NHS for Sale: Myths, Lies & Deception (16 page)

Proponents of the clause tried to reassure its many opponents by claiming that the process would be time limited, transparent and only used in specific circumstances – and be subject to public consultation, although experience of the existing TSA procedure shows this to be untrue. The passing of the clause suggests ministers and commissioners are prepared, where they feel they have no choice, to exploit this procedure to achieve reconfiguration not possible through standard planning procedures.

Even where no Trust Special Administrator was involved, consultation on reconfiguration was seriously limited in its scope, and CCGs were stubbornly resistant to taking any note of critical or opposing views – however well-founded. In west London this led to the railroading through of the inappropriately-named ‘Shaping a Healthier Future’, one of
the biggest-ever closure plans – which called for the closure of four A&E units and two whole hospitals,
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despite the absence of any serious plans (or resources) for adequate alternative services to be put in place before any were withdrawn. Whenever CCG chiefs were confronted by campaigners or the wider concerned public, they simply chose to ignore questions they could not answer, or refer people to the thousands of pages of confusingly written ‘Business Case’ documents – despite the fact that these inadequate plans and evidence-free policies were often the proof that the plan did not hang together.
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Ealing Council failed in its attempt to have these plans overturned on a judicial review (since in this case the extent of consultation and ‘engagement’ with the public was deemed by a judge to have been adequate), so once again the merits of the proposals, and viability of the resulting healthcare system were not even considered. However, Ealing Council did use its one last throw of the dice to invoke the residual powers of its Health Oversight and Scrutiny Committees, (powers left over from the original legislation that scrapped CHCs ten years earlier and not yet swept away by the Health and Social Care Act) to lodge a formal objection, forcing a decision on the closure plans from Jeremy Hunt as Secretary of State.
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Hunt responded by bringing in another relic of the mid- 2000s, the Independent Reconfiguration Panel (IRP), to investigate. When the IRP reported, it did endorse the closure of the two smaller A&E units
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– with, as we have since seen, disastrous consequences in terms of access to emergency services for patients in Hammersmith & Fulham and Brent, reducing parts of north-west London to one of the worst
performances on A&E targets in the country. However the IRP was less than convinced by the robustness (or existence) of plans in ‘Shaping a Healthier Future’ to replace the services that would be lost with the closure of the two substantial hospitals, each with over 300 beds.
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The commissioners and the two trusts involved were required to develop new plans – if need be going back to further consultation – and in the meantime to maintain existing services.

Straight after the IRP report the CCGs and Imperial Healthcare Trust which runs Charing Cross made clear their determination to forge ahead regardless, and plans have now been published by the Trust for the demolition of the majority of the Charing Cross site, and its sale to generate capital for investment in health care elsewhere.
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Local MP Andy Slaughter has summed up the way in which public voice has been excluded in this process:

There will be no public consultation on the plans for Charing Cross and St Mary’s. Public information on the closure of Hammersmith and Central Middlesex A&E has not started, six weeks before closure, but £300,000 has been paid to PR consultants, including £55,000 to M&C Saatchi.

In February 2013 plans to sell the whole Charing Cross site save for a clinic on 3 per cent of the land were met with outrage and the local NHS promised to go away and think again…. At the end of October Health Secretary Jeremy Hunt confirmed his wish to close Hammersmith A&E but said Charing Cross would ‘continue to offer an A&E service’…. Now we have the final proposals and they are worse than we were recently led to believe.

Charing Cross will close as a major hospital. It will be reduced to a primary care centre with some day surgery
and treatment services. … More than half the Charing Cross site will be sold, the existing hospital demolished and new building will provide less than a quarter of the current floor space. All consultant emergency services will close or go elsewhere. The present 360 inpatient beds will fall to just 24. The biggest betrayal is the loss of the A&E. Far from continuing ‘to offer an A&E service’ as Hunt promised, Imperial confirm that A&E will ‘move out’ of Charing Cross under their plans leaving ‘an emergency service appropriate for a local hospital’. This means an urgent care centre staffed by GPs and nurses.
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So even where what remains of an appeals process appears to deliver a victory for the local community opposing a closure, there is no guarantee that the appeal rulings will be respected or upheld. The public voice is less powerful by far than the demands of the balance sheet and the drive for cash savings.

Since then it’s been getting worse. At first, many of the reconfiguration plans had been drawn up by the primary care trusts and inherited by the CCGs. But now various CCGs have been seeking costly legal advice on how NOT to consult local people on substantial changes which they have themselves drawn up or taken responsibility for – such as the tendering of contracts, knowing that there will be no popular support for their proposals.

In Staffordshire, four of the county’s CCGs, advised by the Macmillan cancer charity, are working together to put controversial contracts for the coordination of cancer services and end of life care (worth a combined £1.2 bn over ten years) out to tender. Huge public meetings and lobbies have repeatedly challenged the CCGs to publish their full
proposals and name the companies that have expressed an interest. They have been met by a consistent refusal to share any real information – creating even more suspicion of the long-term implications of a process that could put a private company in charge of such a large budget for crucial services.

Suspicion is further raised by the publication via the EU of the initial invitation for tenders which makes clear that the only criterion for awarding the contract will be the ‘most economically advantageous tender’ – i.e. the cheapest, and the refusal to publish the Pre Qualification Questionnaire which ‘will be used to determine the applicant’s eligibility, economic and financial standing and technical ability’.

In Staffordshire and elsewhere, although CCGs themselves allegedly represent local GPs, the GPs are not really in charge at all. CCGs are all invariably run by a small handful of GPs, most often from the largest and most prosperous practices, who sit with other managers on the board. The CCG boards in turn are told what they can and can’t do from above by bureaucrats from NHS England and its bureaucratic, secretive Local Area Teams (which also control local primary care services).

