primary care but they have generally failed to sign up their "drop-in" patients to regular lists.
The NHS London plan seems to be guesswork hatched up by management consultants from the US, the land of the world's most costly, exclusive, wasteful and hugely inefficient health-care system. And if the guesses go wrong, the health care of millions will be put at risk. Let's stop them before it's too late.

When efficiency means health service cuts

Health minister Mike O'Brien has said he believes health bosses such as NHS London should keep a veil of secrecy over their discussions on how to impose wholesale changes to the service's operation. If information leaked out, he told MPs this week, opponents of the plans could "attack them over their lack of evidence." What a telling admission. Not only are paranoid levels of secrecy now official government policy, but ministers are actively encouraging health chiefs to hatch up plans for which there is no evidence - while opposing those of us who point out that these policies are potentially dangerous. The three remaining strategic health authorities that have so far kept a stony silence on their plans are expected to reveal how they intend to generate their share of a £20 billion financial "gap" in the service in the new financial year. Their policy changes, as called for by NHS boss Sir David Nicholson, are unlikely to contain many surprises. Across the country the same rhetoric is being wheeled out to justify proposals for astronomical increases in "efficiency" and "productivity" which will wind up as cuts. Buzz-words such as "reinventing care pathways" (dumping patients out of hospital A&Es onto untested, supposedly cheaper alternatives in primary care such as "polysystems" - see below) "working smarter" and "innovation" crop up again and again.

But so do more obvious, unambiguous phrases such as "affordability analysis," "decommissioning," "savings," and "tariff reductions" - in other words cutting the amount paid to NHS trusts for each episode of treatment.
Perhaps the most blunt statement about the real driving force behind the various new policies comes from NHS Southwark, which declares openly that its proposals are cash-driven. "Our financial modelling shows that the primary care trust's (PCT's) current profile of expenditure is unaffordable over the next five years. "The affordability analysis requires £18m of savings in 2010/2011. Our commissioning strategy is driven by the need to achieve a system of healthcare which is financially sustainable." (Strategic Plan 2010/11 to 2016/17)."  But this highlights a major question. Can the proposals outlined by health bosses actually work, delivering services to patients while saving a large amount of money? Central to the guidelines laid down by NHS London for cutting £5 billion from its PCTs' spending by 2017 is an assumption that 60 per cent of people who currently attend A&E units with relatively minor problems could be treated satisfactorily in primary care.

On this basis NHS London wants to divert around 2 million people annually away from hospitals and into a new, expensive network of "polysystems" - controversial centralised super-facilities which were originally designated "polyclinics" in Lord Darzi's 2007 suggestions for reform. Similar assumptions have also been made elsewhere and A&E has been a major focus for redesigning "pathways." I have consistently challenged these assumptions, which have become more and more extravagant since the early 1990s, and pointed to the failure of previous attempts to divert smaller numbers patients from A&E to "minor injury units." These turned out to treat mere handfuls of patients at high costs, while queues at A&Es were undiminished. But now we also know for a fact that NHS London's 60 per cent assumption is wrong. A recently released Primary Care Foundation report commissioned by the Department of Health found that less than half the A&E patients included in that figure were suitable for treatment only by GPs. Their figure showed that in some cases as few as 10 per cent, and a maximum of 30 per cent of people in A&E had no need of any form of hospital care. Since we now have fresh and reliable evidence that the 60 per cent figure was wrong, one obvious question is where such a false assumption came from.

It appears to flow from the top-secret document produced for NHS London by US-based management consultants McKinsey's. But where did McKinsey's get the number? Is it based on anything substantial, or just made up to drive forward the reorganisation of hospital care? Another question arises: would it save any money to deliver minor A&E services in polyclinics? Again the answer seems to be No. Lord Darzi's 2007 report on London, which argued A&E patients should be switched to polyclinics, estimated that the cost would be £66 per visit to a polyclinic compared with £81 at a hospital. However transferring the patients brings the added cost of building or renting the new polyclinic and running it day by day. Darzi-style health centres that are already running on a much smaller scale than the London plans are "jaw-droppingly" expensive compared with existing primary care services - with costs ranging from three to seven times more per patient. It seems most improbable that a new network of polyclinics in London will come in any cheaper, especially since private-sector providers such as Richard Branson's Virgin group now see them as an attractive future profit stream. Health chiefs have also been keen to switch a large volume of outpatient treatment - up to half, equivalent to 5 million appointments a year in London - away from hospitals and into polyclinics.

