Wednesday, 21 March 2012

What did Labour gain with #dropthebill?

Time will tell on this one, but I'm concerned that Labour may not realise how much they may have shot themselves in the foot over the NHS reforms, or...even they let political opportunism trump ensuring that the country avoids the dangers that they predicted.

The background is simple, Labour started the ball rolling on privatisation and, in a purely financial way, competition in the NHS. It's been taken further and moulded in to a slightly different shape, but the core is still there. Unfortunately there are also ambiguities, unclear definitions and concerning aspects to the reforms.

Labour chose to outright oppose the bill, opting to try and inflict the ultimate humiliation of forcing a government to drop a flagship piece of law after almost a year's worth of time and effort going in to it. The gains for Labour on this would have been considerable if they'd have achieved it, but as it happens they've managed to only achieve modest gains and failed in their goal of finishing the bill.

Of course that assumes that they ever thought that they would get the bill dropped anyway. And this is why I wonder about the direction that they've taken. If Labour knew that they wouldn't get this bill dropped, and that they would be playing on stirring up hatred of the Tories for "destroying" the NHS, do they also realise this is fraught with public opinion related danger?

This option that they have taken has short term gains, this is undeniable, and unfortunately some people will be misinformed enough (and partisan enough) to believe a lot of what Labour have said long after it has been disproved. In the long term though it relies on the NHS actually falling apart. If, by the next election, waiting times haven't sky rocketed, and patients up and down the country aren't complaining about not being able to see their GP because of all the bus loads of private patients taking all the timeslots, then people will in general see through what Labour have tried to do here.

In the long term, this scenario surely only leads to distrust of Labour, and a cautious sheepishness over believing them compared to those "evil" coalition government members who said that it wouldn't be like that?

But what about the other course they could have taken, constructive engagement? By working with the Lib Dems as they woke up to the dangers of this bill early on, time spent in the house of commons simply trading soundbites for the media, petulantly opposing each other's view points, all three parties could have come to the table and come up with a bill that is not far from what we have now, but with all the ambiguous and potentially bad parts completely removed or cleared up.

As a party they would be able to say, as now Lib Dems will be trying to, that they took a bad bill, put aside political differences, and worked in the interest of the people to make the reforms in the interest of patients, not profits. In the short term it may not have reaped any benefits, but showcasing that they are ready to govern, and that they are growing up out of this idiotic "oppose everything" stage that they're going through, would almost certainly gain them support in the long run.

Instead the coalition had little choice, given the campaign against them, but to spend their effort justifying what was there and getting it to the finish line. Time that they might have otherwise spent engaging was instead spent putting up defences, useless to the enhancement of the bill itself, ensuring that all three parties have ended up neglecting all of us in pursuit of scoring some bloody noses.

If the NHS stays standing, and doesn't seriously decline in standards (which unfortunately may be expected due to reduction of funding that any of the three parties would have opted for), will people still believe the soundbites, or the reality?

Tuesday, 20 March 2012

11 facts about the NHS going forward

1. The NHS is still free at the point of use (as much as it ever was)

With regard to what will be charged for under the NHS, nothing has changed. The same provision for allowing charges to be made existed in previous NHS law, and while responsibilities for deciding what services are required or not have changed hands, the same level of ability for someone to determine that a service isn't needed was in place in previous law.

This could lead to certain areas having services dropped, but to counter this the law states that there is a need for equality in patient care across the country, and it would be interesting to see a healthcare providing body argue how it is meeting it's duty to reduce patient inequality by giving their constituent patient less services than someone next door.

2. Secretary of State for Health: Once secretly delegated, then removed, now transparent responsibility

One major claim that is still repeated, despite the amendments being made and touted over a week ago, is that the Secretary of State for Health (Andrew Lansley) would no longer be the person whose house we turn up outside with pitchforks when sufficiently unhappy with the NHS.

Well cry no more, pitchfork wielders, as once again the Minister is ultimately responsible for provision of the health service for England. Sensibly he now shares the administrative responsibility in a transparent manner with a Board, but the buck stops with with Mr Lansley and his successors.

3. Privatisation: Started by Labour, continued by Tories, regulated by Lib Dems

Remember this, Labour started privatisation. Allowing companies to receive money to carry out certain services in the NHS, regardless of performance or efficiency, it was ushered in gladly by an overly-popular Labour party. When this new NHS bill started it simply took it one step further and made it easier, encouraging those in charge, perhaps even legally mandating them.

