Category: NHS

Increasing rationing in the NHS is incompatible with ‘halving the disability employment gap’

NHS-cuts

NHS England has published an updated list of medical conditions for which you can no longer receive prescriptions for, as part of a wider cost-cutting exercise due to insufficient funding from central government.

Last year I wrote an article about the stealthy creep of rationing of treatments in the NHS, and how gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith. 

One important point I didn’t raise in the article was about how the marketisation of the NHS has given rise to ‘perverse incentives’, which violate the very principles on which the national health service was founded. Neoliberal policies have shifted priorities to developing profitable ‘care markets’ making ‘efficiency’ savings and containing costs, rather than delivering universal health care.

In 2017, doctors raised concerns that vital medical treatments and operations are being increasingly rationed. The treatments affected include hip and knee replacements and cataract surgery to help restore sight as well as drugs for conditions such as severe forms of autoimmune related arthritis.

Such health care is normally given routinely under the NHS, but the British Medical Journal has found evidence it is being cut back, the data showed doctors are having to resort to special appeals to get their patients treated, and that the increasing restrictions were due to a lack of funding. 

The journal gathered evidence from clinical commissioning groups (CCGs) which showed the special requests are increasingly being used for vital non-emergency services, many of which prevent conditions from deteriorating and preserve mobility and vision, for example. 

Responses from 169 of the 209 clinical commissioning groups, which control local budgets, showed:

  • In 2013-14 there were just 49 requests made for hip and knee surgery, but by last year the figure had reached 899
  • Over the same period, the number of cataract appeals trebled to more than 1,000.
  • Overall the number of requests being made through the special cases route rose by 47% to 73,900
  • Just over half of all requests were approved.

Doctors now use a standardised scoring system to assess how much discomfort and lack of mobility a patient has for hip and knee replacements, for example. By increasing the bar at which a referral for an operation is made, the NHS is restricting the numbers of people getting treatment. This will invariably have an impact on the quality of people’s lives, and their degree of independence. 

These restrictions also apply to essential mental health care.

Doctors said the trend was a clear indicator that care was being rationed. For every case where an ‘exceptional argument’ has been made for treatment, there will be plenty more where patients will have gone without care and their doctor did not appealed.

Restricting access to mental health care, arthritis and cataract treatment is a false economy. Patients with these conditions are at risk of social isolation, depression, and the latter two conditions may lead to fall-related injuries and other complications. This cost-cutting approach means the NHS is reduced to little more than a crisis management service, rather than one that treats citizens to ensure they don’t reach a point of crisis in the first place, which is the best possible outcome. 

The administration of health service support impacts on people’s ability to work

The impacts of a profoundly punitive and inadequate social security system on the health of disabled people, and how the cuts have become a barrier to work has been well documented, and the enduring poverty and hardship disabled people are forced to live under. There has been rather less discussion about the impact of cuts to health care, treatment rationing and how this affects peoples’ working lives, however. With the NHS in crisis and waiting times for non-urgent treatments escalating, it’s difficult to see how timely interventions to help people back to work can possibly be delivered. 

One patient who has been caught up in the health care squeeze is Helen Cole, from west London. She was diagnosed with rheumatoid arthritis 11 years ago. This is an autoimmune condition that leads to very severe and disabling inflammatory arthritis and progressive joint damage. It doesn’t only affect the joints, however, as the illness can also affect major organs, such as the heart and lungs. It can cause osteoporosis and affect blood vessels, nerves, tendons and may even affect the hearing. Furthermore, during flare ups of inflammation, rheumatoid arthritis generally makes people feel very unwell.

Most rheumatologists agree that early treatment is essential to try and prevent the disease progressing rapidly.  Helen relies on an immune suppressing drug called rituximab, but it is not being routinely funded by her local health managers, so her doctor has to make a special request for it every six months. This has led to delays in her getting the drug and gaps in her treatment. Last time, she had to wait 10 weeks to get her next treatment. 

“I had a lot of pain in my joints and really big problems with fatigue. It can be really challenging day to day.”

She said she finds the whole process “stressful” and believes it “makes no sense”.

“The whole point of treating a disease like rheumatoid arthritis is to try to keep it under control at all times,” she added. 

