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Hopson’s choice: accidentally destroying the NHS with parliament’s permission?

The starting point is here.

In May 2016, the need for increasing funding for the NHS was mooted powerfully by one of its former chief executives.

“Ministers must increase taxes to raise new cash for the NHS, a former chief executive of the health service in England has said, warning that no developed country would be able to cope with the spending squeeze inflicted on the health since the financial crisis of 2008.

Sir David Nicholson, who served as head of NHS England until 2014, said that last week’s record NHS hospital deficit figures were a symptom of the “serious problem” of NHS under-funding. His call for a boost for NHS spending via the taxation system was echoed by a senior NHS official, who said the only alternative to increasing taxes or national insurance contributions would be deeply unpopular new charges for NHS care.”

In the written evidence submitted by Chris Hopson, Chief Executive, NHS Providers (FIN0003), the following is mooted.

stark choices

Let’s look at the effect of these, shall we?


1. Reducing the number of strategic priorities the NHS is currently trying to deliver. Our members tell us that they are inundated with new initiatives they “must implement” ranging from seven day services and mental health and cancer taskforce recommendations to moving to a paperless NHS and a raft of new patient safety related initiatives. Whilst these are perfectly sensible individually, collectively they are impossible to deliver in the current environment;

It is already known that the NHS offers a seven day service for emergency care, and clinician have been vehement in their opposition to the ‘7 day service’ unless there are adequate resources to ensure patient safety.

The concerns are even reported to be widespread (this extract from August 2016).

“The health service has too few staff and too little money to deliver the government’s promised “truly seven-day NHS” on time and patients may not notice any difference even if it happens, leaked Department of Health documents reveal. Confidential internal DH papers drawn up for Jeremy Hunt and other ministers in late July show that senior civil servants trying to deliver what was a totemic Conservative pledge in last year’s general election have uncovered 13 major “risks” to it. While Hunt has been insisting that the NHS reorganise around seven-day working, the documents show civil servants listing a string of dangers in implementing the plan – as summarised by a secret “risk register” of the controversial proposal that has prompted a bitter industrial dispute with junior doctors. The biggest danger, the officials said, is “workforce overload” – a lack of available GPs, hospital consultants and other health professionals “meaning the full service cannot be delivered”, they say in documents that have been obtained by the Guardian and Channel 4 News.”


2. Formally rationing access to care in a more extensive way;

This has already been happening by the backdoor.

Nick Triggle writes for the BBC in 2012:

“Access to NHS care – including knee and hip operations – is being restricted, data from trusts in England suggests. The evidence, gathered under the Freedom of Information Act by GP magazine, showed 90% of trusts were imposing restrictions. The trend was blamed on cost-cutting by some, but the government says there was no justification for that assertion. NHS managers have defended the practice, saying there were instances when care had to be prioritised. Limits on cataract surgery were in place in 66% of trusts, while more than half of trusts were rationing weight-loss surgery and hip and knee operations Another survey published by Labour found similar patterns, prompting criticism of the trust’s actions from patient groups Clara Eaglen, of the Royal National Institute of Blind People, said: “People should not have to live with a reduced quality of life simply because PCTs are using arbitrary criteria to determine whether they get to keep their sight.””

Caroline Molloy, editor of Our NHS, writes in March 2016:

“Worrying news has emerged this week from the Midlands.

Cash-strapped local health bosses there have suggested that they may in future no longer fund a wide list of procedures on the NHS for many patients, including hearing aids, cataract ops, vasectomies, and hip and knee operations. Clinical Commissiong Groups (CCGs) in Wyre Forest, Bromsgrove and Redditch and South Worcestershire are currently consulting on the proposals, due to a £25million shortfall in government funding. Worcestershire CCG says baldly: “We do not have enough money to continue to buy all the services that we currently do in the same way as we have done before.” A couple of CCGs have already dipped their toe in the water of withdrawing such services – Essex announced in January it would no longer fund NHS vasectomies, and last October Staffordshire CCG started denying hearing aids for the first time in NHS history. The reductions in healthcare build on a longer tradition of short-term rationing fixes.”


3. Relaxing performance targets;

This would prevent the blushes of NHS managers missing A&E targets now virtually every month. “Relaxing performance targets” would help to cover up bad care.

Even in April 2015, the situation was known to be dire.