Thankfully, despite the bluster about the Lib Dems "allowing" privatisation to happen, they have instead helped to secure that where privatisation does happen within the NHS, that it is measured on the core principles set out (see fact 4) and that any process for gifting public money to businesses does not lead us down the anti-competitive route that is based on profits for the business ahead of results for the patients (see fact 5).

It's a case of the ball being set rolling by Labour, kicked harder by the Tories, and then brought back under control thanks to the Lib Dems.

4. More scrutiny, more accountability

an NHS constitution was introduced at the end of Labour's time in office, a set of principles that perhaps could change that various bodies in the NHS were required to pay mind to when making their decisions. But not the Health Secretary.

This, along with quite a few other improvements as to the transparency as to the management of the NHS, has now been rectified. Whereas the National Health Service act of 2006 was light on details about what the Health Secretary's duty actually entailed, and the first draft Conservative bill did even worse...the bill now likely to be made in to law makes the path of accountability clear, and sets in law the factors that such accountability will be measured on.

The Secretary of State for Health will retain over all responsibility for provision of the NHS to England, but will essentially delegate a lot of his responsibilities to a new Commissioning Board who will administer the money for the health service, and the bodies that will be deciding which services should be contracted in or paid for at your local level.

And when making their decisions they must ensure that the NHS is:

Continuously improving safety, effectiveness and quality of the NHS
Providing equal care to different patients, wherever they are in England
Securing autonomy for those providing care (where it doesn't detriment the above)
Improving research, training and education

5. Quality of care first, profits second

Privatisation may be given a certain kind of "thumbs up", but it is a very new approach that doesn't simply hand money to big business and say "See how much profit you can make". The reality is that the law lists very clearly that results are based on the quality of the service being provided. How do patients feel they were cared for, how efficient was their care, and how *good* was their care? These are the questions that every level of the new NHS structure have to answer, and if the answer is not "at least as good as the last patient" then they have legally stepped in to the realm of bodies and individuals failing in their duty.

It's a brave new world, and one that only came about fully after amendments made halfway through the bill's life, after the "pause" to consult properly with healthcare professionals. This is privatisation, in theory, working for the public sector, not the public sector throwing out money for private companies.

Even Monitor, described by some as a body to promote competition as if that is a way of forcing contracts on to private companies, has more to consider in it's day to day life about the way it's purposes affect the equality and quality of patient care than keeping things cheap.

6. Commissioning Groups (CCGs) are Primary Care Trusts (PCTs)

This isn't a major change that is going to redefine the logistics of our NHS. The way money has been funneled, and the way decisions have been made, will not change. What will change is the geography of how these organisations cover the UK, and a likelihood of there being more CCGs than there were PCTs.

With this there is no more responsibility delegated to these groups than was for the PCTs, and there are more checks and balances to ensure that required legals standards are being achieved.

7. No patient left behind

Along with the new groups is a legal requirement, as you would expect, for everyone to be able to healthcare with the NHS. Whether registered with a provider that makes up the CCG in their area or not, that CCG has a duty to provide healthcare for them. Tied with the enhanced accountability in this bill, there is no legal opportunity for that person to recieve any different treatment because of how remote they may be, or poor, or any other factor.

8. Healthcare could be denied to individuals or groups

The law does set out the option for people to be omitted from the population that CCGs have a responsibility to provide care to. In theory this should just be those who are just over the national borders, however it opens the door to...for example...let recently settled immigrants be excluded from the NHS, or perhaps those waiting deportation, or who knows.

The "safety" is that those people would need to be excluded via secondary legislation, a particularly easy way of pushing rules and regulations through parliament since MPs tend not to turn up. For now, unfortunately, we will have to keep an eagle eye on the Statutory Instruments that may arise on this subject, and thankfully a need for both MPs and Lords to vote in favour of such changes we have every opportunity to attempt to lobby politicians to not let any abuses of civil rights happen.

All said, this is still far from ideal and a much more well thought out set of justifiable exemptions should have been included in this bill without secondary legislative power to amend them.

9. Larger "postcode lottery" effect

The reality is that as few as two primary care providers (traditionally GPs, though Labour opened this up to include other organisations) can create a CCG. The prospect for having very "elite" areas fence themselves off and reap both the benefits of an enhanced private funding stream as well as a good baseline for performance through local residents that are less pre-disposed to illness or injury, is a very real one. Even though people could sign up for services with a GP or provider outside of their area of residence, the CCGs are not, as far as I'm aware, obliged to take them on.

