deny it as often as you like

Having denied that the Health and Social Care Act 2012 created a risk of privatisation of the NHS; having denied that the contracting of private providers to replace public provision is privatisation; the latest argument of the privatisation supporters runs something like this:

“Over 4% of the NHS was delivered by private business when Labour left government in 2010. Only  a bit more than 6% is being delivered now. The risk of privatisation was exaggerated.”

In response to the instigators and lazy propagators of this disingenuousness, a few points:

Make your minds up. Is that extra 50% privatisation, or not?

You do Andrew Lansley a great disservice. He was absolutely clear when addressing the NHS Confederation five years before taking up office that in his view previous Conservative privatisations had partly or wholly failed, and that he would have to build a new regulatory structure to create competition between multiple providers and to transfer private provision to multiple private providers. He even had the temerity to tell you this in plain English

I believe that the Conservative Party became confused itself about what the experience of privatisation told us. We interpreted the lessons of privatisation as, literally, that: the transfer of public sector activity into the private sector. With private sector ownership would come enterprise, innovation and, temptingly, private capital off the Treasury’s balance sheet.

Andrew Lansley – “The Future of Public Health and Regulation”, 2005

Not only did Lansley never doubt that

the transfer of public sector activity into the private sector

is privatisation – something,  repeat,  you persist in denying – but he wanted to give you a better privatisation, one not just with added ‘competition’; but competition of a new and magical sort where instead of failing, competing private providers would never fail, but would all drive quality up. He even made up a new saying to prove it, and referred to evidence (though didn’t provide any).

How can competition work, whether on prices or quality, if it does not lead to variation and divergent outcomes? Some will gain. But do others lose? No, the evidence is that in effective competition the response of other producers of good and services is to raise their game, so that even those who are less fortunate or successful purchasers will gain by this. As the saying goes, “competition is a tide which lifts every boat”.

The sheer volume of the Bill would only have shocked you if you hadn’t thought about it as deeply as Lansley: if you had been convinced that all you needed to do was what you had always done: get Goldman Sachs or whoever to create a share issue for the NHS and sell of the lot at one go.

Except, of course, Lansley actually cares for the NHS, perhaps almost almost as strongly as his vision of private competition. He is not like rest of you , who just think it another 60 year mistake, another bit of public property to grab and scarper offshore with, another pile of excuses to help people avoid work. He may not think, as so many of you do that old age is a mistake, and that people with no economic usefulness should be discarded, like old mobile phones.

No, Lansley actually believes in what he did.

That is why the Act was so intimidating even in its first published forms. It simply had to contain all the reorganisation to create his new regulator (Monitor) and all the  foundations of the regulation to create in the real world his vision of competition.

More firmly than you, Lansley had a grasp of what he had to create to push the NHS not into a new state, but in a single and irreversible direction: towards his utopia of proliferating providers,  omniscient customers,  and private capital. In brief:

  1. To  force the NHS to be moved piece by piece from public to private ownership and provision, but never to move in the other direction.
  2. To create, regulate and maintain in perpetuity his vision of competition.
  3. To fortify his machine against attack or disassembly.

Lansley, however, is not so much risk-averse as averse to the very thought of risks (whether to his plan, or caused by his plan), which he sees as mere distractions. Inevitably, he underestimated or ignored some possibilities which became reality: beginning with the risk that not everyone, not even his fellow Conservatives and fellow travellers, would be captured by the brilliance and perfection of his solution.

Political expedience would delay the bill, implementation would eat up two more years of the Coalition, and the practical problems of the privatisations would take up even more time.

  1. The Coalition government could never admit what he was actually doing.
  2. Senior members of the Coalition wouldn’t, or couldn’t understand his Bill, or even bring themselves to read it.
  3. The number of Liberal Democrats in Coalition who would jump at the chance to grandstand and to posture.
  4. The sheer length of time it would take to get the bill through Parliament, with Labour opposition and (3) and Cameron and Clegg’s panic and the delay of the “listening exercise”.
  5. The length of time it would take for the reorganisation to be completed after royal assent, even though begun in advance.
  6. Persistent opposition from NHS campaigners, who at least managed to delay individual tenders.
  7. The length of time, the resource requirements, and the effort necessary to complete a commercial tendering process from start to finish, particularly for high-value tenders.
  8. The cuts in funding for the NHS, which would make tenders less profitable.
  9. The poor performance of existing  – or new – private providers, including the fiddling of performance data.
  10. The collapse in morale within General Practice, where funding cuts, unsubstantiated criticisms from the CQC, and constant attacks from government were completely contrary to Lansley’s vision of crusading commissioners.
  11. NHS staff would be busy trying to provide the services it actually provides, with Lansley’s rebuilding going on around them and the CQC waiting to punish.
  12. Lansley’s massive regulatory machine was built with square wheels, with no-one knowing who was in charge and fights for the steering wheel between Monitor, NHS England, the SoS and the CQC.
  13. As Clive Peedell of the National Health Action Party and many others pointed out, the private providers would only ever want the cherries off the top of the cake; the profitable bits.
  14. Monitor and the regulatory regime would never be strong enough to overcome the private bidders, who would want to protect themselves from competition by demanding ever-longer contracts which they designed.
  15. Commissioners, without support units in the first years, would not have the expertise or resources to commission at a high pace.
  16. By the time the reorganisation was complete and the commissioners ready, the next election would be approaching and the Coalition uncertain of victory;  frightening the private providers.

