The changing NHS: just one question - will the NHS survive?The changes described in outline over this series of articles may well leave a greater mark on our local NHS than did the contentious 'Lansley' reorganisation under the Coalition government.
As these changes are firmly bypassing Parliament and have been imposed by executive fiat, they pose many problems about accountability, transparency and governance.
The parlous - and ongoing - lack of public debate and public access to the Banes & North East Somerset, Swindon and Wiltshire Sustainability and Transformation Partnership (BSW for short), sets a bad precedent for the future. Will the new Primary Care Networks have meetings in public or publish decisions on their care policies and commissioning?
The changes do not of course provide answers about the future of the NHS - fine words and ambitions are not answers. Practicalities may become clearer once government wakes from its Brexit stupor. But here are some questions about the future.
FUNDING: The government's 2017 claim that it is providing an extra £10 billion has been called misleading - giving the erroneous impression the NHS is 'awash with cash' - by Commons' committees and the UK Statistical Authority.
With rising demand, rising costs of drugs and technology, financial consequences of the staffing crisis, the former head of the Treasury's description of the NHS as a 'bottomless pit' that always asks for more, may be justified. Will the new Conservative Prime Minister and his/her's Chancellor find the money to keep the NHS afloat?
Will the Treasury ever stop trying to claw money back from the NHS budget? The CQC has its budget cut, so it charges hospitals more to be inspected. Clinicians and nurses recruited from overseas are charged annual joining fees. Pension costs are raised. George Osborne cancels bursaries for trainee nurses.
Then there is NHS Property Services - set up as a company under the Lansley Act. It was handed several thousand NHS properties and is now busy charging 'market rents' for hospitals and other services using those properties - all money taken away from front line services.
STAFFING: We knew this crisis was getting worse, now thanks to a leaked draft of the government's report on the crisis - the 'NHS People Plan' - we know it is much, much worse. The shortfall of nurses in England in 2018-19 is 40,000.
This widens to 68,500 by 2023-24 - without any 'intervention'. Even after the 'interventions' to be proposed in the report, that 68,500 deficit only drops to 38,800.
And do not doubt that many of those 'interventions' will need funds that will be top-sliced from the NHS budget - whether it is bringing back training bursaries for nurses or supporting colleges financially.
Two years ago we learnt that 40 per cent of GPs were planning to leave the profession within five years. Now we have figures showing that surgery closures across the UK are at record high levels. And the 5,000 extra doctors promised by the government in 2014 have still to emerge.
The staffing deficit is especially bad in mental health services - which we are so often told is a priority for the government. According to Department of Health figures, in England two thousand mental health staff a month are leaving the NHS.
Can the NHS with its plans for local nursing teams to take the pressure off the hospitals, survive the staffing crisis?
ONLINE GP APPOINTMENTS & ARTIFICIAL INTELLIGENCE: there are those in government who hope - even believe - that online services and advances in artificial intelligence will beat the staffing crisis. They are watching various experiments:
- A recent report boosted the effectiveness of the Babylon 'GP at Hand' subscription service for remote GP consultations via text and video messaging through their mobile app. But others point to its weaknesses, to the number of patients who sign up and then drop out, and the 'significant damage' it is doing to GP practices in parts of London. Babylon has worldwide ambitions, but is currently only available in London and is moving into Birmingham. (It also operates in Rwanda.)
- A Birmingham hospital is to try an online triage system that you must go through before you arrive at its A&E department - unless, of course, you are taken there by ambulance or are unable to navigate online systems.
NEW LEGISLATION: consultation is underway on ways the 2012 Act could be 'unpicked' - once Parliament gets back to normal business. A key target is the presumption that contracts must go out to open tender.
A Commons committee was told recently that 'transaction' costs on such tenders run at 14 per cent of the value of the contract - that's more money NOT being spent on NHS 'front line' services.
The question of 'creeping privatisation' keeps coming up in these discussions. If you need evidence that the NHS is spawning businesses, check out the impact of the Primary Care Networks that will be active in Wiltshire soon. These will be groups ripe for eventual privatisation - which may be why GPs are lobbying for the NHS to fund business and management courses for trainee doctors.
The threat of privatisation might become a rout if Brexit has such dire economic consequences that the government scrambles a trade deal with Washington - and in the process gives American health and insurance giants free access to cherry pick the most profitable parts of the NHS.
It would be a good sign that the government really wants the NHS to succeed as a state run service, if it acted in a joined up way. There's the Treasury mopping up parts of the budget - as above. Then there is the Home Office - putting hurdles in front of overseas recruitment and more besides.
Several cases Home Office from the period 2010 to 2016 have recently been highlighted by a former immigration lawyer. They include:
- A radiographer with seven years residence - with a wife and five children at school - was refused settlement rights over a £70 traffic fine. The Home Office ruled they all had to leave the UK.
- An operating theatre nurse with seven years experience submitted her application for residence with photos that were, she was told, 'too dark'. Her application took ages, so her employer checked with the Home Office. She was called to a meeting at her hospital, told her application had been refused and she had to leave work immediately.
Are we surprised that overseas recruitment has fallen off the end of the graph?
We have not had the space to touch on the terrifying plight of adult care. The reduction in local authority budgets has been absorbing NHS money through the Better Care Fund and the reliance on NHS funding continuing health care for those with complex conditions and need too many hours of social care attention for current budgets.
The government's long-promised plans for social care are still in the pipeline/long grass and will be published, a government spokesperson promises, 'at the earliest opportunity' - which is shorthand for 'when it becomes politically feasible or beneficial'.
The NHS may be so big it can, as the saying goes, be seen from space. Unless the government takes urgent action, we may have to test out another saying: Is the NHS too big to fail?
This is the seventh and final in our series of articles on the new shape of the local NHS - following our introductory report of 28 March 2019.