“Commenting on the latest NHS England figures published today (Tuesday) showing that the A&E waiting time target hasn’t been met for 26 consecutive weeks, UNISON Head of Health Christina McAnea said:

“Week in week out, for half a year now, the waiting times target has been missed. It’s bad enough that some sick and injured people were having to wait for more than four hours in the depths of winter – a time when demand on the NHS was at its peak. But for that still to be the case now that spring is here shows just how stretched A&E departments have become. Sadly this is where we are after five years of Tory mismanagement of the health service. The NHS, its patients and its staff need and deserve better.””


4 Closing or reconfiguring services;

This has already surfaced to public discourse.

This for example comes from August 2016:

“Plans are being drawn up that could see cuts to NHS services across England. The BBC has seen draft sustainability and transformation plans (STPs) which propose ward closures, cuts in bed numbers and changes to A&E and GP care in 44 areas.
There have been no consultations on the plans so far. NHS England, which needs to find £22bn in efficiency savings by 2020-21, said reorganising local services is essential to improve patient care. But the Nuffield Trust think tank said while STPs could lead to “fundamental changes”, many of the plans do not meet the financial targets set by the government and will face a “dauntingly large implementation task”.”

Also that month the Guardian carried further details:

“NHS England has divided England into 44 “footprint” areas, and each was asked to submit a cost-cutting “sustainability and transformation plan” (STP). The Guardian has seen the detailed plans for north-west London, while 38 Degrees, a crowdfunded campaign group, commissioned the consultancy Incisive Health to collate and analyse proposals from across the rest of England.

The picture that emerges includes:

In the Leicester, Leicestershire and Rutland region, there are proposals to reduce the number of acute hospitals from three to two.

In the Black Country region of the West Midlands there are proposals to reduce the number of acute units from five to four and close one of two district general hospitals.”

But there are already concerns that extensive cuts done this way are storing up massive problems for later.

“There are also serious concerns that cost-cutting on the scale envisaged under the plan could damage patient care. Jennifer Dixon, the chief executive of the Health Foundation thinktank, said the strategy risked a repeat of a care scandal of the scale of that seen at the Mid Staffordshire NHS Trust between 2005 and 2009. “Getting the balance right between carrot and stick is critical, as history tells us,” she said. “The Francis inquiry, published only three years ago, describes how radical steps by one NHS hospital – Mid Staffordshire – to improve its financial position had terrible consequences for patient care.””


5. Extending co-payments or changes;

The effects of copayments are well known, see for example here Colin Leys and Stewart Player:

“What has already occurred with dentistry, physiotherapy, podiatry and other services will start happening across the board. ‘Top-ups’ and ‘co-payments’ will become standard. Some treatments will cease to be available freely on the NHS and have to be paid for – if you can afford it. ”

Co-payments (and personal budgets) have the effect of rationing care at the individual level, making cuts much easier to get away with.

KONP comments:

“By the use of direct payments and/or ‘personal budgets’14 for an increasing range of conditions – patients are given a fixed sum to buy their healthcare themselves, from either the NHS or private providers. Personal budgets have been trialled since 2009 and are now being rapidly extended. By 2014 they will be rolled out to all patients receiving NHS continuing care. The experience from social care personal budgets here and healthcare in other countries is that risk is passed down to the patient, and state health providers can go under. Budgets often get progressively cut, leaving the individual to top up from their own pocket, or via insurance, if they can afford it.”


6. Reducing / more explicitly controlling the size of the NHS workforce which accounts for around 70% of the average trust budget. But, clearly, controlling the size of the workforce would have to be linked to some form of reduction in what the NHS is being asked to deliver.

The King’s Fund comments:

“Between 2000 and 2010 the nursing and midwifery workforce in the NHS in England grew by 26 per cent, an average of 2 per cent per year, the result of a concerted effort to reverse nursing shortages in the previous decade by increasing training places, improving staff retention and active international recruitment. However, the number of nurses on the Nursing and Midwifery Council’s UK register of all practising nurses, began declining in 2008 and continued to fall in the following three years, while the headcount of qualified nursing staff working in the NHS in England only began to reduce after reaching a high of 375,505 in 2009.”

But this is already an area of massive concern in terms of patient safety:

“The Government has suspended NICE (the National Institute for Clinical Excellence) from producing further guidance on safe staffing levels in the NHS and this is a cause of great concern.

