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Optimism

There is at last some cause for cautious optimism about the NHS, with the belated political recognition that the service is badly underfunded. Significant extra money promised gives the opportunity for major improvement but it is essential that it is used effectively for patient care and not wasted in bureaucratic procedures as it was under the previous Government's "reforms". Otherwise the pressure to look at insurance based systems will again gather force.

NHSCA believed that a market orientated approach to health care was a serious mistake and campaigned against it from the start. Once imposed, although remaining in name a National Health Service, the whole ethos changed. We worked to mitigate the damaging effects on patient care and to promote the essential elements of planning, equality of access and cooperation rather than destructive competition. It is difficult to do this as isolated individuals – the Association provides organisation and support.

Despite some improvements there is still a long way to go in restoring the concept of public service and much to be done in reordering priorities and ensuring full removal of the market – including the key element of the purchaser/provider split.

Our initial reaction to the National Plan(England) is broadly favourable to the central themes, particularly the intention to correct the gross understaffing and we support proposed changes to the consultant contract which recognise the importance of wholetime commitment to the NHS. Areas of serious concern include continued reliance on the Private Finance Initiative and although we would support the use of spare capacity in the private sector as a necessary short term measure whilst the NHS is being expanded, we believe that a long term Concordat is quite a different matter whose implications have not been thought through.

The Executive Committee meets leading politicians, in Government and in Opposition. Although we remain a UK wide organisation, devolution is producing important variations in policy and leading members in Scotland and in Wales have their own meetings with national politicians and others. All members are encouraged to take part in formulating our policy and strategy.

The Consultants Contract

There have been some enquiries, from members and others, about NHSCA’s position on the contract which the BMA has negotiated and which will be going out to ballot, probably in late September.

Historically the Association has avoided getting involved in the details of Terms and Conditions of Service, our position as a pro-NHS pressure group, deliberately not attempting to be a negotiating body for doctors, being seen as a strength in our aim of looking at the needs of the service as a whole.

We have however consistently made one point, that any contractual arrangements should recognise the value of wholetime commitment to the NHS by ensuring that it is a viable and attractive option for all consultants.

For this reason we argued against the changes of 1980, which reduced the wholetime differential from 2/11 to 1/11.

When it became apparent in 1997 that BMA negotiators were intent on removing the remaining 1/11, we expressed our opposition to both the CCSC and the Secretary of State.

This of course considerably predated the Government’s NHS Plan in 2000 and statements from the CCSC in that year confirmed that unsuccessful attempts had been going on for three years to engage the government in discussion on abolition of the 10% rule and other matters.

Towards the end of 2000 the CCSC invited us to comment on their own contract proposals which at that stage were only being distributed to CCSC members and those of other BMA committees.

After discussion in the Executive Committee we responded as follows:
“NHSCA is in agreement that the current “wholetime plus 10%” contract is unsatisfactory and should go. We opposed its establishment in 1980 because it removed the option of a truly wholetime NHS contract and marginalized the concept of working exclusively for the NHS."

In assessing proposals for new contractual arrangements there are a number of principles which should be applied.

1. "A genuinely wholetime (i.e. exclusively NHS) career should be a viable and attractive option. It is wrong to assume that all consultants have come into medicine with the intention of working in the private sector, many would prefer not to do so. Recruitment to those specialties where there is little or no opportunity for private work is also an important consideration."
2. A wholetime contract of this type should be the standard in determining consultant pay and the norm against which contractual variations might be negotiated by individuals.
3. It is illogical to claim, with justification, that all consultants are working excess hours for the NHS whilst demanding the right to do further unlimited work in the private sector.
4. The workload should not exceed a level compatible with patient safety and a reasonable existence for the consultant. It must be calculated as the sum of NHS and any private commitment. This principle will become even more essential with the closer linkage of the two envisaged in the Concordat.
5. Those wishing to work in the private sector should therefore be contracted for a reduced NHS commitment pro rata.
6. We do not share the outrage expressed in some quarters about the proposal that consultants should work exclusively for the NHS in their early years. With appropriate financial compensation ( offered in the National Plan but not apparently explored by BMA negotiators) this could be to the advantage of many young consultants and should be investigated.
7. Whilst this clause in the Plan may be subject to negotiation, the NHSCA position is that the option of an exclusively NHS contract, suitably remunerated, must be available for all consultants throughout their career.

