Daily Hospital News

Thursday, June 30, 2011

NHS reforms could reduce patients' trust in doctors, BMA warns

Association fears that GPs may be suspected of withholding treatments and referrals in order to increase their pay

The leader of Britain's doctors has warned that coalition plans to reward GPs for enforcing budgetary controls could fundamentally damage trust with their patients.

Dr Hamish Meldrum, the chairman of the British Medical Association, said the suggestion under revamped plans from the health secretary, Andrew Lansley, might lead to allegations that doctors were withholding patient treatments and referrals to increase their pay.

The warning, made on the eve of the BMA's annual meeting in Cardiff, will be seen as another direct challenge to the government's plans for the NHS. David Cameron has already been accused by Labour of being forced into a dramatic U-turn after ditching his original reform plans for the NHS in England.

Meldrum said the BMA has "great reservations" about government plans to reward GPs for the high-quality commissioning of services.

"If patients even suspected that their GPs might be rewarded for how well they do, and particularly how well they do financially in terms of commissioning – giving way to suggestions such as 'You may not be referring me, you may not be investigating me, you may not be prescribing for me because that actually means money in your pocket' – well, that would seriously damage the trust.

"While we have always argued that doctors must be a part of the decision-making process, it has to be in partnership with patients and done in a way that doesn't undermine that trust," he said.

He said that the relationship between patients and their GPs would be a theme throughout the BMA's delicate negotiations with the government over the future role that its members would play in a changed NHS.

" At times of crisis, trust is more important than ever. There is a danger that this may be put at risk by some of the government's plans.

"The public is not prepared to gamble with the future of the NHS, and doctors are not prepared to see this trust abused by government policies that could undermine the value of doctor-patient relationships," he said.

An Ipsos Mori survey released by the association to coincide with the conference claims to show that doctors are the most trusted profession, with 88% of the public generally believing they tell the truth. The figure compares with 81% of teachers, 68% of clergy, 29% of bankers and 19% of journalists. Government ministers, on 17%, and politicians, on 14%, occupied the bottom two places. More than 1,000 members of the public were asked to say whether thy trusted people who worked in 21 different professions.

The association is in the middle of examining detailed government amendments to the original bill, and is expected to suggest further improvements, for example, in the make-up of clinical commissioning groups.

Meldrum cautioned the government on allowing cuts to be implemented without proper consultation of doctors and other professional staff.

"The government has correctly said that it is not going to cut the budget, but it's not going to grow as it has done in previous years. We are going to have to use the money more wisely. I have not seen yet how those savings are going to be made.

"We will certainly react strongly to some of the knee-jerk, slash-and-burn responses in some areas where they don't seem to be having those discussions. There needs to be a much more mature dialogue that takes place," he said.

This week's conference is expected to be a heated affair, as doctors debate the future of the NHS while struggling to comprehend government amendments announced last week.

On Monday, they will debate spending cuts within the NHS. The health and social care bill will be debated on Tuesday.

Rajeev Syal

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Who listens to Britain's cleaners? | Ellie Mae O'Hagan

Politicians are deaf to those at the bottom of a recession-hit market and managers cut their jobs. So it's down to the union

Last week I caught up with an acquaintance from my past: Paddy, who acted as my Unite union rep when I worked as a cleaner at Ysbyty Gwynedd hospital in north Wales. At the time I was employed by Initial, a private company whose management was so woeful that the hospital reverted to employing cleaners in-house shortly after I left. Better employee rights would ensue, the cleaners had thought – rights that would reduce industrial disputes, leading to higher wages and better standards.

According to Paddy, my former colleagues' optimism was misplaced. A couple of months ago Betsi Cadwaladr University Health Board, which runs Ysbyty Gwynedd, decided to make 19 cleaners redundant across its three hospitals. The board argues the cleaners were no longer needed.

Unite thinks otherwise, pointing to the fact that the board's poor management has led to spiralling debt; debt for which the cleaners were not responsible but for which they now must pay with their jobs. Lack of staff led to deteriorating standards, says Unite, and the union has now persuaded the board to reinstate the cleaners temporarily, to see if they really are surplus to requirements. Unsurprisingly most of the rehired cleaners are now working fulltime hours again.

