Wednesday, 30 October 2013

How will the proposed changes to the NHS affect healthcare in Sidmouth?

There are a lot of changes happening and being proposed for the provision of healthcare in Sidmouth:
Futures Forum: Stowford Lodge Health Centre: the background
Futures Forum: Stowford Lodge Health Centre: the views
Futures Forum: Stowford Lodge Health Centre: the proposals............... meeting Wednesday 30th October
Futures Forum: Sidmouth Victoria Hospital refurbishment
Futures Forum: Sidmouth Library: revamp £600k or £100k

But what of the wider picture: the changes happening and being proposed within the NHS itself?

Blackmore Gardens Health Centre has several printouts and website references on display in the surgery waiting room:

The Telegraph produced a critique earlier in the year:

NHS reforms: From today the Coalition has put the NHS up for grabs
Under the Coalition's reforms, the NHS’s former strengths are being replaced by a fragmented service, bound not by what is best for the patient but by cost

Jeremy Hunt, the Health Secretary
Who, me? Jeremy Hunt, the Health Secretary, had regulations rewritten after an outcry  Photo: Geoff Pugh
7:30AM BST 01 Apr 2013

Today is a landmark in the history of the NHS. I have no doubt that social historians will look back and define events in relation to this day; we will come to view things as pre- or post-April 1 2013, in the same way that we currently think of before or after the establishment of the NHS.

Today the Health And Social Care Act – in other words, the Coalition’s highly controversial NHS reforms – comes into effect. So how will things change for those who rely on the NHS?

It will not be obvious initially. People will get sick, see their GPs, be referred to specialists, be admitted to hospital or discharged, have blood tests and X-rays, and book appointments with physiotherapists and speech therapists, etc. There will be births and deaths. But, beneath the surface there will have been a dramatic shift in the way that healthcare is being delivered. Its impact should not be underestimated.

Preparations began nearly a year ago, when the Bill became law. As a result, primary care trusts (PCTs) began to disband and hand over power to new clinical commissioning groups (CCGs). As of today CCGs are responsible for commissioning the work – that is to say, treatment – undertaken in the name of the NHS. They will be responsible for organising and paying for care, and deciding who will provide it. For the first time in NHS history, the majority of treatments will be put out to tender: private organisations will be competing to win contracts to provide NHS healthcare.

When the original legislation was passed, there was a clause – Section 75 – that stated that the Government would issue further details on the regulations governing private sector involvement in NHS care at an unspecified date. Those of us who attempted to draw attention to this vital lack of clarification were dismissed as paranoid conspiracy theorists, convinced that rampant privatisation of the NHS was imminent.

But the NHS reform Bill, as first published, was like a jigsaw puzzle with crucial pieces missing, the pieces that would reveal exactly what was being planned. It wasn’t until a few weeks before the law came into effect that those missing pieces became available, when the Health Secretary, Jeremy Hunt, quietly announced the new regulations and attempts were made to push them through parliament. What was now clear was that the regulations effectively forced CCGs to put all services out to tender to the private sector and forbade them to favour the NHS as the provider.

After a public outcry and criticism from the House of Lords at the way the Government had slipped in the Section 75 regulations at the eleventh hour, Hunt had them hastily rewritten. But most experts agree that there was no meaningful change. GPs are allowed to keep some services within the NHS, but only in particular circumstances, such as when no private sector provider comes forward to bid. Everything else is up for grabs. It will take time for this change to slowly spread throughout our healthcare system, but it will.

And we should all be worried. Competition on a small scale already exists in the NHS for certain services, such as breast-cancer screening, physiotherapy and rehabilitation, where these contracts have been put out to tender. I have seen first-hand what it can result in: the bureaucracy, the waste of time and resources, as bids are entered, assessed and contracts issued. I have seen, too, the way that services are, invariably, awarded to the lowest bidder regardless of quality, and I have seen how organisations that win these contracts will maximise profits by employing under-trained, cheaper staff, and replacing doctors with nurses, and nurses with auxiliaries.