In summary we support the proposals as a basis for further negotiation, provided that the principles above are incorporated into later versions.”

A draft version of this response was published in our Newsletter of December 2000, together with information on how to access the CCSC document on the Internet and make an individual response to both CCSC and our Association.

Much has happened since then and what is now on the table involves new concepts, whilst deleting some of the old bones of contention.

As we go to press it is not clear precisely when the ballot will be held, what questions will be asked or perhaps most important of all, what would be the effect of a rejection, continuing with the status quo or a further round of negotiations.

Our recommendation is that when the answers to the above are known, each member considers how far the new contract goes in meeting NHSCA principles and whether the interests of the NHS would be best served by accepting it or not.

Below our Chairman gives his own judgement following the Executive Committee discussion on 21st August.

From The Chairman

Debate continues to rage about the proposals for a new consultant contract. Some parts of the proposals for the new contract match the Association’s policy. Although there is no specific differential for those consultants who choose to work entirely for the NHS, the structure of the contract does reward those who do so. The need to declare the extent of private practice and the obligation to offer a full working week to the NHS do provide greater clarity for doctors, managers, politicians and the general public.

There are, of course, many justifiable concerns about the proposals and I find it difficult to match job planning and sessional allocation to the wide range of different working practices of different specialties. The greatest resistance to the proposals appears to come from those consultants in specialties and parts of the country where a significant private practice income is possible. However, I think concerns run deeper than this. A colleague of mine, not a member of the Association, recently said that his main objection was that “they were trying to turn us into employees”. I have never felt uncomfortable with the idea of being an employee, and will bore colleagues by reminding them that our training, in part, was paid for by the tax payer, our salaries are paid by the tax payer and that the tax payer, therefore, through an elected government, has a right to influence how we work.

I heard on the radio recently a philosopher and author describing the condition of “status anxiety”. This is when we perceive that we are being treated below the level our status dictates and that moves are afoot to lower that status. I can understand why some consultants might perceive the new contract as a threat to their status but, personally, it does seem to me a reasonable trade-off between our rights as professionals and our obligations as public servants.

I hope that the ballot will not simply ask for a “yes” or “no” vote, but will seek opinions on the different elements of the contract so that the door is left open for further negotiation. If the vote is for all or nothing, I will probably be voting “yes”, because I feel that the overall package is an improvement on the current contract and there will inevitably be opportunities for re-negotiation of some elements in the future when the very real practical difficulties of implementation are encountered. I do not feel that the Association should have a policy on how members should vote, but would like to think that they will consider the benefits of the proposals to the NHS as well as self-interest.

Guy Routh

Concordat

The agreement signed between the Government and the Independent Healthcare Association may have great significance for the future of the NHS.

So far most commentators, including Government spokespeople, have failed to make the all important distinction between the short and longer term.

Despite the very welcome recognition that the service has been seriously underfunded and therefore chronically short of both facilities and staff and the pledge of additional funds to correct these deficiencies it is obvious that there will be a gap of some years before building can be completed and staff trained. In these circumstances, if spare capacity in the private and voluntary sectors can be leased it would be perverse not to use it in the short term until the deficiencies in the NHS have been made good.

It does appear however that what is envisaged is not a short term pragmatic measure of this type but a long term agreement whose conesquences do not appear to have been thought through.

We have sought assurances that this concordat will not prejudice the necessary development of the NHS but have not received them.

Detail available is scanty but it would appear that much will be left to the discretion of individual Trusts.

The best information we have so far been able to elicit is 4 pages entitled "For the benefit of patients" and available on the DOH website at:
http://www.doh.gov.uk/commissioning/guidance.htm

It focuses initially on three categories, elective care, critical care and intermediate care.

The section on Elective Care reads:

2.6 There is a wide range of options available to local health communities for working together to deliver elective care. This concordat is not intended to negate arrangements designed to meet local needs. However, the following examples are offered as a guide to involvement.