Having timely and effective treatment which manages symptoms as effectively as possible can make a lot of difference to a person’s quality of life and independence, including being able to remain in work.  

Autoimmune conditions such as rheumatoid arthritis leave a progressive wake of damage that cannot be undone, which is why early treatment is essential. Patients are not always given treatments that are the most effective. The new generation of biologics –  such as rituximab –  are  very effective, but cost much more than older ‘disease modifying’ medications such as methotrexate, which is a chemotherapy that suppresses the immune system. Between 15 – 25% of people with rheumatoid arthritis respond positively to methotrexate. 

The new and expensive biologics, on the other hand, tend to be prescribed to those people whose disease is deemed ‘severe’, and who have not responded to methotrexate. But classification of ‘severe’ disease is an imprecise art and definitions are now invariably tied in with available funding. It means that people are waiting until their disease becomes aggressive, and damage to their joints has progressed before even being considered for a treatment that could have helped prevent the damage in the first place. In other words, NHS cuts are leading to disability, when it may have been prevented with effective treatments.

Stephen Cannon, of the Royal College of Surgeons, said local health managers were “unfairly and unnecessarily prolonging the time patients will spend in pain, possibly immobile and unable to carry out daily tasks or to work”.

The latest list of restrictions on prescriptions includes those for:

  • Acute Sore Throat 
  • Cold Sores
  • Conjunctivitis
  • Coughs and colds and nasal congestion
  • Cradle Cap (Seborrhoeic dermatitis – infants)
  • Haemorrhoids
  • Infant Colic
  • Mild Cystitis
  • Contact Dermatitis
  • Dandruff
  • Diarrhoea (Adults)
  • Dry Eyes/Sore tired Eyes
  • Earwax
  • Excessive sweating (Hyperhidrosis)
  • Head lice
  • Indigestion and Heartburn
  • Infrequent constipation
  • Infrequent Migraine
  • Insect bites and stings
  • Mild Acne
  • Mild Dry Skin/Sunburn
  • Mild to Moderate Hay fever/Allergic Rhinitis
  • Minor burns and scalds
  • Minor conditions associated with pain, discomfort and/fever. (e.g. aches and sprains, headache, period pain, back pain)
  • Mouth ulcers
  • Nappy Rash
  • Oral Thrush
  • Prevention of dental caries
  • Ringworm/Athletes foot
  • Teething/Mild toothache
  • Threadworms
  • Travel Sickness
  • Warts and Verrucae
  • Probiotics, vitamins and minerals are no longer available on prescription.

Although there are over-the-counter medications that people can buy for most of these conditions, those living on low incomes may not be able to afford the treatments. Effective pharmacy treatment for cystitis, for example, is around £25. If left untreated, cystitis can lead to kidney infection, which will require urgent treatment. Conjunctivitis is an eye infection that can be caused by bacteria, and this type most frequently needs an antibiotic ointment to prevent it from becoming more serious, because the eyes are very vulnerable to infection. Left untreated it can damage the eye and may cause blindness. 

There are exceptions to the restrictions, however. Circumstances where the product licence doesn’t allow the type of medication to be sold over the counter to certain groups of patients, for example. This may vary by medicine, but could include babies, children and/or women who are pregnant or breast-feeding. Community pharmacists will be aware of what these restrictions are and can advise patients accordingly. 

Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC (over the counter) product may also be prescribed treatment.

Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor ailment may also be prescribed medication for some of the above conditions. For example, chronic dry eyes many be one symptom of an underlying autoimmune condition, without effective treatment, it may cause progressive damage to the cornea as well as recurring bouts of conjunctivitis. Recurring mouth ulcers may be a symptom of a chronic condition, such as an autoimmune disease – for example lupus. 

In circumstances where the prescriber believes that in their clinical judgement exceptional circumstances exist that warrant deviation from the recommendation to self-care, they may prescribe medication for the above conditions.

Patients where the clinician considers that their ability to self-manage is compromised as a consequence of social, medical or mental health vulnerability to the extent that their health and/or wellbeing could be adversely affected if left to self-care may also warrant prescribed treatment for these conditions.

NHS England chief executive Simon Stevens, said: “To do the best for our patients and for taxpayers it’s vital the NHS uses its funding well.”