Last month I was working in a drugs service in the Home Counties. Some agencies, such as those providing drugs and alcohol support services, were opened up for competition by Labour years ago. This particular service was taken over by a non-NHS organisation last year which made a bid considerably lower than what it was then costing the NHS to run it. They did this by reducing the medical input and replacing the majority of nurses with “drugs workers”, many of whom were dedicated and thoughtful, but were not medically trained.

This organisation is only paid for addicts whom they successfully wean off heroin. It receives £3,000 per patient if they abstain for three months, then a further £5,000 if they are still drugs-free a year later. So each patient is worth about £8,000 to the organisation – but only if they stay off heroin. And this is at the root of the problem. I saw a homeless patient who had had several failed attempts at detoxing. He was injecting five bags of heroin a day (about £50 worth). He was incredibly frail and I knew that if he continued, he would soon be dead. To make matters worse, he was injecting into his groin because he had no usable veins left in his arm, running the risk of an infection that can result in amputation of the leg.

I reasoned that although it was unlikely we would cure him of his addiction easily, it was worth trying to engage him in treatment and get him on a prescription for methadone. We would be able to reduce the amount of heroin he needed to take – this, in turn would reduce the amount of crime he committed, the number of needles left lying around, the frequency of injecting. He might even stop using heroin altogether and we could maintain him on methadone while we tried to help him get his life together.

The manager of the clinic, however, was clear: they wouldn’t get paid for this approach as he wouldn’t be regarded as detoxed. Discharging him back on to the streets was the solution. I was horrified: if I discharged him from the service, we were sending him to certain death. There was no NHS service to refer him to because this organisation had taken over the entire contract for drug services in the area. I was staggered that there was no NHS help available to this man. This is just one example of what happens when services go out to tender.

You might think that, well, you’re not a drug addict so why does this matter? This will never affect you. But you’d be wrong. From today, this is the model that is being rolled out across the whole of the NHS. So, say for example you need a knee replacement. The provider commissioned to deliver this by your local CCG will have stipulated in the contract what work it will undertake and how much it will get paid. This is fine if you’re a straightforward case. They do the operation, you’re discharged and they are paid the set fee. But what happens if your knee operation is more complicated?

What if your knee joint has twisted and is now deformed (it does happen), which means the surgeon has to avoid damaging the nerves that run down your leg? All of a sudden, the provider won’t turn such a tidy profit on your knee replacement. This is outside of the terms of their contract. So they reject you and discharge you back to the care of your GP. And what then? There’s no longer an NHS to pick you up because this private organisation has taken over knee operations in your area. So where do you go? Suddenly my heroin-addicted patient being told there’s nothing anyone can do doesn’t seem so far removed from your own situation.

In the new NHS, everything will be about payment by results, because this is all the private contractors are interested in. All “clinical encounters” have to have an easily definable, objectively measurable end point. But what about chronic conditions? Or treatments where the chances of success are low and complications high?

This is what saddens me: what were once the NHS’s strengths – resources, expertise and the united focus on the patient – are being replaced by a fragmented and atomised service, bound not by a duty of care but by a contract and driven, not by what is best for the patient, but by the cost of the encounter. It will be a slow, insidious creep but it’s coming. Be prepared. This is the way the NHS ends: not with a bang but a whimper.

NHS reforms: From today the Coalition has put the NHS up for grabs - Telegraph

The editor of the Lancet has reviewed the book "NHS SOS" by veteran health writers Jacky Davis  and  Raymond Tallis and talks about a 'revolution':

Richard Horton, editor of the Lancet: Cowards, betrayers and appeasers have destroyed the NHS

All three parties have colluded in the creation of ideal conditions for an unprecedented colonisation of the NHS by an aggressive, profit-seeking private sector. NHS SOS, a new book edited by Jacky Davis and Raymond Tallis, explains how it was done.