Yet the Health and Social Care Act 2012 and the enabling legislation are on the books, Monitor exists, and the CCGs are commissioning by competitive tender: the NHS is privatising itself, as Lansley envisaged.

To argue that this was never privatisation, or that the amount of privatisation completed via the Health and Social Care Act 2012 is so low as to prove it was never about privatisation, is drivel. The Act was intended to privatise as much of the NHS as possible; to salami slice it into pieces which could never be reassembled.

Either you truly don’t understand what Lansley has achieved and you think he failed (Letwin promised you the NHS would be gone within one Conservative government; the NHS was to be shown “no mercy”, remember?) or you know full well what the Act does and that privatisation must follow and you’re being economical with the truth (or fooling yourself).

Whichever, do us all a favour, and stop insulting us with this nonsense.




The NHS (Procurement, Patient Choice and Competition) Regulations 2013. An Idiot’s view.

Statutory Instrument 2013 No. 257 was “Made” on 11th February, 2013; “Laid before Parliament” 13th February, 2013; and is “Coming into force” on April 1st, 2013.

I do not intend a legal analysis, because there’s an excellent one here; neither do I intend a comprehensive translation into plain English. because that’s available here.  I would just like to take a seat on the Clapham Omnibus and make a few observations, and in no particular order.

I don’t read very newspaper or listen to every news broadcast. That notwithstanding, my sense is that without that original blog on the SHA website, written by Dr Shibley Rahman and promoted through the social media by NHS supporters, these Statutory Instruments would have come into force without mention in the mainstream media; which would have remained –  as George Monbiot described the BBC on another matter – “disgracefully incurious”.

The UK system of government – the arcane, unwritten rituals and processes of our Parliament – is a set of Mithraic mysteries (or Masonic) kept so, and quite impenetrable, to Her Majesty’s subjects. It constantly surprises and appals. One day we learn that Lords and Ladies may speak in debates where they have a vested financial interest.  On this occasion we learn that highly significant changes to the lives and wellbeing of everyone in England can “come into force” without debate in either House, let alone a vote. Unless someone says a prayer.

Dr Sarah Wollaston MP tweeted today that she was shocked by the negativity faced by MPs, and how wearing it is . Surely here is an egregious example of why our democratic process is in such a deficit;  MPs almost cannot remain principled when such huge changes are slid into place without public consent (the more cynical amongst us might suggest, deliberately so).

Because as Nicola Cutcher and Lucy Reynolds point out in their blog for Open Democracy, these Regulations implement exactly what former Health Secretary Andrew Lansley said in 2005 that he would do in government. What we have had between that date and now, most especially since the Coalition Agreement and now, and most particularly during the passage of the Health and Social Care Act 2012 (which enables these regulations, and not the other way around) was near silence on this matter; a silence only broken by denials and obfuscation.

The genesis of these Regulations as much as their contents screams at us that our political system is unfit and undemocratic; and that too many of its denizens are (and have been) as dishonest to the public as they are craven to their real masters: the lobbyists, private corporations, the so-called Big 4 accountants, and the mendacious mesh of rightwing thinktanks.

Barely more than a week before  these regulations were laid before Parliament (and don’t fail to consider that untimely haste), the National Health Service had been presented with the third of three man-made (or politician-made) challenges. To the challenge of a reorganisation so large it could be “visible from space”; and the “Nicholson Challenge” to cut an unprecedented £20B in five years; was added the Francis Report: the only one of these three of actual, real relevance to patients and the public, and the only one to base improvement on evidence not ideology or whim.

The Francis report laid bare how the reorganisations and management targets, the bullying and distractions and failures in patient care actually impacted patients and their families. Francis set out nearly 300 proposed improvements, the implementation of  any number of which might conflict  with either the Nicholson Challenge or the Health and Social Care Act. Utterly unbelievably to anyone who has been involved in service or project delivery, that Act was written and put into legislation while the Francis report – commissioned by the very same Health Secretary – was being compiled. It was almost as if Lansley had raced to get the Act into law before Sir Robert could recommend anything. Just in case.