The dispute struck me as a grim microcosm of the circumstances we find our country in, where those at the bottom are beginning to suffer the consequences of mistakes made at the top.

Public opinion is slowly conceding the unfairness of this situation as stories of obscene bonuses and soaring executive pay roll on. Our collective British sense of fair play is beginning to flinch in response to an austerity that is anything but transparent and equitable – yet we've stopped short of a discourse on what the cuts reveal about the way our society treats the people at the bottom of the chain.

Hospital cleaning is one of the most important jobs in the workforce – to the extent that the NEF estimates that cleaners generate £10 in social value for every £1 they are paid. Yet it is not cleaners who are offered handsome bonuses and enviable job security, but City bankers who, by the same token, destroy £7 of social value for every £1 of their income. A society with such topsy-turvy values might seem perverse but it is a natural consequence of capitalism: in a system where money talks, low earners are not only left penniless but voiceless.

Our politicians vie for the affections of the "squeezed middle" while those at the bottom are quietly airbrushed out of the picture. So it seems paradoxically reasonable that the leader of the opposition should promote a living wage while extolling the virtues of social mobility. Ed Miliband may pay lip service to the value of jobs like cleaning, but ultimately he sees it as something one should escape from, not aspire to – a job to be done not by him, not by his children, but by others his rhetoric has so far left unacknowledged. From my own experiences at Ysbyty Gwynedd, this lack of acknowledgement is all too familiar: I remember the managers who avoided eye contact, the sense that I couldn't be trusted, the company's lackey with his suit and ample payslip who listlessly assured us that he "understood our concerns".

It is to be expected that a group that society views as "other" will be subject to inhuman treatment. Our politicians showed contempt of their own this week by refusing to ratify an otherwise unanimous UN convention to improve international rights for domestic workers. A spokesperson from Anti-Slavery International said the decision meant the UK was "letting down other countries, it's letting down those most vulnerable to forced labour and abuse … the UK is not only not pulling its weight but is actually trying to pull others back".

Maybe our government thinks it's OK to deny working rights to other functional beings. They probably won't complain, and if they do, nobody will listen. They are, after all, just cleaners.

A country sinking into recession cannot rely on its social strata remaining fixed. Rising unemployment means that those in the squeezed middle might find that they are – like Ysbyty Gwynedd's cleaners – falling through the cracks. At the dark heart of capitalism lies an acceptance that certain people's lives will always be worse than our own. As the comforts most of us take for granted begin to be eroded, it is an acceptance that badly needs to be challenged.

Ellie Mae O'Hagan

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Doctors could take industrial action over 'assault' on their pensions

BMA chief says his members 'will consider every legitimate action' to defend doctors' pensions from overhaul
• Follow developments and have your say at our live strikes blog

Doctors could take industrial action over the government's "unwarranted and unfair assault" on their pensions, the profession's leader has warned ministers.

Dr Hamish Meldrum, chairman of the British Medical Association, delivered a sharply worded rejection of the coalition's pensions plans in his keynote address to the doctors' union's annual conference on Monday.

"Let me make it absolutely clear: we will consider every possible, every legitimate action that can be taken to defend doctors' pensions," he said in a speech to 500 doctors' representatives in Cardiff.

"I have this message for ministers. Whilst we will be reasonable, whilst we will not rush to precipitate action, whilst we will not put patients' lives at risk, do not in any way or for one single moment mistake this responsible attitude as a reason to underestimate our strength of feeling and our determination to seek fairness for those we represent.

"The profession will act responsibly, but we will not accept an unwarranted and unfair assault on our pensions."

Meldrum's remarks, which were greeted with loud applause, underline the strength of feeling among doctors over changes which he said should not be "just a poorly concealed tax on public sector workers".

A doctors' strike is highly unlikely. But there are other forms of industrial action they could take in order to apply pressure, although doctors have not done so since a work-to-rule over contracts in 1975.

The BMA leader was speaking ahead of a pensions debate by delegates on Thursday, where there will be discussions of what steps to take if ministers ignore their concerns.

There are calls for the union "to ballot the BMA membership regarding all forms of industrial action" if there is no rethink.

Dozens of conference motions on the issue show that doctors feel strongly about the possibility of paying more in contributions and losing their final salary scheme.

Meldrum called the government's pensions plans "another major threat hanging over the profession".