Yet even according to Lord Darzi's projections this would save no money at all. Instead it would massively inflate the costs of providing and running the polyclinic. It would also of course make running hospital services less efficient if consultants and staff have to spend hours at a time trekking round to small-scale clinics instead of working from a central base. The Audit Commission at the end of last year highlighted another reason to doubt the viability of these plans. Their report More For Less pointed out that while hospital unit costs were falling and productivity improving, there had been "no shift from hospitals to care closer to home in the community; either in terms of investment or activity." Nor, argues the Audit Commission, had PCTs succeeded in "dampening demand" for hospital care, despite years of promises. In fact the most recent figures show another substantial increase in numbers of patients referred to hospitals by GPs for inpatient care. These are not "inappropriate attenders" in A&E, but people whose condition requires treatment that primary care and community services cannot provide.



Flying in the face of all this hard evidence of rising demand, and offering no explanation on how it might be achieved, NHS London has said it wants to cut the number of hospital beds in the capital by a third. Even if they only focus on front-line acute beds that would mean a staggering 5,700 beds to go - equivalent to around 12 district general hospitals. This might save money - but only if the services are not replaced by any alternative. None of these proposals seems to have any basis in evidence in this country or elsewhere. Nor do they seem to fit with experience on the ground. Doctors are increasingly required to demonstrate the "evidence base" for the treatment they deliver.

But it appears that the most senior levels of NHS management feel no equivalent obligation to show that their plans are evidence-based, organisationally viable or likely to yield the promised cuts in costs. If the plans go wrong patients and NHS staff lose out either way. If they prove to save little or nothing, these policies will widen the gap they are supposed to help close and force another round of even bigger cuts. On the other hand short-sighted closures and excessive reduction in staff numbers can result in local collapse in service and the quality of care. Lurking in the background is the grim example of Mid Staffordshire hospitals, where the quest for just £10m of cuts resulted in the loss of 150 clinical posts and a total collapse in care, with dozens or hundreds losing their lives as a result. Managers who fail to learn from existing evidence could be doomed to repeat this type of failure.

The buck stops with Brown

Someone ought to remind Gordon Brown that the massive crisis that rocked the economy was caused by the privately owned banks not by the Civil Service or any other part of the public sector. This government has treated the financial sector with kid gloves. No matter what its excesses, from irresponsible gambling with other people's money to mind-boggling bonuses for the favoured few and sickening displays of ostentatious consumption, this allegedly Labour government cannot hide its deep conviction that financiers are a special breed. Banks are too important to be allowed to fail or to be taken into democratically accountable public ownership. But steelworkers, carworkers, fishermen, building workers, call centre staff, postal workers, bank staff and workers in many other industries can be dumped on the scrapheap with nothing more than a "how very disappointing" from Baron Mandelson and the rest of the new Labour crew. And, when it comes to civil servants, far from "how very disappointing," Labour's front bench competes with the other parties to outbid them on how many "bureaucrats, pen-pushers, back-office staff" it can get rid of to save the economy.

It's only two years since Brown had some of the more loathsome creatures that populate the Labour benches guffawing out loud when he announced that 96,000 Civil Service jobs would go as though this trumping of a Tory policy ace was a great leap forward. While most people were incandescent with rage over the bankers' outrageous conduct, the government is pointing in a different direction. It's aiming at the Civil Service, with Brown fulminating against a "culture of excess" in reference to salaries of over £150,000 and bonuses of £50,000. These are certainly among the higher end of salaries across the spectrum of wage-earners, but they are dwarfed by the seven-figure salaries and bonuses in the City. And while the government boasts that it will cut 20 per cent or £3 billion from the senior civil servants' pay bill over three years, it ignores its own responsibility in pushing up Civil Service costs through its obsession with public-private partnership, which has cost, in the Ministry of Defence alone, no less than £6bn on failed IT projects and private consultants. Nor is it simply the highest-paid civil servants who are bearing the brunt of ignorant comment by right-wing politicians.

Tory frontbencher Liam Fox recently launched a grab for the headlines by telling bereaved families who had lost loved ones in Afghanistan that British soldiers were dying because they are ill-equipped while civil servants were being paid £47 million in bonuses. These were not bonuses but one-off payments that had been insisted on by the government as a cost-saver, taking the place of a pay rise so as not to affect pension entitlement. And the vast majority of the Civil Service "fat cats" getting these one-off payments have an average annual salary of less than £20,000 and each received about £300. It is disgusting that a Labour Prime Minister - a Labour Prime Minister - implies that Civil Service excess is reducing money that should be spent on health, schools, policing and social services. He, of all people, knows that it is his own refusal to tax fairly the banks, big business and the wealthy and his obsession with supporting US foreign wars that leaves too little to spend on manufacturing, services and welfare.

