NHS for Sale: Myths, Lies & Deception (28 page)

We all know that things have turned out very differently from the promises that were made by the Tories in opposition. Along with the A&E and maternity units that have closed, the period from 2010-14 has seen the loss of 8,649 beds – two thirds of them the frontline ‘general and acute’ beds which care for emergencies, elective admissions and older people. One in five mental health beds (1,693) are also among those lost, while mental health spending has been falling year by year for the first time in over a decade.
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None of this was included among the pledges and promises as the Tories chided Labour for planned local cuts and posed in front of threatened hospitals, promising to save them if elected.

Indeed Tory justification for the ‘reforms’ and policies they have introduced has been to improve performance. But again reality has been very different. The reduced capacity, at a time of rising demand, has brought sharp increases in the numbers waiting (up almost a quarter since the 2010 election), waiting times, and numbers waiting over eighteen weeks for treatment (up 12 per cent). The percentage of
patients waiting less than nine weeks for cancer treatment, which peaked at 88 per cent, has fallen below the 85 per cent target and well below the levels achieved in 2010. In January 2015, newspapers and other media were full of reports on increased waiting times in A&E departments.

Coming as it did after a decade of investment and improvement, the prolonged freeze on NHS spending imposed since 2010 has resulted in a decline in performance, while the cash constraints have opened up a new drive for cuts and closures – which are now discussed under the much less explicit heading of ‘reconfiguration’.

Like many euphemisms, this buzzword is inherently misleading, since ‘reconfiguration’ implies that the same level and range of resources are being reorganised. In fact, whatever else people may claim, the bottom-line objective of reconfiguration is to make substantial and sustained reductions in spending.

Dishonesty is at the centre of the presentation of plans for reconfigurations. Any suggestion that the gallons of red ink on financial spreadsheets are the real reason behind such reconfiguration plans, rather than a response to patients’ needs, is always immediately and indignantly refuted. How dare we suggest otherwise?

These plans, we are told, almost always by some managerial bureaucrat with a straight face and increasingly lengthening nose, are certainly not financially-driven. They are claimed instead to be ‘clinically-led’ proposals to improve patient care, proposals that (they hope) just happen to cut costs. It’s not clear if anyone at all believes this.

If anyone
does
believe it, it is clearly not local communities whose hospitals face a downgrade, loss of services or closure:
they are swiftly able to see through the rhetoric to the reality.
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They are all too aware that the issue of whole populations facing longer journeys for treatment (or to visit relatives and friends in hospital) has been largely ignored. Time and again they find that the management consultants or senior NHS managers who drew up the plans either live miles away, or have comfortable cars to convey them wherever they want to go – and perhaps even private health insurance.

Of course, the managers driving these projects can never let on that they know that
we
know that what they say is at best economical with the truth, and based largely on wishful thinking. They plough on, spelling out proposals using a language which consistently misleads those who look simply at the words and not the essence of what is proposed.

A closer look at many of the plans reveals the true picture. In north-west London, for example, where one of the biggest-ever packages of cuts and closures has been proposed, the underlying aim is clearly a reduction in services to generate cash savings. The projection was a £1bn potential cash gap over five years, to be met by £553m of commissioner savings and a requirement for NHS trusts (those not yet foundation trusts) to generate savings of £360m over three years.
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The cost-saving schemes (mapped out in a separate document from the hospital reconfiguration) fall into six main categories, all of which can also be seen in many other reconfiguration plans:

• Cutting back on the contracts for acute, community and mental health providers. This is officially described as
  Contract Management.
  
• Diverting patients away from hospitals and existing services and moving them into ‘lower cost settings of care’ (many of which do not yet exist) and ‘care closer to home’ (also largely non-existent). This is officially described as
  Changing setting of care.
  
• Reducing overall numbers of patients accessing treatment – not necessarily the same as the much more complex issue of reducing the levels of medical need. In the jargon of NHS speak, this is
  Reducing demand.
  
• Changing the ways in which patients access services (again requiring investment and new services which have not yet been established). This is described by NHS bureaucrats as
  Pathway redesign.
  
• Corporate ‘efficiency savings’ through outsourcing, centralisation, shared services and the asset-stripping of estates. This is generically described as
  Back office and corporate savings.
  
• Savings from prescribing and medicine management, either by better use of generics, or by restricting access to more costly drugs and imposing limitations on GP freedom to prescribe. This is described officially as
  Reducing drug spend.
  