So now, on top of the £20B of so-called “efficiency savings”, on top of the cost and effort, and issues of implementing the Health and Social Care Act, on top of the to date unbudgeted costs and effort of implementing Francis; the Department of Health sees fit to bring into effect major changes through Statutory Instrument.

And how are these changes to be implemented anyway? What well-run business would throw out a major reorganisation (on top of three other major reorganisations) without an implementation plan, a risk register, programme managers to manage the whole thing, and – not least, a budget to pay for it? The whole thing is insanely incompetent.

Let’s not forget that the impact of all this will be – as Francis recorded in his report – suffering, anguish, and unnecessarily and untimely deaths. While the real problems facing care of the sick and elderly in England accumulate, the management of the NHS will be reading through these regulations and buying advice on EU competition law.

As it has for so many years, the actual effort of caring and treating the citizens of England will crash with increasing pressure upon the staff of the NHS. And yes, England. Because England has been singled out by English MPs for this awful experiment and experience.

Coming into force on April 1st. April Fools’ Day. How our political system makes sorry fools of us all (at least, in England).

Who failed Bob and Eve Tonkin?

Amongst the disturbing lapses in this case study of NHS Cornwall’s outsourced out-of-hours GP service there is an alarming report of the initial telephone conversation.

The caller, anxious to get urgent assistance to his suffering wife, recalls telephoning the out-of-hours GP service at about 7:40pm, when he is warned that “it could be a six-hour wait despite his assessment of the urgency of the problem because it was so busy”. (The call is logged by the Service Desk at 20:01)

This alone raises serious concerns about the quality of the contractual arrangements between the Primary Care Trust and Serco Healthcare. Such an excuse is not permissible. If it was an honest assessment by the agent who received the call, it flags a failure in the service and in the management of the service. But by which party to the contract: the PCT or Serco Healthcare?

Central to the delivery of an outsourcing agreement are the Service Level Agreements (SLA).  SLAs are the detailed definitions by which the quality of service to be delivered are constrained and monitored. The contract between NHS Cornwall and Serco Healthcare will (hopefully) include SLA related to response times, and these should include different response times based on the priority and impact of the telephone call.

The SLAs are there to be met, and regular service management meetings between PCT and Serco Healthcare will review Serco’s performance against the SLAs, using key indicators as measures. Such KPI might be, say, 99% of telephone calls answered within 6 rings”. If, as implied by this part of the story, SLAs were being set aside because the services were “too busy” or “undermanned” then there is clearly a problem.  The question then is, what happens when the SLAs are not being met?

Outsourcing a service successfully is a complex task; and the experience of many businesses is that no matter how thoroughly the outsourcing is done, it doesn’t bring expected benefits.  It may be that these were never properly defined or implemented:  it may be that outsourcing was done for the wrong reason, and the most common wrong reason is to outsource in a leap of faith (or desperation) that it will cut costs but leave a service intact or even improve it (the “more for less” challenge).

The tragic experience in this case was that although the NHS staff were superb,  interleaved between personal contact with NHS services is an outsourced service which failed these patients; or which could not meet their needs because healthcare professionals were spread too thinly.

Because that is the difference between an SLA for mending printers and an SLA for assigning care to patients. Best practise service level management is to avoid 100% performance indicators for SLA, because any single exception is immediately a failure. Unfortunately – tragically – a failure to provide adequate service to a patient can easily mean loss of dignity, excess suffering, or death.

Thus we return to the question: who is failing the public in Cornwall, the PCT or Serco Healthcare? Elsewhere in this report there are suggestions that Serco is not keeping or providing accurate data on the service, which would mean its performance cannot be fairly judged and improved.

Whether Serco Healthcare is not providing the service which it has been contracted to do or Serco is providing the service in the full spirit of the outsourcing contract to the SLA and performance indicators agreed, the responsibility for failure in the service must lie with the PCT. Whether the contract is not being met or it was inadequately drafted, or it was done for the wrong reasons, or it was badly implemented so that the processes cannot work, or it is inadequately resourced, or inadequately funded, or the relationship between PCT and Serco does not work effectively: the PCT is responsible and must be held accountable.  Outsourcing a service does not outsource responsibility or accountability: in fact, managing an outsourced service is a challenging management activity. It is not a hand-off that the managing business can then forget about.

The statement from the PCT is therefore dismaying: “We are confident the service is adequately resourced and meeting the required national quality standards.” This reads very like a denial of responsibility. The second half of this excuse “meeting the required national quality standards” returns us to the important point that targets make organisations witless. “This is not an abstract point: targets can kill.”

But the issues this awful experience raises move beyond whether the service is suitably resourced and whether it is being properly delivered and overseen.  The real issue is why the service was outsourced in the first place, and an important factor here is the role of cost-cutting. Cost cutting is driven from the very top of the management hierarchy: in this case, the Secretary of State for Health, Andrew Lansley MP.