Two nurses aid an elderly patient.
Andrew Lansley, upon arrival at the Department of Health, ended "more than 60 years of consensus" that secretary of state should keep the NHS "free at the point of use". Photograph: Getty Images.

NHS SOS: How the NHS Was Betrayed and How We Can Save It
Edited by Jacky Davis and Raymond Tallis
Oneworld, 288pp, £8.99
Andy Burnham, the shadow secretary of state for health, tells a revealing story about his last days in the Department of Health, back in May 2010. As Burnham was saying his goodbyes to civil servants in Richmond House, David Nicholson, the fierce chief executive of the National Health Service, warned that if he returned after the election, his priority would have to be efficiency – achieving a better NHS with less money. A financially fragile health service could tolerate no more reorganisations.
When, just two months after the election, Burnham read Andrew Lansley’s extra - ordinary white paper Equity and Excellence: Liberating the NHS, he was dumbstruck. A huge top-down reorganisation was being proposed, despite what he knew to be the department’s view that such changes were unwanted and unsustainable. Something seemed to have gone very wrong at the heart of government.
What we now know – and what Jacky Davis’s and Raymond Tallis’s new book, NHS SOS, so lucidly describes – is that a very British coup had taken place. During the run-up to the election, the Conservative Party had claimed that there would be “no more top-down reorganisations of the NHS”. Despite this, Lansley soon infiltrated the Department of Health, ignored the advice of his most senior civil servants and implanted his carefully constructed plan to end more than 60 years of consensus that it was the duty of the secretary of state to provide a comprehensive, continuous and equitable health service that was free at the point of use.
Lansley set about a major – indeed, revolutionary – reversal. Like many coups, this did not result in immediate victory but it started a civil war within the NHS that today threatens to create further crises, providing justi - fication for even more destructive reforms in the future.
Conservatives have an honourable philosophy that unites them and that seems to make some intuitive sense. They argue that competition is by far the best way to solve society’s ailments. Competition certainly works in sorting out the best football teams from the worst. In business, competitive instincts can sharpen minds to create new products that transform important aspects of our lives. It would be entirely natural to think that competition among health providers would enhance the quality of our NHS. The problem for the Conservatives is that there is not one shred of reliable evidence to prove that competition improves health. On the contrary, we know only too well that creating competitive markets in health is extremely harmful.
The US has the most advanced marketbased health system in the world. There, competition has driven up costs, created enormous variations in the quality of services available and fuelled distortions and disparities that make the idea of equity a pipe dream. Despite this, Conservatives, ably and surprisingly supported by their Liberal Democrat partners, have succeeded in creating conditions for the unprecedented colonisation of the NHS by an aggressive, profitseeking private sector. For these reasons, it is a simple, although appalling, truth that the Health and Social Care Act 2012 marked the end of the NHS.
NHS SOS explains how it was lost. It is a painful story and one that we must confront if we are to have any hope of reclaiming what was once ours. There were three catastrophic failures. The first great error was made by the Labour Party. As Tallis argues, “Labour was most culpable.” It was a suc - cession of Labour ministers, led by Alan Milburn and Patricia Hewitt, who prepared the NHS for privatisation. Having betrayed their visionary Labour forebears, many of them went on to line their pockets with well-paid consultancies in the private sector that they had done so much to foster.
The second failure lay with the media and especially with the BBC. Journalists consistently failed to ask questions about who would profit from Lansley’s reforms. They failed to explain the conflicts of interest staining so many of those designing his plans (from management consultants such as McKinsey to “think tanks” such as the King’s Fund). And they failed to point out that Lansley’s bill would dissolve the vital link between the secretary of state and his duty to provide care.
Perhaps the most atrocious betrayal of all came from an unexpected quarter – the medical profession. The British Medical Association pursued a policy of appeasement, which rendered it guilty of a crime of quite astonishing proportions: the death of a health system that had led the world in proving that a universal right to health could also be a universal symbol of our respect – and responsibility – for one another.
The Royal Colleges preferred to fight their own internecine wars rather than unite in opposition to a government that they each privately detested. The most senior medical leaders within government – notably the chief medical officer – chose to remain silent. The authors of NHS SOS use words such as “feeble” and “dismal” to describe their medical colleagues. They are too kind.
Tallis writes, “There is room for hope.” Maybe. Labour must unequivocally commit to repealing the Health and Social Care Act 2012. Campaigns must be launched, political pressure applied, evidence of harm gathered, so-called leaders held to account. Most of all, we need “an urgent inquest into the abysmal failure of professional leadership” within medicine.
What we have learned from the past decade is this: Labour, yes Labour, initiated a process that eventually erased an institution that had become a beacon of advanced democracy. The Conservatives happily used Labour’s perversions to accelerate this destruction. And the Liberal Democrats? They colluded and connived. If there is a hell, I look forward to the day when I meet these cowards, betrayers and appeasers – burning in obloquy.