On the flip-side there will be CCGs that have to exist in a geographic location that will content with higher levels of poverty, more difficult logistical considerations, and the prospects for these CCGs to benefit from any performance relate bonus, or to even keep their head above water, financially, is a real risk. It's also a risk that could mean these more vulnerable people are provided with fewer services, however this would seem in contention with the greater scrutiny and standards that this bill sets out.

It will be all too easy for the well off to fence themselves off, and not "share" their facilities...the hope would be here that the Commissioning Board would see their duty to maintain an equality of outcomes, nationally, for patient care and use their powers to amend and/or merge CCGs to ensure that patient care is not compromised.

10. Definition of who provides each service is poorly defined

It is my opinion that the spirit of the law is that the Secretary of State needs to ensure national level services are in place for dealing with issues of national importance, especially the potential of outbreak of disease or outcome of catastrophic events. CCGs would be responsible for ongoing care and emergencies, while Local Authorities would work alongside CCGs to provide regional based healthcare, more focused on education, but also including keeping the local area healthy through health services.

It all overlaps a little bit too much, while CCGs have set areas, they don't need to cater for people such as tourists, workers on the road (perhaps visiting a client in another part of the country), or visiting family members. In theory I can see that this would need to result in local authorities and CCGs working in partnership to provide services, with transient populations relying on the local authority's provision, but the reality is far from being as clear as it should be for a top-down re-organisation such as this.

11. The NHS will not now collapse/disappear/explode/be destroyed because of this bill

The way in which the NHS functions, the people that are involved, the NHS will seem almost to be the same after this bill becomes law as it was before the last election. Some may even see improvement if providers in their area are set up to exploit these changes. That doesn't mean that the service the NHS provides won't decline, and that problems won't happen.

This, however, will not be due to the bill..instead it will be down to the lack of funding that any of the three parties are willing to give the NHS to continue improvements. With tighter budgets all round the NHS is going to struggle until the next election and beyond to provide the same level of service, or better, for less money and resources.

This bill hasn't changed this reality, and abandoning the bill completely wouldn't change it either.

If this leads to a level of inequality in the NHS, the reason some critics are claiming that this is the end of the NATIONAL health service and instead the start of the break up in to many regional health services (as if this wasn't somewhat the case already, where different PCTs have provided different services to their neighbours for some time), then it will be a failure of adherence to the law, since the underlying principle of equality of care for all patients means that allowing areas of the country to fall in to poor quality, inefficient or unsafe healthcare would be a breach of at least one, if not more, group of people's legal duty to the people of this country.

Thursday, 15 March 2012

NHS Bill, a revisit: Part 1

In September I looked at the NHS reform bill and decided that, on balance it wasn't a bad situation, as long as some concerns were dealt with...specifically on issues of regionality of commissioning bodies, how competition balances with patient care, and giving watchdog bodies more "teeth".

Since then the government has done it's best to portray this bill in it's worst light, not really answering criticisms, deflecting (quite accurately) on Labour's own history of privatising the NHS, and taking quite bizarre actions that make ordinary people question the government's motives, the main case in point being the refusal to publish a document of the risks involved in the reforms being proposed.

Combine this complete lack of political ability with professional bodies themselves, GP's and doctor's representative groups, calling for the bill to be completely scrapped and my view...previously ambivalent, has turned distinctly negative to the bill.

But does that mean the bill itself is actually as bad as Labour are claiming? Will it actually destroy the NHS, leaving nothing like it in it's wake? Will it mean higher waiting times for the poor as the rich get preference? Will it mean universal healthcare only for those with enough funds or insurance?

Let's see... Warning, this is long.

For a start the bill now explicitly says, for the first time since these reforms started, that the minister in charge of healthcare in this country retains responsibility for the provision of services. This keeps the largely symbolic link of democratic representation in place, the idea that we can demand the government do more on the health service because it is that member of the cabinet who needs to ensure provisions are adequate.

Furthermore there is an explicit legal requirement for the NHS to remain free at the point of delivery, with exceptions. These exceptions are detailed elsewhere (namely dentistry, etc), and is kept open ended for pragmatic reasons. This is exactly the same as it was in the last law, the NHS 2006 act.