But that flies in the face of the ‘preventative approach’ that health secretary Matt Hancock has proposed recently.  For example, contact dermatitis may become infected if left untreated, especially if the person affected can’t isolate the cause. If one member of a family has head lice (and children pick them up very easily from nursery or school) and this isn’t treated promptly, the whole family is likely to catch them. Effective head lice treatment is costly and needs to be repeated. 

Threadworms are also highly contagious, and children pick them up very easily, as they are transmitted via microscopic eggs that can stick to clothing, towels, bedding, carpets and on unwashed hands. One study showed that up to 40% of children at primary school age will have threadworms. If access to prescribed treatment is restricted, children with embarrassing and very unpleasant, uncomfortable conditions like threadworms and head lice in poorer families may be left with the conditions longer, and may well pass on the parasites to others.

Deflection is when patients who are unable to get a GP appointment or adequate treatment seek treatment elsewhere – for example, an accident and emergency (A&E) department. The national GP patient survey asked patients who were unable to get a convenient appointment last time they called their GP what they did instead. It found that people end up going to an A&E department or a walk-in centre. Again, cost-cutting leads to further costs further down the line. 

Restricting treatments for those with mental health conditions and chronic illness means that these citizens are less likely to be able to work. This is at odds with the government’s pledge to ‘half the employment disability gap’.

GP’s are being ‘incentivised’ to reduce referrals to specialists

It was announced in April last year that General Practitioners across England will be able to “better manage” hospital referrals with a “digital traffic light system” developed by the Downing Street policy nudge wonks. This nudge is designed to target the ‘referral behaviours’ of GPs.

GPs are being offered cash payments as an ‘incentive’ to not refer patients to hospitals – including cancer patients – according to an investigation by Pulse, a website for GPs. 

Furthermore, a leaked letter sent by NHS to England to Clinical Commissioning Groups (CCGs) and seen by Pulse magazine last year, asks that all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals.  

A “clinical peer review of all referrals from general practice by September 2017”, will be required, the letter said. 

To ‘incentivise’ the scheme, the letter said that there will be “significant additional funding” for commissioners that establish peer-led policing schemes. It added that it could reduce hospital referral rates by up to by 30 per cent. NHS England said that they want to introduce the “peer review scheme” whereby GPs check the referrals of one another to ensure they are ‘appropriate’. However, experts warn this increasingly Kafkaesque layer of bureaucracy could lead to more problems and possible conflict with patients’ safety and standard of care. 

“Cash incentives based on how many referrals GPs make have no place in the NHS, and frankly, it is insulting to suggest otherwise,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs.

Of course, it’s important to take measures to ensure that GP referrals are appropriate and high-quality, but payments to reduce referrals would fly in the face of this, and erode the trust our patients have in us to do what is best for them and their health.” 

The NHS has been squeezed for increasingly drastic ‘efficiency savings’ in the past eight years. It’s absurd, however, that a huge amount of money is being spent on restricting access to healthcare, rather than on simply adequately funding healthcare provision.

Potential impact on social security assessments for people with chronic illness

Something else to consider is the potential impact this may have on people needing to claim social security disability support. The private company assessors hired by the government to determine eligibility for Employment and Support Allowance (ESA) and Personal Independence Payment (PIP) tend to regard people who haven’t been referred to a specialist as being less ill than those who have.

They also tend to take prescribed treatments into account when assessing the severity of illness, the needs of claimants and their eligibility for an award. Being let down by the NHS potentially has a knock-on effect which may leave some people in a situation where they can’t get either the health care or the financial support they need to live independently, increasing their vulnerability. 

There is no specific list of services to which individuals using the NHS are guaranteed access. Instead individuals have a number of legal rights that are set out in the NHS Constitution. These include the right to: receive most NHS services free of charge; receive certain treatments within a maximum waiting time; be treated in a safe and clean environment; have access to drugs and treatments recommended by the National Institute for Health and Care Excellence (NICE), if a doctor says it is appropriate. 