• Primary Care Group or Primary Care Trust commissioning or renting accomodation from the private and voluntary health care sector with the service delivered by NHS consultants and other NHS staff under their NHS contracts.
• An NHS Trust "sub-contracting" the provision of a service to the private and voluntary health care provider. In this case the NHS Trust would be fulfilling its obligation under a service agreement with the Primary Care Group(PCG) or Primary Care Trust(PCT) but would meet the cost of the "sub-contracted" service from the resources received from the PCG/PCT.
• Primary Care Groups or Primary Care Trusts commissioning directly from a private and voluntary health care provider.

2.7 This is not an exhaustive list and local health communities can explore ideas for attractive partnership working relevant to their local circumstances, as long as they can demonstrate high standards and value for money.

The first option makes clear that NHS staff would be working under their NHS contracts and is therefore the least controversial but it does not address the question of who would carry out the after care.

The second and third options make no reference to NHS contracts and the assumption must be that as far as the staff are concerned this would be private work. The question then arises of who would pay the medical fees. As by definition the patients are being treated under the NHS it would not be them or their insurers, so presumably it would come from the budget of the Trust in the first instance or that of the PCG/PCT in the second.

As so much is apparently being left to local discretion it is going to be difficult to get an overall picture of what is happening and we are therefore asking NHSCA members to let us know of any such arrangements that are being negotiated in their locality.

NHSCA Submission to the Commission
on Representing the Public Interest in the Health Service

Accountability in the NHS

The accountability of the NHS to the general public has never been very effective at any level below the ultimate one of Parliament. Now that so much emphasis is being put on devolving decision making to local level it is appropriate to address the problem of local accountability.

Prior to 1974 the Hospital Management Committees – at least outside the conurbations – had lay members chosen with some reference to the local geography ensuring that there was someone to speak for each significant centre of population.

This was not reflected in the same way in the make up of the subsequent Area and District Health Authorities although they did contain an element of elected responsibility through their Local Authority members. These had of course been directly elected to their Councils which then appointed them to the HAs by some reasonably democratic process.

They were however swept away by the 1990 Act, with Health Authorities returning to a purely appointed membership of Executive and non Executive Directors and a similar system for the independent Trusts. In recent years there have been attempts to improve the system of non-Executives by inviting applications from a wider range of people and by a more open system of appointment based on Nolan principles. Despite this and despite genuine attempts in many areas to inform and consult the public the element of accountability is still largely absent.

During the "market" era, with the emphasis on competition, the Authority and Board members lay as well as professional were styled "Director" and non Executives were sought and appointed who could bring business related skills. Inevitably this led to them being selected largely from one section of the population and their role was primarily to run the organisation rather than to be representatives of the public. With no constituency to report to it would have been difficult for them to do the latter in any effective way.

With the demise of the market and the return of planning and cooperative working it is time to reassess the role of the lay member and to consider whether the emphasis should change from that of Director to Public Representative. Do we really want the lay members to act like professional managers or should their role be to monitor the work of the professionals and act as a channel for the views of the public?

With all its shortcomings, Local Government does offer a useful model in that there any member of the public does have at least one Councillor to whom they relate and who has a particular responsibility for them, as well as playing a part in the general business of the Council. That person can be asked to elicit information, speak about a particular problem and if necessary raise it in public session.

Something of a similar nature is needed for Health. The big question is whether such members should be appointed or elected. If the former there would need to be some form of constituency, geographical or otherwise. The latter is simpler, more democratic and gives better accountability. It is perhaps open to the criticism that it could become too politicised in Party terms. There are ways of avoiding that but it might be a very appropriate case for pilot studies of different systems in different areas.

The interest, understanding and involvement of the public are not enhanced by a system where responsibility is not clear. Where it is divided it is too easy for people to become bewildered and frustrated, with organisations "passing the buck" and blaming each other.

The continued separation of purchaser from provider is the fundamental problem. If a hospital does not meet the expectations of its local population how can they assess where to begin?

How much simpler, cheaper and better to have one properly representative and democratically accountable body whose responsibility it is to assess the health needs of its population (in the manner envisaged in the Health Improvement Programme) but then to provide the means to meet them, being ultimately responsible for all the staff and facilities.

With such a system in place, the formal lines of accountability would be established and clear.

