Write up of the Public Meeting with Jonathon Parry (Chief Executive of Southport and Ormskirk NHS Trust) and the effects of the incoming Health and Social Care Bill.

The Meeting was fairly well attended last night with most seats filled. As people entered they were asked to fill in two forms, one asking for fairly intimate details and intrusive information like sexual orientation and whether you were still the gender you were designated at birth. The other, a registration form, took contact details and had a tick box which asked if you were interested in becoming a supporter of the Foundation Trust. The explanation of what a Foundation Trust is, what becoming a Supporter of the Trust might involve and how it would affect the two hospitals, I felt, was woefully inadequate even on request.

I asked for an explanation and the response was basically "well the hospital want to become a Foundation Trust and your involvement could be anything from recieving newsletters to being actively involved, Jonathon will explain more in his talk". Since the box was on the registration form, you were required to decide before the talk was given. I thought this was poorly planned and this made me wonder if there is more to this "Foundation Trust" status than meets the eye. If the idea is so good why set people up to fail by putting the question about support on the registration form before you find out what the Foundation Trust is and decide whether you want to support it?

The idea behind a Foundation Trust is that it is meant to give the Hospital greater independence from central administration. It will be administrated by a board of Governors, the trusts are meant to be run mutually and are designed to be more accountable and involve local people and service users more in the operation of NHS services. There is no guarantee however how "mutual" the Foundation Trust will be or what targets and motivations will guide its operation. Localism in this way opens the door for privatisation and fragmentation and incentivises a "postcode lottery" by creating potential for huge differences in care, services and priorities between areas.

Currently, Foundation trusts are restricted in the number of private patients they can treat. The new Health and Social Care Bill, which is still at Committee Stage in The Commons seeks to end this restriction and supposedly free up Trusts to make an income from private care which they state Trusts can use to fund NHS services. These two things are, I suspect the "more than meets the eye". What will this actually mean? Clearly if NHS services are to be in competition with private services the private services have potential to be more profitable for the trust, especially when postioned against the heavy sanctions and fines for relatively common occurrences within NHS treatments which are often beyond the Trust's control or responsibility as detailed below.

The Health and Social Care Bill, according to Mr Parry's talk, seeks to fine Trusts for readmissions after elective procedures even if the readmission is unrelated or beyond the control of the hospital i.e. attributable to patients not taking prescribed medication e.t.c. Last year had those fines been in place the trust would have been fined £5m, Mr Parry stated. There will also be fines for patients staying longer than they are meant to in hospital and fines for not respecting privacy and dignity.

Fines for "elective procedures" will apply, not just to what some might imagine (optional procedures) but also to scheduled or planned procedures. Anything which is not an emergency is an "elective procedure" this will disencourage Trusts to provide anything but Emergency Care on the NHS as the sanctions appear to be so heavy and so unfair that it may become too risky to provide the service at all. This is even without taking into account the "patient tariffs" - how the new system will place a monetary value on services in order to make them competitive,  mentioned by Mr Parry, that may mean it is no longer economically viable to provide certain types of care.

I was under the impression that when people stay longer in hospital than medically necessary it was because it was inappropriate to discharge them - they maybe had nowhere to go, possibly because they couldn't afford nursing home care or had an inappropriate home environment. So, given that a person's home circumstances are beyond the NHS's control and I believe many, specifically elderly people, are coming into hospital because their home circumstances are inappropriate in some way. Or alternatively, because of the increased chance of poor health and complications and the complexity of managing what is likely to be multiple complaints and conditions they have found that their home environment has become inappropriate whilst they are in hospital. How much can the NHS reasonably expect to change this situation? It seems it is another, large area of care - geriatrics, that will become too risky and too expensive to be provided on the NHS.

The fines for not respecting privacy and dignity, on the face of it seem great for patients. We are likely to be luckier than in some other places because our hospitals are relatively modern says Mr Parry. What is missing from this picture however is the context. Trusts are being asked to, in many cases, entirely redesign the layout and physical structures of their buildings. This costs money, money which has not been given to aid these changes. In fact, nationally the NHS, according to Mr Parry, is being cut by £20bn which, by my maths, is around £325 each for every man, woman, child, baby e.t.c. in the UK - a cut of 4.5% across all NHS services (again by my maths and assuming the cut is spread across 4 years). What this will mean is that if separate wards cannot be provided and privacy targets met, the service will be considered too risky and there will be a temptation not to provide it.

Going from Mr Parry's talk last night what this means is gaps in services. If the "patient tariff" is not in your favour, if your illness or pregnancy, is not profitable for the Trust to treat or manage because of sanctions/competition/patient tariffs then those services will not be provided. Mr Parry admits the system is modelled on US and European "evidence" but our health system is unique so how well does that evidence translate?

The fact that anyone would see the US system as desirable makes the mind boggle until you realise who does best. In a market driven "Health Economy", as Mr Parry puts it, i.e. not a universal healthcare system but one that provides services that are profitable rather than necessary, who are the winners and who are the losers?