Like our social security system, the NHS should be there for all of us in our time of need, based on principles of inclusion, support and security for all, assuring us of our safety and dignity. However, chronic under funding, rationing and the increasing marketisation and ‘efficiency savings’ demanded by the government are incompatible with supporting citizens – especially those with multiple disadvantages – to live full, healthy and independent lives.

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Related

Tories propose nudge, big business AI initiative and ‘personal responsibility’ in place of adequate health care funding

Cash for Care: nudging doctors to ration healthcare provision

 


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The NHS business services authority is creating a hostile environment for vulnerable patients

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Patients claiming universal credit who are exempted from prescription charges are receiving penalty notices because prescription forms have not been amended to include the benefit – six years after it was introduced. Some people have reported receiving multiple charge notices. Many people are being penalised for a pharmacy error or because of a misunderstanding. A third of the 2017 penalties imposed were overturned on appeal so far.

Patients who are suspected of wrongly claiming free prescriptions face a penalty of five times the prescription charge plus the charge itself. The maximum is £100; £50 is added if the bill is not settled within 28 days. 

The NHS Business Services Authority (NHSBSA), an arm’s length body of the Department of Health and Social Care (DHSC), says a universal credit tick box should be added “later this year”. Until then, claimants entitled to free prescriptions must tick the “income-based jobseeker’s allowance” box. However, some who did so report they have still been penalised. Furthermore, no one is informing people which box to tick.

Many of the patients who receive penalty notices simply failed to realise that they no longer qualified for free prescriptions and dental treatment. Exemption certificates are automatically issued to those who earn less than £15,276 a year and receive working tax credit, child tax credit, or income support, as well as income related Employment and Support Allowance.

However, apparently, the certificates are only valid for up to seven months and recipients are not notified if they do not qualify for a renewal. The new fraud prevention system seems to be set up to penalise people because of the fact they are not kept informed of changes to their entitlement to free prescriptions, which is categorically unfair.

Moreover, it is creating severe distress and harm.

The devastating impact on vulnerable patients

Last year, Labour called for an overhaul of the system when a woman killed herself after receiving nearly £200 in penalty charges. Penny Oliver, a part-time chef, had not realised her exemption had lapsed after an ESA assessment deemed her fit for full-time work. Because her benefits had been cut she could not afford the penalties. In June 2018, she took an overdose of antidepressants – the medication that had created the debt.

Oliver owed sums of just £8.60 and £20.60. But with penalty fees and surcharges these rocketed – the second one alone soaring to £120.60. That’s ten times the amount for that prescription. After having lost hundreds of pounds a month when her benefits were cut, she simply couldn’t pay. Her housing benefit and council tax reduction were also cut, leaving her facing recovery action for an overpayment. 

She had just a few pounds in her account and was surrounded by payment demands when her family tragically found her dead last in June. Letters from the council, the NHS and Department for Work and Pensions included threats to take her to court and inform her employer if she did not pay.

At the time, shadow Health and Social Care Secretary Jonathan Ashworth said: “This is shocking. Questions have to be asked about the humanity of a system that does this to vulnerable people.

Penalty charges should be scrapped – it’s a disgrace to exploit vulnerable, ill people in this way. Ministers urgently need to step in and review this system.

“Our NHS is there to help patients get better not make their condition worse by putting ­unacceptable burdens on people like this.”

Single mother Sue Carpenter was ordered to pay £100 after mistakenly claiming a free dental check-up. “I have had an NHS exemption since my daughter was three, but I received no reminder that it would run out when she was 18,” she explains.

“I knew my child tax credit would change, but I’m still eligible for working tax credit and I assumed the exemption was linked to the entire tax credit award, not just to the child component. The dentist didn’t ask to see my certificate, which I now realise expired two weeks before.”

Carpenter says that the expiry date should be made clear. “The NHS exemption seems a unique instance of a status that runs out with no clear warning, allows you to continue using it when it has expired and then incurs a steep penalty without prior notice of the consequences.”

The NHSBSA says it is a patient’s responsibility to check the expiry date on their exemption certificate.

However, recovering costs someone incurred in error is one thing, but fining people because they didn’t read the very small print, especially given that the citizens affected are likely to be ill and also on a low income, is a step too far. While it raises revenue for a cash-starved NHS, it is at the expense of those with the least, as usual. Fining people for a genuine mistake because they are not provided with sufficient information in the first place is outrageously mercenary.