Richard Horton, editor of the Lancet: Cowards, betrayers and appeasers have destroyed the NHS
NHS SOS by Jacky Davis, Raymond Tallis | Oneworld
NHS SOS: How The NHS Was Betrayed – And How We Can Save It: Amazon.co.uk: Raymond Tallis: Books

The BMA website is advertised on the wall of the surgery as a reference for what our doctors think. 
It seems very critical:

NHS changes and pressures - what doctors think
The NHS has to continually adapt to meet the changing needs of patients and the introduction of new technologies and medical treatments.
Doctors are at the forefront of these changes, driving service improvements and clinical innovations across the UK.
But many doctors are really worried about several aspects of the latest changes to how the NHS is run and to how the financial pressures are being managed. 
Here are the main concerns of the BMA, representing UK doctors and medical students:

The Health and Social Care Act
The Health and Social Care Act, which came into full effect on 1 April 2013, is the legislation setting out changes to how the NHS is run in England.
The BMA was worried about many aspects of the Act and lobbied Parliament not to let it pass. We remain worried about its impact, especially in the longer term, and we are monitoring its implementation on the ground carefully.
Three of our biggest concerns with the changes are:
·         Competition:  the BMA is very concerned that increasing competition could make it harder to offer patients ‘joined-up’ services and that local NHS providers could be left with the complex services, making it harder for them to balance their budgets. There are also concerns that when profit-making companies with shareholders win contracts, money will leave the NHS unnecessarily
·         Empowerment:  we are concerned that decision-making will not always be passed to local clinicians and communities.  Doctors are still finding that they have to meet new centrally set targets rather than having the autonomy to focus on local priorities
·         Cost:  the transition to the new system is costing over £1 billion of taxpayers’ money. This is a very expensive and distracting, top-down reorganisation at a time when the NHS can ill afford it

Funding pressures
So far, around £3 billion of the £20billion savings expected of the NHS have been found by freezing the wages of many of its staff, including all doctors.
While doctors are clear that we need to play our part in continuing to improve quality while increasing efficiency, just cutting staff pay is not going to be a realistic or sustainable solution.
We are very worried that the current financial pressures are driving a range of local cost-saving initiatives that will be damaging in the long term.
We believe service change is important when it will improve quality as well as save money. NHS managers and staff need to be allowed to work together to find ways of improving care and saving money.
We also need to do much more to reduce demand, not by quick-fix solutions like offering rewards to GPs for fewer hospital referrals but by tackling the big public health challenges – alcohol misuse, obesity and smoking.

Politics and the NHS
Despite recent government promises to “take the politics and politicians out of the day to day management of the NHS”, the NHS continues to be used as a political football.
Recently, for example, pressures on emergency services have been the subject of arguments between the political parties.
NHS England is now supposed to work independently on the basis of a three-year mandate set by the government, but there is still day-to-day interference from politicians.