Losers:

1. If we look at America's competitive free market "Health Economy" the vast majority of ordinary people are losers. In the USA the Government spends more on healthcare than in the UK, almost twice as much in fact, but do the patients get more? If we look at WHO statistics it would seem not. According to WHO, UK public healthcare (NHS) in 2006 cost 8.4% of GDP. In the same year it cost the USA (medicare, medicaid e.t.c.) 15.3% of GDP. In the UK the probabilty of dying between the ages of 15 and 60 is 98 in 1000 for men and 61 in 1000 for women. In the USA it is 137/1000 and 80/1000 respectively. Life expectancy at birth is slightly better in the UK too (2 years more for men, 1 for women). More children under five die in the US too - (6/1000 in UK, 8/1000 in the US). In the UK you can expect to be healthy for longer too - an extra 2 years for men and 1 year for women. If you look at the breakdown of WHO statistics in both the USA and over here you can see that as health spending has risen over time infant mortality has fallen. Time will tell whether cuts to health spending will have the converse effect.

Wikipedia says the WHO:

"in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study).^[12][13] The Commonwealth Fund ranked the United States last in the quality of health care among similar countries,^[14] and notes U.S. care costs the most.^[15]" 

A damning article in USA Today  (22/05/2002) builds on other things mentioned in the wikipedia article saying:

"Among the study's findings is a comparison of the uninsured with the insured:

• Uninsured people with colon or breast cancer face a 50% higher risk of death.
• Uninsured trauma victims are less likely to be admitted to the hospital, receive the full range of needed services, and are 37% more likely to die of their injuries.
• About 25% of adult diabetics without insurance for a year or more went without a checkup for two years. That boosts their risk of death, blindness and amputations resulting from poor circulation.

Being uninsured also magnifies the risk of death and disability for chronically sick and mentally ill patients, poor people and minorities, who disproportionately lack access to medical care, the landmark study states."

This article refers to an Institute of Medicine study from around that time that found, amongst other things, that over 18000 people per year die as a consequence of not having access to health insurance and therefore healthcare.

In 2010 the Patient Protection and Affordable Care Act became US law, designed to protect patients, and public health from the adverse effects of their "Health Economy"'s free market. So America are trying to make patient care and public health more of a priority whilst the UK is trying to create a competitive "Health Economy" driven by competition and the market rather than health needs. America and the WHO seem to consider the American model of free market competition a failure.

There is a misconception sometimes that lack of adequate insurance is something which exclusively affects the poor. This is not true either. If the insurance company believes you are a risk, for any reason, then you will be charged a higher premium or be unable to get decent cover.

2. NHS services will be a big loser over here. The point of the NHS has never been to make a profit or be a financially viable business - it has been to provide healthcare services free at the point of use. This is designed to improve public health, wellbeing and standards of living. In a market system where patient care is given a monetary value rather than a quality/medical value this means public health will be compromised. We will no longer treat people when they are sick, or even before they become critical. We will provide emergency care and that is all, and people who cannot afford to travel or buy private health insurance will not have access to healthcare and people will die just like in the USA. It will be the end of the NHS, by very definition the Health Service will no longer be National because of the fragmentation caused by Foundation Trusts and the market economy approach potentially brought in by the Health and Social Care White Paper.

3. People living in rural areas, Children, the Elderly and the Vulnerable (the poor, deprived, mental health services e.t.c.). These areas of healthcare, which are often complex and costly and often require multi agency involvement, are the first things likely to go as they are labour intensive, complex, costly, time consuming and often unpredictable and will likely not fit well into the new "Health Economy"as profitable services.

4. Small Businesses. As private healthcare takes over from state provided universal healthcare businesses will be expected to provide healthcare for their employees as they do in the USA. This makes jobs with big multi-national wealthy corporations more attractive to prospective employees and will further strangle small businesses as they struggle to compete. Small businesses contribute more to the economy (pay higher rates of tax, promote local business communities, employ local people e.t.c.) whereas whatever profits big businesses make they tend to exploit cheap labour abroad and avoid/evade taxes which means less coming into the UK in emplyment terms as well as in potential tax.

Here is an interesting page about the benefits Universal Healthcare would bring to the USA - it is basically an argument to keep Universal Healthcare in the UK too:

http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm


Winners

1. Private healthcare companies. More NHS services will be outsourced to be provided by private companies as the NHS is put under pressure to do more with less. Like with hospital cleaning, the utility companies, social housing e.t.c. what we will see is a decline in the quality of the service and therefore even if the cost of the service decreases, which given the evidence is unlikely, the associated costs rise (associated costs of privatisation of hospital cleaning were the development of hospital superbugs). This will not stop private companies making a profit from the inadequate service being provided and since private companies are motivated by growth year on year the companies will have to provide an increase in profits at the expense of something else leading to a race to the bottom on quality.

2. Insurance companies. As NHS services evaporate private companies will move in to fill the gaps meaning that the last remaining NHS services will be competed out of the market and even further evaporate making people more and more reliant on private healthcare and insurance which insurance companies stand to profit from hugely.