The high cost of countering pre-estimated fraud

It is unsurprising to learn that the NHS counter fraud authority was created by legislation, launched in 2017-18, and is subject to direction by the Secretary of State. It’s also worth noting that the majority of health funding goes to the Department’s
arm’s-length bodies. 

In 2016-17 the Health Department had an overall revenue and capital budget of £122.2 billion. Less than 4% (£4.7 billion) of its funding was allocated to the core Department, according to the National Audit Office (NAO). The remainder  (£117.5 billion) was allocated to its arm’s-length bodies. That’s a huge sum of public money that is spent on managing the NHS and not on delivering frontline services. 

Furthermore, amendment was made via statutory instrument to the Regulation of Investigatory Powers (Directed Surveillance and Covert Human Intelligence Sources) to ensure that the senior officers of the NHSCFA will have the power to authorise the conduct of covert directed surveillance. The health authority is directed to carry out the Secretary of State’s functions in relation to counter fraud against or affecting the health service in England.

Usually when Conservatives claim to “counter fraud”, it entails the creation of a hostile environment. Social security, for example, has been transformed from a redistributive system for the public protection from the ravages of poverty to one that administers the discipline, coercion and sanctions, using absolute poverty as a punishment for “non compliance”.

Professional and patients’ bodies have also expressed their concern that the system designed to detect fraud is undermining the whole ethos of the NHS.

Rachel Power, chief executive of the Patients Association said: “Serving penalty notices on patients cannot be a caring way to manage this system.” 

“Some of the people who received these notices will be in vulnerable situations, and the impact of letters threatening court action, particularly for those who are receiving treatment for mental illnesses, should not be underestimated.

“While it’s important that fraudulent and incorrect claims are identified, nearly one in three penalty notices had to be withdrawn because they were issued in error. This shows a system that is highly dysfunctional.”

It also indicates the introduction of an increasingly hostile environment within health services, especially for those ill people on low incomes. 

The health secretary, Matt Hancock, has previously said: “The message is clear. The NHS is no longer an easy target, and if you try to steal from it you will face the consequences.”  

I’m wondering how it is possible to steal healthcare, bearing in mind that the same minister insists that the healthcare in the UK is still “free at the point of access”. I think this systematic restriction of access to public services more generally is precisely what David Cameron meant when he said that he wanted to tackle the “culture of entitlement”.

The public pay taxes and national insurance – “social insurance” – for increasingly little return while millionaires get tax cuts and carrots while everyone else gets the austerity stick, and told to live within our increasingly diminishing means. We are being dispossessed, so the very wealthy can accumulate even more wealth.

This year the NHS is piloting a digitised system that it claims will enable pharmacists to check eligibility instantly. However, surely the same system could be used to inform patients of their eligibility status also. That would reduce error considerably, too. 

The NHSBSA say they are digital by default, and: “We use complex algorithms and data mining tools as a means to identify both normal behaviour and outliers in NHS data, within which fraudulent behaviour may be found.

The resulting “analyses” are used to support ongoing investigations as well as inform the intelligence picture and guide fraud prevention steps.”

The “complex algorithms” are very clearly being used as a blunt instrument, resulting in least one death, to date. Yet one of the highest costs of “highly probable” fraud, according to the NHS BSA is from procurement and commissioning fraud, at an estimated cost of £266m £266m between 2016-17. (See page 8 here). 

The key stakeholders of the counter fraud authority include NHS England, NHS Improvement and the Cabinet Office.

The Royal Pharmaceutical Society and the British Medical Association fear the new system will withhold vital treatment from people on low incomes who remain eligible for free prescriptions but have failed to renew their paperwork.

“Pharmacists don’t want to be the prescription police, spending their time checking exemptions rather than advising on patient care,” says Sandra Gidley, chair of the Royal Pharmaceutical Society’s English pharmacy board.

“It’s very easy for mistakes to happen. Sometimes it’s that the computer says ‘no’, on other occasions people have simply forgotten to renew. Some don’t know if they’re exempt or not, or wrongly assume they are.”