Simon Stevens, Chief Executive NHS England says he has requested Jane Cummings, Chief Nurse NHS England, to incorporate nurse workforce planning into the 5 year forward plan initiatives. This is a serious backward step as NICE were commissioned to provide an independent review on safe staffing levels based on research and expert advice from the healthcare field. NHS England is not in a position to provide an independent view and the outcomes will be fragmented across its various initiatives with no standardized approach to staffing levels resulting in a serious risk to patient safety. (It is of interest that on the same day of the suspension, NHS Wales voted unanimously to pass a safe staffing to its second stage.)”

And it doesn’t stop there.

“Healthcare services and its professionals are “heading into an extremely difficult autumn”, the Royal College of Physicians (RCP) has warned as the latest workforce survey from the RCPCH revealed widespread staff shortages and rising rota gaps in the field. The survey, which has been collecting evidence since 2009, found that more than one in four general paediatric posts at senior trainee level are now vacant, with over half of paediatric units not meeting recommended staffing standards. To keep services running, consultants are increasingly providing unplanned cover in addition to covering their own roles. Perhaps even more worryingly, four out of five, or almost 90%, of clinical directors are worried about how services will cope in the next six months. Doctors argued children’s services are “at a breaking point, sustained by existing junior doctors and consultants struggling to plug vacancies”.”

The problem with NHS Providers putting so much effort into laying out these disastrous options is that they begin their negotiations from a starting of point of (unintentionally) destroying the NHS?  They should emphasise at all times this will only be solved by proper funding to both NHS and the social care.

The “zombie policies” keep on coming up again and again.

Caroline Molloy again, this time from 2013:


Reform acknowledge that the last major review of NHS funding found that charges were “inefficient and inequitable” and that taxation was the most effective way of paying for healthcare, just as NHS founder Nye Bevan insisted when he dismissed means-testing, charging and insurance, saying:

“The means of collecting the revenues for the health service are already in the possession of most modern states, and that is the normal system of taxation.”

Taxation is – Reform admit – still the model of NHS funding “preferred by the public”.

But these days it’s surprisingly rare to hear a politician explicitly defending this core principle of the NHS. Cameron’s appointee as new NHS Chief Executive, former United Health chief Simon Stevens, wrote an essay for Reform last year that appeared to problematise the “the NHS’ tax-funding mechanism”.

Heavy lifting

There are other think tanks prepared to help Reform do the political dirty work – or ‘heavy lifting’ as it’s now known – to try and shift the public away from their commitment to a tax-funded comprehensive NHS towards one based on charges and insurance.

Reform cite a recent Kings Fund report to back their assertion that “attitudes to charging have begun to shift in recent years”. In fact the Kings Fund’s focus group strongly rejected NHS charging and preferred increased taxation if necessary. Only after two days of being brow-beaten with the “inevitability” of the NHS’s financial “crisis”, did attendees reluctantly concede that if they absolutely had to accept charging, they would prefer it applied to less vital procedures and to more irresponsible patients.

Reform also try to claim that GPs and the British Medical Association are shifting towards supporting charging – an attempt at co-option roundly rejected by both the BMA and the Royal College of GPs. Dr Chaand Nagpaul, chair of the BMA’s GP Committee said yesterday:

“This proposal undermines the core value of our NHS: universal access based on need, not ability to pay. If a charging system is introduced there’s a risk it would deter patients from seeing a doctor and getting the treatment they desperately need.””


Accidentally destroying the NHS with parliament’s permission?

It would be a disaster if Chris Hopson going into his negotiation had effectively given up on the notion of funding the NHS properly, and suggested effectively only a route for destroying NHS as a comprehensive and free at the point of use service.

Remember the ‘sustainability and transformation plans’ which have wrought widespread concern?

Chris Hopson again:

“We strongly support the current sustainability and transformation planning (STP) process to enable local health and care systems to chart a path to sustainability by 2020/21. But the problems the NHS faces are immediate. Trusts and CCGs must develop immediate plans that close the larger gap they will face from April 2017. Failure to do this now means the NHS will be unable to livewithin its 2017/18 budget.”

The original Hobson choice is described as following:

Hobson's choice

Or to bring up to date, Hopson’s choice, destroying the NHS with the permission of parliament?

I am certain Chris Hopson doesn’t intend this, to be clear.


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