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.