3. The very wealthy. In a universal healthcare system where no or little private healthcare exists the very wealthy have to use the same standard healthcare services that everyone has access to. In a system where there is competition (a nicer way of saying inequality) the very wealthy, who do not have to worry about the cost of healthcare, can potentially buy a higher quality, priority service with access to the best resources and medical professionals. Without this private system they cannot pay for the priority service. With the private system the cost of providing the priority service is that some people have no access to healthcare at all.

The Integrated Care Organisation

The main body of Mr Parry's talk was about the new "Integrated Care Organisation" which the Trust are planning to take effect from 1/4/11. There was a lot of spin and not much substance to Mr Parry's talk so I am unsure exactly what the effects of the ICO and eventual Foundation Trust status will be. When facing questions from the public it seemed Mr Parry was fairly unclear about this too. The main focus seems to be gaining Foundation Trust status although it was not adequately explained why this is so necessary.

The meeting was an "engagement" meeting rather than a consultation which I felt was difficult since what is proposed is a big change, shouldn't the public have a say?

The creation of the ICO, Mr Parry says, will;

1. Move care into the community and patient's homes.
2. Provide integrated care
3. Saves resources
4. Meet the targets set out by the Health and Social Care Bill
5. Improve services

The benefits he believes, as seen in Europe and the US are as follows;

1. Continuity of Care
2. Care in the community and home
3. Reduced length of hospital stay
4. Smaller waiting times
5. Uniform services - evening out services across country boundaries

They also plan to introduce a new IT system to make medical records available in real time to hospitals, community services and Social services. He says GPs are keen on this system and it would reduce paper waste. It was asked how patient confidentiality and privacy would be respected and whether patients would be given an opportunity to opt out of the system. Mr Parry's response was that he wasn't sure of the specific legal duties involved but they would be considered in the planning. My concern would be mainly around the security of the information. By making the information available for use they potentially compromise confidentiality and privacy. Should Social Services really be allowed to indiscriminately access any medical record they like for example? The benefits to the healthcare profession are fairly clear but what are the benefits to patients and do they outstrip the costs?

They want to introduce a forum called the "Clinical Senate". A question was asked about whether there was space on this for a patient representative and Mr Parry said he believed so. The clinical forum will be made up of representatives from all healthcare providers and Social Services.

They want to become a Foundation Trust by 1/4/13 which is why the introduction of the ICO is happening so quickly.

Mr Parry says the Trust must make a 4% saving this year followed by a 5% saving (-£8m) next year. This will mean cutbacks in beds, which was clarified by a question from the audience from one of the doctors saying the trust were planning to cut the number of wards from 6 to 3 - a 50% reduction, but not cutbacks in Community Care. This could mean reductions in frontline staff and compulsary redundancies. It could also mean service closures although it is too early to say where any of these redundancies or closures could happen.

Mr Parry said the Trust had been consulting the medical staff about the changes but was unable to satisfactorily answer a question about how the staff felt about the changes and whether they had concerns about risks to patients and worries about patient safety. He said the clinicians felt "down" but would not answer whether they felt the changes would affect safety and efficacy.

When questioned Mr Parry also stated that although the "Health and Social Care Bill" was still being considered by Parliament and so these changes might be a bit early since the white paper was not yet law, it was "a white paper" and it would become law. This seems a little inadequate as an answer. Whilst it is very important for the public to try and protect services from big changes, this seems quite radical considering the legislation is not yet passed and could be massively amended or not made into law meaning Mr Parry and the Trust might have to reconsider their plans.

A question was asked about the Trust's marketing budget in the face of the new "Health Economy". Would money be being spent on marketing instead of medicine in order to attract patients and generate income? Mr Parry's answer was that the marketing would be targetted to the type of patients the trust would profit from and would not be indiscriminate. This clearly confirms the worry that less profitable services might disappear.

Mr Parry, when questioned, answered that he came into the NHS because he believed healthcare should be responsive to the needs of the patients but that cost was also important.

The overwhelming feeling I came away with was, if this is such a great way of doing things - cheaper and better, why isn't it being used now? If it was so good why, when it was used in the past, is it not still being used? If people can be sent home earlier why aren't they being sent home earlier now? If these things are within the scope of the NHS why are they not already standard practice? My knowledge and experience about length of stay in hospitals says the patients that stay longer stay longer because they have nowhere else to go - there is no current incentive for hospitals to keep patients longer than they need to as far as I am aware and it, I believe is being done with the patient's needs in mind. 

The Integrated Care Organisation isn't a new system it has been used in the past. How Jonathon Parry portrays it - all things wonderful with no drawbacks, saving money, providing better care, just seems too good to be true. That combined with his lack of knowledge about what services might be lost but a feeling that jobs and services may go e.t.c. makes me worry. Now is not the time for spin. We want to know what is going on and how our services will change. The news of ward closures and the reductions in beds and staff and the lack of reassurance about how the clinicians feel is also worrying.