On this firm basis other advisory roles for the public could be established. For instance it would not preclude lay membership of bodies responsible for local planning like Primary Care Groups but it would remove from a single individual the impossible burden of being the only channel of accountability as would be the case with current arrangements for PCGs.

Similarly, Community Health Councils would continue to have an important role in patient advocacy and statutory consultation as well as bringing together a wide range of patient support organisations and special interest groups. In order to carry this out effectively they will need enhanced funding and access to specialist advice.

In the longer term the development of democratically accountable authorities, as described above, will lead to a redefinition of the functions of CHCs.

Further Comments following the Interim Report of the Commission

With regard to the problem of the "democratic deficit", we note the preference for election rather than appointment but at this stage no definite decision between reconstituted Health Authorities or Health being part of local government.

We would support the principle of election but would favour retention of separate Health Authorities, where Health would not have to compete with the many other responsibilities of local government and it would be less likely to become polarised on party political lines. Close cooperation between health and local government bodies would of course be necessary.

The question of interest and low turn out at elections has been raised. This should not be seen as a problem. In a typical Health Authority area with perhaps 250,000 people on the electoral register, even a 10% turn out would result in the members having been chosen by 25,000 more people than at present. Those who did not express an opinion would at least have had the opportunity to do so.

We agree that PCGs/PCTs as currently envisaged present a difficulty.

If there is to be democratic accountability with the present structure, it would have to apply not only to the Health Authority which even with its reduced role is to be the prime mover in the Health Improvement Programme but also at the PCG/PCT, where the budgetary power will lie and at the Hospital Trust. This would be absurdly complex, costly and time consuming with the different bodies of elected members in likely conflict over many issues.

We would refer again to the proposal in our original submission, that the whole problem could be solved by removing the purchaser/provider split and making the District Health Authority the democratically accountable body with overall responsibility for all health services in its area.

Although a body of consultants most, but not all, of whom are hospital based we are not opposed to a greater influence for Primary Care in the planning of secondary provision and welcome discussion with our Primary Care colleagues on the local pattern of hospital services. This is not dependent on a budgetary role for PCGs and is indeed more likely to progress with a cooperative approach rather than the adversarial situation which might well develop with a purchaser/provider relationship.

This scenario would also solve the question of the most appropriate area of influence for the CHC, whose relationship would properly be with the democratically accountable body, the Health Authority.

The thesis was developed in our response to the Government White Paper, "The New NHS" a copy of which is enclosed.

NHS Consultants' Association
September 1999

Response to the Consultation
on the Findings of the National Beds Inquiry

NHSCA welcomed the setting up of this Inquiry and is pleased, but not surprised, by the principal conclusion that recent trends in bed reduction are no longer sustainable and that under any scenario more beds are needed in the system.

Considerable attention is paid to the setting up of an intermediate form of care, designed around the needs of older people, to act as a bridge between home and hospital.

Comment is made that 2/3 of hospital beds are occupied by patients over the age of 65, many suffering from chronic diseases who need proactive and ongoing care as well as reactive and episodic treatment.

Concentration on the latter was one of the fallacies of the market system and it is encouraging to see recognition now being given to the importance of what cannot be as readily counted or costed.

None of this of course is new, the techniques referred to have been standard practice in departments of geriatric medicine for decades. In order to achieve full potential however issues of staffing and complementary primary care and community services have to be addressed and ways found of ensuring the same approach in other hospital specialties which care for older patients.

There are many areas of health service provision needing attention, none of which can we afford to neglect but the key to future bed requirements is clearly how we respond not only to the increasing number of elderly people but to the increasing proportion of them living alone.

It is essential therefore to examine particularly the issues raised in Scenario 3.

1. There is reference to a possible reduction in acute overnight beds after 2004 provided there are adequate community alternatives.
   
   The service requirements between now and at least 2004 must first be addressed. There would need to be a moratorium on further bed reductions and an urgent reappraisal of bed numbers in all new hospitals being built or in the planning stage, whatever their method of financing.
   
   
2. Best practice already established in the care and rehabilitation of older patients should be identified and introduced in all hospitals and all specialties dealing with these patients. This means multidisciplinary assessment with active rehabilitation and discharge planning from the time of admission. It needs adequate staffing levels in the health professions, and in social work support both inside and outside the hospital.
   