Civil servants fight back

The government is going ahead with its plans to rip up the civil service compensation scheme (redundancy protection pay for civil servants). But members of the PCS civil servants' union have voted for strike action to oppose the changes. The government's plans would mean many staff losing tens of thousands of pounds if they are made redundant. The government is looking to 'save' £500 million by doing this, but only on the basis of cutting tens of thousands of civil service jobs. Imagine the devastating effect that job cuts on this scale will have on vulnerable people in our society who rely on these services. 64% of members who voted chose to strike, and 81% voted for a ban on overtime. This was despite a massive anti-strike propaganda campaign by senior managers. The millionaire-owned media often tries to portray civil servants as under-worked, over-paid, and having cushy jobs with massive pensions. If you have been into an over-crowded Jobcentre in the last couple of years, you'll know there is no truth in this.

Many people working on the frontline only get paid about £15,000 a year. While this is more than the miserly minimum wage, it is less than the amount that New Labour MP Elliott Morley claimed for a mortgage that didn't exist! And it is about the same as Fred Goodwin (failed ex-boss of Royal Bank of Scotland) is rewarded each week by the taxpayer for his part in destroying the economy! Frontline civil servants provide a much more important service to society than fat-cat bankers. But compare Fred 'the Shred's' pension with that of an average civil servant who gets a pension of no more than £10,000 a year and very often a lot less.
If the government is successful in its plans to cut the redundancy scheme, it will mean that our public services are more likely to be privatised. Private companies want to make as much money as possible, and they will try to do this by getting rid of staff and reducing services. This will be easier if redundancy protection is cut.
The trade union movement has an old saying - an injury to one is an injury to all. Workers from across the public and private sectors, as well as unemployed people, pensioners and students need to unite together to oppose the cuts agenda.

In 1982, the official unemployment figure topped three million for the first time since the 1930s. Then came almost a decade of redundancies and industrial battles as work shifted away from manufacturing and towards the financial sector - the eye of today's economic storm. For the 2.5 million unemployed today and for those facing redundancies, an organised fightback against all job cuts is as urgent now as it was then. Whoever wins the general election, workers, trade unionists and socialists have to prepare now to mount a determined struggle to defend jobs and working conditions. We must oppose attempts to pass on the bill for this crisis through public sector cuts or through redundancies and closures in the name of 'efficiency', 'modernisation' and cries of poverty from millionaire shareholders and employers.

Struggles to defend jobs should go hand in hand with socialist demands such as a massive job creation programme, investment in socially useful work including the development of renewable energies and a massive building programme of affordable housing. We should demand a living wage for all, without exemptions and for the available work to be shared out for the benefit of all. Britain's working week is one of the longest in Europe. Hundreds of thousands work over 50 hours a week, while record numbers of workers have switched to part-time work to avoid the poverty trap of the benefits system. Sharing out the work would dramatically cut unemployment. The idea of a standard 35-hour week has always been attacked by employers and governments, for them 'casual' work means the employers' right to hire and fire without consequence.





















The influential think-tank, the New Economics Foundation recently published its findings on the working week. They predict that a 21-hour working week will become the norm in a future capitalist society - for them however, a shorter working week is for the capitalists' benefit not the workers'.





















In reality, they argue for a super-casualisation of working life, with annualised hours (they talk of working a 21-hour week or its equivalent in hours spread across a month or year). Workers will be left waiting for the call to come to work and will only get paid when the employer feels they are needed.





















We must argue that the need for shorter working hours and employment for all should not be paid for by the working class, but by the giant monopolies which exploit us to line shareholders' pockets and dominate the economy. Share out the work, with no loss of pay!





















There is more than enough wealth in society to make these demands a reality. The economic crisis means redundancies and repossessions for many, but it is business as usual for the super-rich, who remain super-rich at our expense.





















The modest demand for a 35-hour week should form the backbone of trade union campaigns for jobs now and for future generations. If capitalism can't afford a 35 hour week or a living wage for all workers, then we can't afford capitalism!




The alternative is a 'race to the bottom' in services and working conditions, leaving only under-staffed and over-crowded offices or call centres, and insecure, temporary, low-paid jobs with minimal or no sick, holiday and pension rights. We cannot let this happen. Come to government offices on the strike days and give your support to workers on picket lines taking action.