She says that the prescription system should be overhauled to prevent confusion and reflect medical advances. “Medical exemption criteria have not changed since 1968. This means they are completely unjust. For example, those with long-term asthma have to pay for prescriptions, whereas people with diabetes don’t. Many new long-term conditions have been discovered in the past 50 years and they aren’t covered at all.

“It would be much simpler to have free prescriptions for everyone, as is the case in Scotland and Wales, because then no one would have to worry about remembering to fill out the right form.”

Data released under the Freedom of Information Act last year shows that 1,052,430 penalty notices were issued to patients in England in 2017 – about double the level in the previous year. But the data confirms that 342,882 penalty notices were subsequently withdrawn because the patient was entitled to free prescriptions after all, upon further investigation. 

The NHSBSA, the agency in charge of issuing the fines, said it was “continually reviewing its data-matching process and making improvements to ensure eligible patients were not wrongly pursued.”

The agency said it was also trying to educate patients on the importance of keeping the details on both their GP records and their exemption or prescription prepayment certificates up to date. 

It’s yet another public service system that’s been designed to assume people are guilty of fraud, with the onus on patients to provide proof that they are innocent.

“The NHS loses millions each year through fraudulent and incorrect claims for free prescriptions,” said Alison O’Brien, head of loss recovery services at the authority. “On behalf of NHS England, and in discussion with the Department of Health and Social Care, the NHS Business Services Authority checks claims randomly and retrospectively to appropriately recover funds and return them to NHS services.”

However, as the data strongly suggests, in far too many cases, it isn’t appropriate to recover funds and impose fines. Errors are happening all too frequently, creating anxiety, distress and hardship. When accusations of fraud are made which are not true, it causes humiliation and creates scapegoats.

Given that the neoliberal state treats citizens as if they have done something wrong as a starting point – which is the key message embedded in hostile environments; creating stigma and criminalising already marginalised groups –  it’s become a standardised form of political abuse which is entrenched within our public services. It’s designed as a punitive form of resource gatekeeping, resulting in withholding service and support from the very people who those services were designed to support.

Unfortunately, there is a pathological political narrative that tends justify cost cutting measures and punitive policies which portray the state and the mythically discrete class, “the taxpayer”,  as victims, when the state is actually perpetrator, and we all pay taxes for the services that are being dismantled by stealth.

Many of us have raised concerns related to the impact of the government’s various “hostile environment” policies in the health, housing, welfare, finances and banking, education, social services and other sectors, on vulnerable groups and those who share protected characteristics. The Equality Act was originally designed to address this kind of discrimination. But as we have learned over the last eight years, the government regards human rights and equality frameworks as a mere inconvenience. 

Peter Burt, a patient who was wrongly issued with one of the NHS penalty notices, said he worried about how certain patients would react to receiving one. “Some of the people who received these notices will certainly be in vulnerable situations and some will be receiving prescription medication for anxiety and mental health issues,” Burt said.

“They should not be receiving letters threatening court action just because the NHS can’t be bothered to check the records to see whether they have a prepayment card – especially if there is no intention of carrying out the threat. It’s hugely disappointing that, at a time when clinical services are clearly facing financial strains, the NHS bureaucracy is wasting money by sending out hundreds of thousands of inaccurate demands every year.”

Watson said more problems lay ahead if further planned changes to the way medicines were prescribed were introduced.

“The bureaucracy around prescriptions is unfit for purpose, and will only get worse if NHS England introduces its planned restrictions on prescribing over the counter medicines,” she said. “Serving notice of penalties for free prescriptions on patients who may be vulnerable and unwell and are then required to demonstrate their right to a free prescription cannot be a compassionate and caring way to manage this system.”

It certainly seems to be the government’s modus operandi to withdraw compassion and care when it comes to public policy design, which have been templated to implement austerity rather than ensure delivery of public services that are fit for purpose.

You can check your eligibility for free prescriptions and other health services here: National campaign launches urging patients to ‘Check Before You Tick’ for free prescriptions.

 


 

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Cash for Care: nudging doctors to ration healthcare provision

Image result for NHS rationing treatment

Today, while everyone is being distracted by the continuing resignations from Theresa May’s disintegrating government, the Conservatives are openly talking among themselves (again) about charging for NHS services. So much for the government’s continued reassurances and promises about UK healthcare continuing to remain ‘free at the point of access.’  