Finally, County Cllr Claire Wright, who has worked for the NHS, is a member of the DCC Health and Wellbeing Overview and Scrutiny Committee (OSC) - and gave this report last month:

Councillors ask for more time to scrutinise NHS changes

Concerned councillors sitting on Devon County Council’s health and wellbeing overview and scrutiny committee (OSC) have asked for more time to look into health services that are undergoing a major change, across Devon.
Councillors ask for more time to scrutinise NHS changes
At the latest OSC meeting on Friday (6 September), of which I am a member, there was a bumper agenda, with 14 items listed, including:
- information on how £1m cuts to the maternity budget in north Devon, may affect frontline care
- a north Devon community hospital that is planning a public consultation after suddenly closing all its beds
- plans to shut all the beds at Budleigh Salterton community hospital, including an eight bedded stroke unit serving East Devon, to make way for day care services
- the progress of plans for a major change in the way community services are delivered, called “transforming community services.”  This document, once published in consultation form in the next few months, will set in train plans to significantly change the way in which Devon community hospitals are used.
Around 600 people attended the “health summit” events, which ran across Devon in many towns over the summer.
I asked what the feedback was from these events in terms of what services people had said they wanted to keep. The answer,which was along the lines of high quality clinically led care etc, was a bit vague, in my view.
I asked that the raw data in terms of typed up notes from these events, be given to the committee for the next meeting.  It is vital that scrutiny councillors are aware of what people said what health services are most important to them.
Changes to the way in which community hospitals are used
I don’t yet know the detail of these proposals, suffice to say I think we can look to what is taking place at hospitals in Torrington and Budleigh Salterton and Ashburton (which announced similar plans last year) to get a flavour of what may be around the corner.
To those of us who are familiar with what is happening at the major hospitals – the RD&E, for example, is under significant pressure with major staffing cuts and the numbers of people being admitted – it is hard to believe that community hospital beds, often used for recuperation, simply aren’t needed. 
Yet the message given at Friday’s meeting by several NHS staff, was that community hospital beds in question were lying empty and therefore, surplus to requirements.
The forthcoming changes are set amid a push to care for more people in their own homes and this was a position frequently articulated on Friday.
The coalition claims that NHS budgets are ringfenced, however, in March this year it announced that the NHS must make £20bn of “efficiency savings” by 2015, accompanied by the following nonsense statement:  “So there are more funds available for treating patients and to allow the NHS to respond to changing demands and new technologies.” – see policy document here -https://www.gov.uk/government/policies/making-the-nhs-more-efficient-and-less-bureaucratic
So NHS budgets are already being crippled – and that’s before any ring-fence is removed.
One of the issues of concern that came out of Friday’s OSC meeting, was that Northern Devon Healthcare Trust (NDHT), which runs community hospitals across Devon, seem to often have staffing difficulties, and services are affected as a result.
Managers insisted on Friday that NDHT’s staffing issues were no worse than anywhere else, however, Cllr Polly Colthorpe raised concerns about a minor injuries service at Tiverton Hospital, which has been reduced to just one day a week. As a result barely anyone uses it, she said.
Staffing difficulties appear to have also played a part in the sudden removal of all the beds at Torrington Hospital, which has infuriated the community there. Although, the message from the NHS staff was that they simply were not needed.
This struck a chord with me because at Ottery community hospital at least, beds have been gradually closed.  This link states that Ottery Hospital has 24 beds -http://www.northdevonhealth.nhs.uk/services/community/ottery/ 
Not any more. Over the past year or two, Ottery hospital’s beds have been closed bit by bit so that there are now around only 12 beds in use, I believe.  The general answer when enquiries are made, is that the beds aren’t needed and are lying empty for much of the time.
In July, Ottery Hospital’s minor injuries unit closed for three months because of staffing issues, and instead is now operating out of Coleridge Medical Centre. 
When I worked for the NHS, Ottery Hospital’s minor injuries unit was operating from something like 8am-8pm, then the hours were reduced to 9-5pm and now the unit is open during the mornings only. 
The knock-on effect is that people turn up and are turned away and then gradually fewer people use the service ….
Chairman, Cllr Richard Westlake, requested details of all staffing vacancies across Devon community hospitals, for the next meeting.
Stroke care in East Devon
Going back to what’s happening at Budleigh Salterton Hospital, the eight bed stroke unit is a service for all East Devon patients and its proposed loss will affect people across East Devon who need help with recovering from strokes, after being discharged from the RD&E.
Scrutiny councillors were informed by health service staff that feedback had revealed that Budleigh Salterton Hospital was tricky to get to for stroke patients and their visitors.
However, the same member of staff also indicated that recovery for patients staying at Budleigh Salterton Hospital’s stroke unit, was “fantastic.”
Presumably, the argument about being tricky to reach could apply to most community hospitals in East Devon.
The continual unsettling messages of forthcoming significant change, the effect of budget cuts, hints at staffing problems, and the difficulties getting clear answers, prompted councillors to request more scrutiny meetings, to look into issues more closely.
The Francis report
One of the agenda items was a resume of the Francis report – related to the appalling series of unnecessary deaths at Mid Staffordshire Hospital. Here, it was clear that the health scrutiny function had failed and many reports to the committee had simply been “noted.”
This prompted me to outline concerns at the number of verbal reports that NHS staff were giving during Friday’s meeting, without any supporting paperwork. Previously, I have objected to tabled reports, which are equally frustrating and not good practice.
Proper scrutiny can only be effectively carried out if adequate information is received by councillors in advance of the meeting, so I proposed that this happened in the future. Other councillors agreed.
Officers confirmed that they had repeatedly and unsuccessfully asked for such information.  Hopefully things will now change.
Health and wellbeing OSC chair, Cllr Richard Westlake will now write to DCC leader, Cllr John Hart, to formally request that the number of health and wellbeing scrutiny committee meetings are increased.
The webcast, with index points relating to agenda items and speakers, can be viewed here: http://www.devoncc.public-i.tv/core/portal/webcast_interactive/93464
Photograph:  The excellent Ottery St Mary Hospital.