Behind the bland phrases, to which few could object on principle, come plans for very large scale cutbacks in hospital care in the next few years, which many object to in practice. In north-west London, for example, the plans aim to reduce hospital activity by:

• 19 per cent fewer ‘non-elective’ (i.e. emergencies and urgent referral) admissions to hospital. This is equivalent to 55,000 hospital admissions a year, and would open the way to close 391 hospital beds.
  
• 22 per cent fewer outpatient appointments – a massive 600,000 reduction in hospital appointments.
  
• 14 per cent fewer A&E attendances – 100,000 fewer to be treated.
  
• 14 per cent fewer elective (waiting list) operations – a reduction of 10,000.
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In other words each of these ‘efficiency savings’ is part of a planned
reduction
in the availability of services. This also raises questions about whether existing services that close would be replaced at all. Tucked away at the back of the document were projections of how many jobs (up to 5,000, most of them clinical posts) might be cut to generate the savings required.
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Of course all these savings also have a cost: the financial impact on local hospitals of cuts on this scale could throw the finances of already troubled trusts into crisis. According to figures produced for the 2007 Darzi report on London’s NHS, in the north-west London example the non-elective cuts alone could cut hospital revenues by at least £330m, spending on outpatients by £60m, and elective services by another £40m – an overall cut equivalent to
20 per cent of the income of local trusts.
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Developments since then have demonstrated that the critics were right, and those driving the reconfiguration had no serious plans to replace the lost services and beds when A&E units and whole hospitals close: in north-west Thames,
just two months after the closure of the relatively small A&E units at Hammersmith and Central Middlesex, performance of the neighbouring hospitals in handling emergencies has plunged to the lowest levels anywhere in England. Trust managers at nearby Northwick Park Hospital, in the same trust as Central Middlesex hospital, have complained that bed numbers were inadequate as queues grow for treatment.
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Scratch the surface of almost any local reconfiguration plan, and a similar set of less obvious objectives and dubious assertions will emerge.

The deception begins on the covers of the documents outlining the plans: they invariably carry absurdly positive, happy-clappy titles that belie their real purpose. Many such titles have already been tried –
Shaping a Healthier Future, A Picture of Health, Better Care Closer to Home, Healthier Together, Investing in Excellence
… there are many more.

Somewhere in the bowels of NHS England or some management consultants’ headquarters a title generator must be cranking out endless permutations of a few positive words to create a steady flow of vacuous reassurance. However, nobody is that easily fooled. It’s instantly clear that none of these documents really means what the title suggests, and so the tactic is immediately counter-productive, since the unreality of the title annoys the plan’s opponents rather than soothing them or allaying any fears.

The structure of such documents is always similar, and many of them appear to have been bolted together from ready-made pre-drafted sections from some restricted access NHS England website with only a few ‘local’ details thrown in.

That’s why almost every consultation document begins
with at least 10-15 pages of general twaddle on public health. All that’s needed is a series of truisms on national and local prevalence of disease, mortality statistics, smoking, drugs, alcohol and other health issues, deprivation, demographics, ethnic mix and inequalities. And of course a disquisition on the benefits of preventive health campaigns and the need to combat inequalities in health.

Anything will do, as long as it’s dull and non-contentious. Nobody will be against any of it, but none of it bears any relation to the plans that are being proposed. The idea is to bore potential critics who may pick up the document, and persuade them there is nothing to get their teeth into.

However significant they may be in their own right, the data, the statistics, and the hopes to effect a reduction in hospital caseload through improving the health of the local population are not the real reason for change, or the basis for the plan. But including this information does have a purpose: it ensures that all the practical content of the document and any controversial plans or figures can be pushed to the middle, or to the back, of a document that will be frustrating to read for any but the most determined critic.

Despite the pages allotted to them, many plans in practice ignore the public health and health inequalities issues altogether when they get down to the real business of closing hospitals and services in the most deprived areas. This has been the pattern of proposed closures in north-west and south-east London.

One feature which almost all reconfiguration documents have in common is a focus on downgrading or closing A&E services, often leaving only an Urgent Care Centre (UCC), so
diverting all those with the most serious and urgent health needs much longer distances to centres elsewhere.

The rhetoric to conceal this involves two deceptions: misleading use of statistics showing lives saved as a result of centralising highly specialist services for stroke and trauma services (comprising less than 5 per cent of all A&E attendances)
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on the one hand, while on the other arguing that an inflated proportion of current A&E patients who have only minor problems might be treated in primary care or in community services if they were ever to be made available. So far we have seen varyingly exaggerated claims ranging upwards from 60 per cent – with some saying 70 per cent, 75 per cent, 77 per cent or even 80 per cent of A&E caseload is so minor it could be dealt with on the same site in a scaled-down, nurse-led UCC, in conjunction with other services in ‘community settings’.