So, the government is still responsible to provide a national health service, the buck stops with the Minister for Health. Furthermore, the idea of the NHS suddenly getting more expensive to use as a patient is no more a threat than it was in the past. No-one has made it so that suddenly private companies, or the NHS bodies themselves, can start charging you for your cancer treatment.

So far, so 2006.

Added to the above we have newly defined responsibilities, an added layer of transparency as yet unseen in setting out what the Secretary of State for health should be ensuring.

The most interesting is a new legal responsibility for the Minister, not only to provide for the NHS to run, but also to ensure it improves. OK, it is "woolly" meaningless language, but the intent is clear...the Minister for Health needs to show that he is making decisions that are for the betterment of the NHS. Specifically he needs to make the NHS safer, more effective and of better quality, and the outcomes of those three areas must be measurable.

Does this mean that if the NHS performs inadequately on such issues that legal action could be taken against the Minister and their department? Absolutely! Of course the threshold for proving that proper care hasn't been taken to try to achieve improvements would be very high, but the principle is there.

Then we also have:

  • Adding the Secretary of State for health to the list of people that need to respect the NHS constitution.

  • It will be enshrined that, aside from situations where autonomy detriments the achievement of improved safety, quality or success of the NHS, people providing healthcare must be allowed to do it their way.

  • Research must be provided for, so we must assume the Minister has to make sure it's funded.

  • The buck now legally stops with the Secretary of State for health when it comes to training and educating NHS staff. If people aren't doing their job properly because they haven't had the right guidance, it's the health department that needs to explain why.

  • Finally, the Minister must also make sure no organisation is at a disadvantage when applying to provide supplies to the NHS. Particularly specific this one, and seems to surrounding the issue of VAT for supplying the NHS.

Along with the Minister for Health, there will also be a Commissioning Board set up. They will also share many of the responsibilities above, perhaps sensible when considering the amount of time that a Minister will realistically be spending on a multitude of governmental and parliamentary duties. The board don't share total responsibility on issues such as health emergencies, and local health promotion.

And then there is also, of course, the creation of the "Clinical Commissioning Groups" that will be responsible for "arranging for the provision of services". More on that later...

Local councils also retain a level of responsibility for promoting and funding health beneficial services, as well as providing facilities for healthcare.

So, to recap, centralised responsibility by an elected member of parliament to provide the NHS, free of charge, with specific duties properly and transparently defined for the first time, along with a board to help achieve those aims. Hospitals and clinics are maintained or funded by local authorities.

The gist of this is that a national infrastructure is maintained through our representative governing bodies, while strategic direction is provided at both a national and local level, with key responsibilities detailed further than they ever have been about the duties of the Minister ultimately in charge of it all.

I'll look in to the newer parts of the reforms, commissioning groups, competition, in a further post later...but right now the claim that this bill destroys the NHS, removing the "national" from our health service, just doesn't stack up.

Friday, 2 March 2012

Image Replacement Technique

Just a bit here for me to be able to keep this somewhere I shouldn't lose it! Many people seem to be sticking with the old "Phark" method of replacing text with an image, but this forces the text off screen and invisible if the images are turned off for whatever reason. It may end up being the best solution when fast internet is ubiquitous, but even now it feels a bit presumptuous that people (especially on mobile devices) would all have images downloading.

Anatoly's method is as below...

h1 {
width: 247px;
height: 27px;
line-height: 1em;
white-space: nowrap;
font-size: 100%;
overflow: hidden;

h1:after {
display: block;
content: url("logo.png");
width: 247px;
height: 27px;
margin-top: -1em;

/*IE hacking */
* html h1 {
background-image: expression(this.runtimeStyle.backgroundImage = "none", this.innerHTML += '');
position: relative;
z-index: 1;

/*Now the simple and effective IE styling.*/

* html h1 span {
display: block;
width: 247px;
height: 27px;
background: url(logo.png) no-repeat;
position: absolute;
top: 0;
left: 0;
z-index: 2;

I would go one step further, however, and say that you could turn either the height or the width to something more variable as long as the image you were using (logo.png in this case) had "dead space" on it to cover the text up if it grew (due to people having higher text sizes set on their browser, for example), and get rid of that white-space:nowrap to enable the text to still be displayed. A min-height or width would have to be used, and IE can see this action using the following expression:

height: expression(this.offsetHeight > this.parentNode.offsetHeight ? '100%' : this.parentNode.offsetHeight +"px");