He also criticised Danny Alexander, the chief secretary to the Treasury, for, he said, making the job of negotiating a settlement "impossible, if all we hear are public ultimatums and ridiculous threats such as those we heard just a few days ago".

Alexander's signal that ministers planned to press ahead with their overhaul of public pensions drew criticism from Lord Hutton, the Labour peer who drew them up.

Meldrum said that big changes to the NHS pension scheme were unnecessary as it was updated as recently as 2008.

"Fact: even before the imposed change from RPI to CPI and the threat of the imposed Treasury levy, the NHS superannuation scheme was in surplus, and by 2015 the scheme will have contributed over £10bn to the Treasury," he said.

The post-2008 scheme already has tiered contributions to guarantee fairness for lower-paid workers, while all members of the scheme are paying more into it, with the highest-paid contributing 8.5% of their salary, he added.

Dr Andrew Dearden, chairman of the BMA's pensions committee, has warned that if ministers press ahead with their plans more doctors could opt for early retirement in order to benefit from the more advantageous current system.

A doubling of the usual rate of retirements could lead to contributions going down at the same time as costs rise, he said.

Meldrum also warned that, despite the recent changes made to the health and social care bill, the BMA would scrutinise the government's 180 amendments to ensure that "what's been promised is being delivered [and] that this isn't just a case of turning a pig's breakfast into a dog's dinner".

He also urged NHS bosses not to "slash and burn" as they try to operate within the tightest financial climate in the service's 63-year history.

And, while stressing that doctors are not against competition, he reiterated the BMA's opposition to attempts to introduce a free market into the NHS.

Denis Campbell

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Social care is on the critical list. But Dilnot won't cure it | Polly Toynbee

A nation that spends less than 0.5% on old age can hardly expect anything other than a decrepit system. We can do better

Another week, another care home shocker. The family of a resident in Ash Court Care Centre in London hid a camera in a clock and allegedly caught a care worker repeatedly slapping, hitting and shouting abuse at their demented mother, with other staff joining in.

The victim was an 80-year-old former dinner lady, seen on camera crying as she was hit in the face. The family suspected something was wrong when she wept whenever they visited, but she was past explaining. Police arrested a male care worker and suspended four women at the home, run by Forest Healthcare, which owns what its website cosily calls "a family of homes" all over the country. The scandal of these end-of-life warehouses will worsen, subsisting on lower fees, banished to the margins of political concern, the cash-starved regulator cutting inspections by 70%.

Money may not guarantee kind care, but the extreme lack of it makes unkindness, neglect and sometimes cruelty almost inevitable. Labour's record was poor: from 2004 total spending on older people's social care rose by just 0.1% in real terms, despite growing numbers of the very old. In the same years, spending on the NHS rose by an unprecedented £25bn. AgeUK and other charities estimate that home and residential care is £3bn short of the total needed to bring it up to official minimum standards. The political imperative is always to fund the NHS, not social care – a good reason why some suggest forcing the funding together under one budget.

Cameron and Osborne claim their cuts only trim away fat from Labour's spending years. But by no stretch of even their thin grasp on reality could they claim social care was anything but a pitifully skeletal service already. Yet in the last year councils have cut care by a devastating 8.4%, while inflation runs at 4.5%. Social care has moved from the serious to the critical list. How lucky for government that behind the secret walls of care homes, or hidden in people's homes, neglect and cruelty stay unseen as underpaid, untrained agency staff have too little time for washing and feeding, with none at all for "care".

Next week Andrew Dilnot publishes his report on social care. But its headline purpose touches none of the above. Its remit is to solve a problem that you might not think the most pressing of all in these straitened times – to relieve homeowners of the burden of paying so much for their nursing home care.

The coalition agreement promised a commission to "consider a range of ideas, including both a voluntary insurance system to protect the assets of those who go into residential care and a partnership scheme as proposed by Derek Wanless". (The King's Fund/Wanless report proposed a system of joint state and personal). In social care the most pressing political problem has often been dealing with the rage middle-aged children feel at finding their inheritance eaten away when an elderly parent has to go into care: any savings above £23,500 and the value of a property vanishes into nursing home fees. This means-testing falls hardest on those with a few savings and modest homes who lose every penny they planned to leave their heirs. It touches the richest less while penalising the thrift of small savers.