   
3. Ways can be explored of providing in the community both rehabilitation and those forms of medical treatment not requiring the facilities of an acute hospital. There are however well founded concerns that such schemes of intermediate care, whether in the patients home, community hospital or residential home, could lack the necessary numbers and skill levels of rehabilitation staff to achieve results.
   
   They will also need to be designed with characteristics of the community in mind. The non medical determinants of health such as poverty and housing conditions will be very relevant to the success or otherwise of intermediate care.
   
   There are undoubted economies of scale in grouping together patients with similar needs, as occurs in hospital. The possible increased cost of providing a similar level of service in the community has to be acknowledged.
   
   
4. There are major staffing implications of scenario three. The one that will take longest to solve, in view of the length of training, is the increase in general practitioners. The number of therapists will need to be increased to take into account the greater time expended in travelling and in treating patients in smaller groups. Similar considerations apply to nursing, both in overall numbers and their distribution. Until nurse recruitment and retention are in a much more healthy state, particular care will need to be taken to ensure that hospital posts do not become less attractive than those in the community.
   
   
5. It is postulated that with better community provision fewer elderly patients would need to be admitted to hospital. This is certainly both possible and desirable as long as it does not prejudice the right of elderly people to hospital treatment when it would be of benefit to them. It will only take place if community support can be provided as soon as required, including the middle of the night and at weekends. The needs will arise on any day of the week and will take no account of public holidays. At a time when Social Service departments are struggling with underfunding and having to make cutbacks in domiciliary support, it will not be easy to achieve. There is also an issue of the increasing charges being levied for this service.
   
   
6. If successful, the effect on the hospital service will be fewer emergency admissions of elderly people, but those who are admitted will tend to be more seriously ill and require a longer stay.
   
   As hitherto success in coping with a heavy work load has been judged as more admissions but shorter stays, there is a danger that crude statistics and a "league table" approach could give a false message.
   
   
7. Many of the projections relating to the development of intermediate care are theoretical and involve changes which have not yet been fully evaluated in practice. Pilot schemes are essential before widespread introduction.
   
   
8. The question of long term care and the Government's still awaited response to the Royal Commission is very relevant to the whole proposal.
   
   
9. The additional health spending announced in the Budget gives a real opportunity to make successful changes but the effect of developing intermediate care would take some time to work through. The first imperative is to ensure that the emergency and acute services are able to cope in the next few years, without wasteful disruption of planned work and without subjecting patients to less than optimal treatment in inappropriate wards.

It may well in the future be possible to move some funds from hospital to community services but this could only be after the latter have been demonstrated to be successful, using bridging finance for their development.

In summary, NHSCA favours exploring the course proposed in Scenario 3, but with the provisos outlined above.

8th May 2000

NHSCA has just published a 50-page report on the use of the Private Finance Initiative in the NHS, of which the following is the conclusion:

Conclusion

Of course it is true that the NHS needs investment. And it is true that many of the brightest sparks in design, project control and management work in the private sector. And it is true that, in the right circumstances, competition can promote efficiency and innovation. And it is true that with any large contract close attention needs to be paid to the system of penalties and incentives. But none of this demands, or justifies, the Private Finance Initiative.

The PFI was not drawn up by common-sense pragmatists interested in a non-ideological way in getting the best possible 'partnership' between public services and for-profit corporations. On the contrary, the PFI was designed as a stand-in for privatisation, given the unpopularity of any proposal to directly sell off the supply of health care services. It was a highly complicated scheme to smuggle in the profit motive where – due to decades of neglect – the NHS was at its weakest. And this Heath Robinson Trojan Horse was initially unimpressive, not least to the private sector: during 1996 and 1997 the Initiative appeared still-born. It required three pieces of legislation and the return of New Labour to acquire its present health.

And why not the PFI? Because there are good reasons for the NHS to remain a public service, publicly funded and publicly owned. Those characteristics express our recognition of our common humanity and allow us to hold the decision-makers to account. The NHS needs to be more accountable (not less) and more focused (not less) on the needs of its clients rather than the demands of its vested interests.