1. At 10:56 am on 10th Sep Robert Crick wrote:
Many thanks for this detailed report. The issues are a source of great concern but the fact that Councillors are taking them seriously is encouraging. It is good to have scrutiny by those who have worked in the NHS not just professional politicians, who in the April 1st Act pushed through a revolutionary top down change that massively increases the cost of NHS administration and has already transferred £2.5 billion per year from the NHS budget into the hands of private companies, normally based in tax havens, whose legal duty is to prioritise shareholder profit. Our doctors are now so over worked that many had not even noticed that childcare in Devon has been taken over by Richard Branson’s Virgin Group. It would be very valuable to see the result of the Health Summits. No feedback or information has yet appeared following a very lively and informed summit in Sidmouth several weeks ago. There is not even a list of representatives on the Patients Participation Group in the public domain. The task of watchdogs like you Claire is massive and massively important.
2. At 12:51 pm on 11th Sep Elli Pang wrote:
As Secretary of the Devon Health and Social Care Forum (DHSCF) I was present at the Scrutiny meeting you report on. All as you say.
The Forum is (and has for some time) trailing these and other issues.
I agree that there should be more and better informed scrutiny function. The issues presented to Scrutiny are complex, have often a long history and involve often a whole range (fragmented) service components. The whole picture needs to be understood in order for scrutiny to be able to ‘scrutinize’ and make observations / recommendations. And these need to be followed up much more rigorously as is possible under the currently available time-scale and information.
The Forum would be pleased to meet with you (and anyone else interested to share the information and thoughts and any concerns we have. Elli Pang, Secretary Devon Health and Social Care Forum.
Claire Wright - Your Independent East Devon District Councillor for Ottery Rural
Health and Wellbeing Scrutiny (Minutes) - Fri Sep 06 2013
Health and Wellbeing Scrutiny - Minutes & Agendas

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