Dilnot's reasonable proposal is to cap what anyone pays at about £50,000, with the state paying anything extra – allowing people to keep the remainder of their wealth. The hope is that on retirement people will voluntarily take out insurance to cover that £50,000, if they want to safeguard it. The state will have to pick up a bill of less than £2bn that is currently recouped through means-testing.

Oddly, yesterday's media protested with "middle classes to pay more" stories, the exact opposite of what is proposed. Middle classes will pay less, the state will pay more, and it's voluntary: only one in six go into care homes, so you can stay uninsured and take your chances. Dilnot sees it as restoring welfare state fairness, since fate and Alzheimer's disease come down so heavily on some families and not on others. This builds a care payment system with public consent that will last, whatever the level of social care funding in future.

Naturally all the care charities, including AgeUK, are enthusiastic. What's not to like in cutting bills for some? Just as naturally, the Treasury is rattling its sabre at any suggestion of paying out more: if it happens at all there will be a white paper and eventually legislation, but with no chance of implementing it until well after the next election.

Osborne is said to be concerned that this smacks of Labour's pre-election plan for a National Care Service: Andy Burnham proposed it be paid for with a compulsory contribution of £20,000 on retirement by everyone with a property, either paid upfront or attached to the value of homes after death. It could only be kept as low as £20,000 if everyone had to pay into a pooled system. Although it, too, preserved inheritances, the Tories hammered it as Labour's "death tax". Mendacious but effective, the slogan worked: few voters understand the care payment system until they need it – then they are shocked to find it's not part of the free welfare state they imagined. Even this system still won't pay full costs, or for care at home.

This is a hot marginal constituency issue as 60,000 families a year are forced to sell parents' homes to pay for care. But it is a sideshow compared with the real crisis. Expect Dilnot to use strong words about the state of decay in care services – but that's beyond his remit. So is the bigger picture, where wealth is sucked up from younger generations to older ones. It may be in his remit to point out that we spend just 0.5% of GDP on social care for an ageing population. The richest generation is my own – the 55- to 64-year-olds – which has enjoyed four housing booms that poured wealth into our pockets for doing nothing at all – and now Dilnot removes the risk of losing much of it when we reach decrepitude.

So if the Dilnot plan is adopted, it should be balanced by other taxes. A mansion capital gains tax on the sale of homes sold over £1m (or less) would raise a hefty contribution to pay back some of the ill-gotten gains of my generation. Why do the over-60s pay no national insurance, however much they earn? Abolishing that would bring in £3bn, and that is enough to repair the shaming state of care.

Polly Toynbee

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NHS patients' complaints procedure must be reviewed 'immediately'

With over 1m complaints a year about the NHS, a cross-party report has recommended stronger safeguards for patients

The government should immediately review the way NHS trusts handle patients' complaints, according to a report by MPs.

The current structure is not working and more needs to be done to encourage a "more open culture" when it comes to dealing with complaints and admitting mistakes, it says.

The report, from the cross-party Commons health committee, says the government has sufficient data to conduct a review and "should do so without delay".

Ministers should seriously consider whether two systems should be created, one dealing with complaints about "customer care" and a second examining more serious complaints about clinical issues.

The role of the health service ombudsman should also be expanded to allow more claims to be examined as part of an appeals process when patients are unhappy.

At present, patients complain first to the NHS trust in charge of their treatment. If they are unsatisfied with the trust's response, they can ask the ombudsman to review their case. But MPs said the ombudsman's remit is much narrower than patients think it is.

A complaint is only accepted for formal investigation or intervention if the person has suffered injustice or hardship as a result of poor service or maladministration, and only if there is the prospect of "a worthwhile outcome".

Only about 3% of the complaints received by the ombudsman are accepted for formal investigation or intervention, although many more are examined unofficially.

Today's report said: "The committee is of the view that a complainant whose complaint is rejected by the service provider should be able to seek independent review.

"The legal and operational framework of the ombudsman's office should be reviewed to make it effective for this wider purpose."

The number of complaints about the NHS is rising and now tops one million a year.

The number of patients seeking independent review from the ombudsman has also risen.

Experts believe the rise could be down to a mixture of factors including worsening NHS care, increased demand for healthcare and better awareness of the complaints process.