The present Government has abandoned the explicit model of an 'internal market' which assumed that health care goals could be maximised through competition. The new NHS structures are based on ideas of 'partnership'. So far as it goes, this is an eminently sensible development: it allows information to be shared, risks to be pooled, projects to be planned, patients to receive the treatment most appropriate to them. But this shift from competition to partnership – the cornerstone of Labour's health policy – is severely compromised by the PFI which underlines and underpins the separation of interests between one Trust and its neighbours.

These are still very early days for the thirty-year contracts. It will of course be fascinating to see what actually happens. But we can expect that both nationally and locally the PFI consortia will become major players in NHS management and policy. The more they are embedded, the more their confidence and influence will grow. They will become another vested interest rooted in political compromise – like the pharmaceutical companies which drive up prescribing costs and the private medical sector which draws staff away from the NHS. They will become a new for-profit force within health care politics with its own ambitions, its own vision as to how health care could be reshaped, its own imaginative schemes for maximising the return to its shareholders. Locally, the consortia will take a close interest in the clinical and financial management of their hospitals. Nationally, they will push for the goal-posts to be moved even further in their favour including, political circumstances being favourable, through the privatisation of clinical services. How many of our leading politicians – outside Scotland, anyway – can we trust to stand up to the consortia over the next thirty years? Once it became the accepted wisdom that it was in Labour's interest to embrace the PFI in health care, the silence has been deafening – and interrupted only by cooing sounds.

The Private Finance Initiative has cost and will cost the NHS dear. Huge expenses have been incurred – directly and indirectly – due to the processes which NHS Trusts have been forced to go through, often fruitlessly. The tests of Affordability and Value For Money are bogus or, at best, ineffective, failing to prevent consortia being bailed out with subsidies from the public purse. The new hospitals are far smaller than the old, creating additional demands for primary care services, and they are far more expensive, leaving the Trusts with less to pay for nurses, doctors and other clinical staff. Above all, the PFI developments must be paid for out of the Health Service revenue budget, not out of capital allocations funded by public debt. Politicians boast of additional revenue for the NHS but do not stress that a large chunk of that must now go on capital costs which used to be funded separately. Without significant new increases in funding, the NHS will end up handing over a larger and larger proportion of its income to the consortia. Even Norman Lamont, who brought in the PFI, acknowledges the risk of a "silting up of public expenditure with a stream of never-ending rental payments".

NHS Confederation:

"We do not want to have demoralised, demotivated staff who are unhappy to work for usthe PFI processis at best a hindrance to the way we plan our capital developments. PFI is slow, it is bureaucratic, it requires us to put up a vast amount of management time and consultancy fees at risk without the certainty of success. The schemes are notnecessarily better value for moneyor, they achieve that by reducing the terms of working conditions of the staff involved. There is an element of profit in PFI, which is necessarily taken by the private sector to motivate them to go into it in the first place, which results in an element of bad value for the NHSAt ground level [PFI] is a very damaging development in terms of staff morale and inter-disciplinary working."

Like a park, an NHS hospital is a public space, a public asset and a public service. We can use it not because we are rich, or poor, but because we are citizens. It says we all get ill, we are all mortal and in the eyes of God (even if there isn't one) we are all equal. When things go wrong, there are people to blame. If we want to spend more money on it, or less, we elect politicians to that effect. The staff work for us and their managers bear cost in mind, but other things too.

In future, the hospital will be owned by Something plc (and later, no doubt, Something International inc). The staff will wear their uniforms and uniformly smile and wish you a nice day. But the bottom line will the only one that counts. The responsibility for failures and corner-cutting will be lost in the usual morass of who-pays-who-for-what (with lawyers, like flies, to sort it out). And there will - for thirty-odd years - be nothing you can do about it.

Despite the massive cuts in beds, the high costs and the threats to quality, equity, accountability and public service values, PFI projects are supported by many people whose intelligence, awareness and commitment to the NHS is beyond question. But for all their virtues, they are closing down hospitals and passing assets and control over to another set of men and women who have not necessarily demonstrated any interest in health care, let alone any enthusiasm for the guiding principles of the NHS. Apart from their own personal ambitions, the driving motivation of these people is to maximise the profits of the companies for which they work.

And all other considerations can go hang.

Details of the full report entitled 'Private finance in health care: why not' can be found under 'Publications'.