CCG boards seldom consult the wider local body of GPs, let alone allow them any kind of ballot or democratic vote on controversial policies. The one time this did happen, and a ballot was held among GPs in Surrey Downs CCG over a controversial plan threatening the future of the local Epsom Hospital and the relatively nearby St Helier in Carshalton – the majority delivered a resounding thumbs down to the proposals. The CCG was obliged to withdraw its support, and the entire ‘Better Services Better Value’ plan had to be abandoned.
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Other CCGs have drawn the obvious lesson: don’t ask GPs, or you may be forced to change course.

These unrepresentative bodies, now spurred on by the growing financial pressures of a frozen budget and constantly increasing pressures and demands on frontline services, are driving forward plans for reconfiguration of local NHS services. It seems the documents are largely based on blueprints and off-the-peg generic arguments and statistics supplied by NHS England, and often in open defiance of local public opinion.

Unlike PCTs and SHAs, CCGs have no responsibility to ensure the viability of local NHS providers or the local health economy – and some clearly feel free to take decisions which could seriously undermine local providers, despite long-term serious consequences for access to care for local populations.

There is no longer any wider system of regional overview to ensure the coherence of local plans. Local Area Teams of NHS England, which have now effectively replaced strategic health authorities, are not public bodies, appear to have no formal structure of meetings or public access to their discussions, publish no board papers, and avoid serious engagement or consultation with the local public at any level other than the highest level of abstraction.

There are also problems of reduced public voice in relation to the providers of health care. The Act requires all trusts to become foundation trusts, regardless of the fact that those which have not yet done so are almost all confronted by serious financial obstacles, and could well be driven in desperation to some of the cash-saving cuts in staffing that caused the massive crisis in Mid Staffordshire Hospitals Trust. Yet these changes in frontline care are not always visible in the high-level analysis presented in board meetings and published for local scrutiny.

Many foundation trusts still withhold publication of board
papers, and meet in secret with only minimal engagement with their own ‘governors’ rather than the wider local public even as their financial situation worsens. According to Monitor, more than half of the 164 foundations are now in deficit,
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but the first local people are likely to hear about such problems is when substantial cutbacks or service changes are announced, and appear in the local news media.

So what of the bodies that we might expect to represent the views of local people? Healthwatch (
www.healthwatch.co.uk
), which is organised at local and national level, was established under the HSC Act, subordinate to the Care Quality Commission. The new bodies were designed from the outset to be toothless, with a limited frame of reference, primarily offering advice, and with no independent role. They have been scarcely visible in many areas, in some cases openly arguing that their brief is not to campaign or speak up for local communities as the best of the old CHCs once did.

From a London perspective on what is clearly a national problem, the People’s Inquiry into London’s NHS, supported by Unite the union, concluded from the evidence heard that there seemed to be:

no real public awareness of, or confidence in the effectiveness of the new bodies established by the Health and Social Care Act to represent local views and give a limited degree of local accountability of NHS commissioners and providers.

Healthwatch, despite the efforts and good intentions of some working within the local groups, appears to be uneven and largely ineffective, with little if any public
profile – and virtually no involvement in the issues that have galvanised the most active public interest in the last year. And in only one of our hearings (North Central London) was there a report indicating any impact or role for Health and Wellbeing Boards.
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The Inquiry also noted that in theory there should be a Healthwatch functioning in each London borough, but even where they do exist the local bodies lack both the legal powers of the old Community Health Councils and the expertise and links with the community that made the best CHCs a real force to be reckoned with. Even worse, while Healthwatch groups are supposed to be resourced by local authorities, a quarter of the funding that should have been funnelled to local Healthwatch groups from the Department of Health through their local councils had been siphoned off, and apparently used to pay other council bills instead – with no significant protest being raised.

In Bracknell, frustrated campaigners, seeing no sign at all of life in Healthwatch, have taken the initiative to set up their own, unofficial People’s Healthwatch to keep a close eye on the local trusts and CCG and ensure that important issues are reported in local media. The first they heard from the official Healthwatch was a letter urging them not to choose a similar name, for fear of confusing people. The reply was that there could be no confusion, because no members of the public would ever have heard of the official Healthwatch!

The People’s Inquiry concluded that Healthwatch in its current form is unlikely to deliver an effective voice for local communities, and recommended that they be wound up, with new bodies established that should be separated from the CQC and modelled on the old CHCs.

They should link up with local community organisations, pensioners groups and other community organisations, and be given the statutory powers to inspect hospital and community services, to object to changes which lack public acceptance, and to force a decision on contested changes from the Secretary of State.

The invisibility and impotence of Healthwatch is rivalled by many of the Health & Wellbeing Boards (HWBs), which were also established under the HSC Act. However HWBs are not NHS bodies, but controlled locally by councils with social service responsibilities. The unusual flexibility of the phrasing of the Act gives council extensive discretion on how public and outward-going the HWBs should be. There is the possibility to make them campaigning platforms, or a way to hold local health managers to account. But so far not one council has taken the chance to co-opt campaigners, community leaders and advocates of patient groups, and create HWBs as a vibrant, proactive public forum for scrutiny of local NHS commissioners or providers.

The London People’s inquiry again recommended a substantial change, calling on councils to ‘make underachieving and narrow Health & Wellbeing Boards into genuine platforms for the planning and scrutiny of public health, health and social care in each borough’. It suggested that one way forward might even be to merge HWBs with Healthwatch,