MPs also used today's report to calls for stronger safeguards for patients in the government's reform of the NHS.

Foundation trusts, which all hospitals will become under the plans, do not currently have a duty to supply data on the complaints they receive, but this must change.

The committee also condemned the activities of claims management companies (CMCs), which collect claims, assess their likely value and then sell them on the personal injury lawyers or legal firms.

MPs said claims are sometimes sold to the highest bidder without regard as to whether that lawyer is best placed to help the patient.

These "claims farmers" are worrying because they "encourage people to go straight to litigation rather than use the complaints resolution mechanisms" and can "unduly contribute to the rising costs of litigation to the NHS".

The report adds: "The committee therefore proposes that the government review the regulatory structure within which these businesses operate in order to ensure that patient and taxpayer interests are properly safeguarded."

MPs also scrutinised the government's plan to end legal aid for clinical negligence cases, saying the public will judge these proposals by how they alter access to justice.

Tory MP Stephen Dorrell, chair of the committee, said: "The legal and operational framework of the health service ombudsman should be widened so that she can independently review any complaint which is referred to her following rejection by a service provider.

"The ombudsman's current terms of reference prevent her from launching a formal investigation unless she is satisfied in advance that there will be a 'worthwhile outcome'.

"We have concluded that this requirement represents a significant obstacle to the successful operation of the complaints system.

"Patients should be able to seek an independent review of the findings of internal reviews by care providers; the terms of reference under which the ombudsman works prevent her from properly fulfilling this role. This needs to be changed."

Peter Walsh, chief executive of Action against Medical Accidents, said: "This report could not be more timely and underlines the need to rethink current proposed health and legal reforms.

"Like us, the committee welcomes the introduction of a 'contractual' duty of candour, as announced by the government recently, but sees that this must be augmented by making such a duty a condition for licensing by the Care Quality Commission.

"We urge the government to take this step without delay."

The report covers the complaints system in England.

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The small mental health services struggling to fit in

As health provision is restructured in the face of cuts, there are fears that small, voluntary mental health services are the casualties

Housed in a nondescript building among a row of shops, Camden Psychotherapy Unit (CPU) is a small community-based voluntary mental health service providing long-term psychotherapy for residents of Camden, in north London. A typical patient might have long-standing problems with depression or anxiety that antidepressants or less intensive "talking therapies" such as cognitive behaviour therapy have failed to address.

It treats around 80 patients a year, most of whom are on low incomes or on benefits and would not be able to afford this kind of treatment privately. Many are self-referrals, for whom the long waiting lists for therapy in the statutory sector are a major hurdle to recovery, says unit head Ora Dresner. Because CPU is not in a traditional clinical setting, vulnerable people, who would find the "institutionalised" environment of hospitals intimidating, feel comfortable approaching, she adds.

Dresner, who has been at CPU for almost two decades says the service, which is now threatened with closure, plugs a gap in statutory provision.

The unit costs £7,000 a month to run – just £33 per counselling session. But last autumn it learned that, due to changes in local commissioning of psychological services, its funding from Camden primary care trust would be withdrawn from the end of this month. Since then, local GPs, senior psychiatrists and former patients have tried to save the centre.

CPU supporters say that amid efforts by health bodies to calibrate services in the face of cuts and reorganisation of provision of therapies, some voluntary organisations no longer slot into new commissioning criteria.

As a small, specialist voluntary sector service, Dresner says CPU is "not in a position" to apply for funding under the new tender requirements. She approached a large bidder, Camden and Islington NHS foundation trust, suggesting CPU become a partner in its bid, but was unsuccessful.

Campaigners argue that concerns about closures and cutbacks are being echoed in small voluntary organisations across the country and it would be wrong to see the problems faced by CPU as some kind of inevitable, if regrettable, fallout of restructuring health provision.

Robin Anderson, a consultant psychiatrist, says the threatened loss of small services need to have a spotlight shone on them because they are often innovative linchpins in an otherwise inflexible, monolithic system. "Commissioning is an issue. There are massive cuts across the health service. It's a tough time and the weak go against the wall. You get to a point where [an organisation] doesn't fit in to the structure."

David Bell, president of the British Psychoanalytic Society, says services like CPU are a crucial part of the broader fabric of services and that when they disappear an already overstretched mental health system is put under even more pressure.

"Mental health services in general are seriously underfunded and there is a scarcity of the kinds of therapy that CPU provides.

"Here is a service that grew up organically from its community. Many of the people who go to CPU would find other services alien. It is staffed by highly qualified professionals and has a very low drop-out rate. It provides for an underserved portion of the population and it stands as a beacon for good, local services. Once it's gone you can't re-establish it," he says.

Seven years ago, a counsellor at Benedict Vallis' GP's surgery suggested that she needed long-term, intensive therapy and recommended CPU. "It was a lifeline for me. Simple as that," Vallis says. "From the moment I was there I felt supported. I felt I was part of something that would make a difference in my life, and it did."

Dresner hopes to stretch resources at CPU to allow it to operate for another year, while trying to raise funds from alternative sources. She says: "If we close, a choice will have been taken away from people who really need it. It would be a tragedy."

• To find out more about the service or to make a donation to the CPU fundraising campaign, go to camdenpsychotherapy.org.uk

Mary O'Hara

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Doctors reject coalition's changes to health plans

British Medical Association delegates call for the controversial health and social care bill to be withdrawn despite recent amendments, saying it will not protect the NHS

Doctors have dismissed the coalition's changes to its health plans as inadequate to protect the NHS and demanded that the controversial health and social care bill be withdrawn altogether.

Delegates at the British Medical Association's annual conference defied calls from the union's leadership and backed a motion that demanded further big changes to key elements of the bill.

Large majorities of the 500 delegates at the BMA's annual conference in Cardiff voted for a motion, underlining the fact that many medics remain fearful for the NHS's future, despite the recent concessions over the bill.

Doctors' representatives expressed serious unease that changes to the bill agreed by ministers after the NHS Future Forum report do not go far enough.

The government was also accused by Labour today of retaining key elements of the controversial reforms, despite promising to change them in the wake of its NHS "listening exercise".

The shadow health secretary, John Healey, said that despite ministers tabling 180 amendments to the bill, the Tories' long-term aim of breaking up the NHS and establishing a "full-scale market" remained intact.

The BMA conference passed a motion that said the government's response to the forum's report earlier this month "fails to satisfactorily address the concerns of the profession". It identified four key areas of continuing anxiety about the reformulated bill, which has begun a second period of scrutiny in the House of Commons by a public bill committee of MPs.

Speakers argued that the Secretary of State for Health's duty to provide comprehensive health services in England – which ministers said they would restore after it was removed in Andrew Lansley's original version of the bill – was still not guaranteed. They rejected the reassurance of the BMA's leader, Dr Hamish Meldrum, that legal advice taken by the union meant that the minister would remain ultimately responsible in the future.

Delegates also voiced dissatisfaction that the health regulator, Monitor, would still promote competition between hospitals as envisaged by Lansley in his NHS blueprint, which led to a split in the coalition, despite David Cameron agreeing to replace it with a duty to promote integration of services instead. They voted by 70% to 22% to defy Meldrum's advice that the duty to promote competition "has gone" as part of the government's rethink.

Delegates also backed, by 93% to 5%, the part of the motion that argued "that competition should not be forced on the NHS by imposing any duties on commissioners to promote choice as a higher priority than tackling fair access and health inequalities".

Meldrum warned that a vote to withdraw the bill altogether would weaken the BMA's position in ongoing negotiations with the government. Delegates nevertheless voted by 59% to 35% for the union to continue to call for the bill to be withdrawn rather than simply amended.

The vote is a setback for Meldrum, but will make little difference to the passage of the bill through the Commons, especially as Liberal Democrat MPs' fears about it have now been successfully neutralised.

A Department of Health spokesman said: "This vote is disappointing, because only a few weeks ago the doctors' union said there was much in our response to the listening exercise that addressed their concerns, and that many of the principles outlined reflected changes they had called for.

"The independent NHS Future Forum confirmed there is widespread support for the principles of our plans to modernise the NHS, including handing more control to doctors, nurses and frontline professionals.

"The bill has changed substantially since the BMA first voted to oppose government policy. Our plans have been greatly strengthened in order to improve care for patients and safeguard the future of the NHS."

Denis Campbell

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