The NHS has never been safe in  Conservatives hands.

Last week I wrote an article about the stealthy creep of rationing of treatments in the NHS, and how gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith. 

One important point I didn’t raise in the article was about how the marketisation of the NHS has given rise to ‘perverse incentives’, which violate the very principles on which the national health service was founded. Neoliberal policies have shifted priorities to developing profitable ‘care markets’ making ‘efficiency’ savings and containing costs, rather than delivering universal health care.

Another shift in emphasis is the “behavioural turn”. It’s politically convenient to claim that people’s behaviours are a major determinant of their health. Some illnesses are undoubtedly related to lifestyle – type two diabetes, for example. But it is difficult to blame individual’s behaviours for type one diabetes, which is an autoimmune disease, and these may happen to people who lead very healthy lifestyles, as well as those who don’t. This ‘behavioural turn’ shifts emphasis from the impact of structural conditions – such as rising inequality and poverty – on public health. It also provides a political justification narrative for cuts to healthcare and welfare provision. (See also The NHS is to hire 300 employment coaches to find patients jobs to “keep them out of hospital”. )

Behavioural economists have claimed that ‘nudge’ presents an effective way to ‘change behaviours’ within the NHS and ‘improve outcomes’ at lower cost than traditional policy tools. Back in 2015, the Nudge Unit were looking for “many potentially fruitful areas in which to use behavioural insight to improve health and health-service efficiency, either by retrofitting existing processes or by designing completely new services most effectively.” ‘Fruitful’ as in lucrative for the part-privatised company, but not so lucrative for the NHS.

Behavioural economists are working for the government and public sector to “harness [public] behaviours to shift and reduce patterns of demand in many public services.” The problem is that human needs arising from illness are not quite the same thing as human behaviours and roles, yet the government are increasingly conflating the two. (See discussion on Talcott Parsons and the ‘sick role’ in this article, for example, along with that on ‘work is a health outcome’.)

Public services are associated with fundamental human rights, which in turn are based on notions of fundamental human need. Addressing basic human needs is fundamental to survival.

As Abraham Maslow concluded, motivation for behaviours is is closely related to fulfilling our basic needs, because if they are not met, then people will simply strive to make up the deficit as a priority. This undermines aspiration and human potential. Fulfilment of psychosocial needs will become a motive for behaviour only as long as basic physiological needs ‘below’ it have been satisfied. Health is a fundamental human need. To paraphrase Maslow, we don’t live by bread alone, unless there is no bread.

Public services are an essential part of developed democracies, they ensure all citizens can meet their basic needs, and therefore, the provision promotes wider social and economic wellbeing and progress.

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Maslow’s hierarchy of human needs

The Nudge Unit had already run a trial in Nottingham, which provided feedback to doctors of the cost of a commonly used discretionary lab test. This prompt retained clinical freedom, and did not ask doctors to order fewer tests – but the number of
tests fell by a third.

anttibiotic resistance

In 2016 the UK government set a target to half ‘inappropriate’ antibiotic prescribing by 2020. The Nudge Unit set out to “improve prescribing in line with government ambitions”. 

Behavioural economists from the Unit claimed that by informing doctors that they are prescribing more antibiotics relative to 80 per cent of their peers, they are reducing the number of ‘unnecessary’ prescriptions by 3.3 per cent (more than 73,000 prescriptions) – helping to address what the Chief Medical Officer has identified as perhaps the greatest medical threat of our age – antibiotic resistance. 

Between 2014 and 2015, the Behavioural Insights Team sent letters to 800 GP practices, telling them that other practices were recommending the use of antibiotics in fewer cases. (There is no evidence presented to determine if this was actually true, and judging by the template letter, it’s highly unlikely that it was true.)

The nudge method employed is called ‘social norming’, which operate as a kind of community enforcement, as norms are unwritten rules that define ‘appropriate’ behaviours for social groups. We tend to conform to the expectations of others. Changing perceptions of norms alters people’s expectations and behaviour.

Understanding norms provides a key to understanding social influence in general and conformity in particular. The Conservatives have traditionally placed a significant emphasis on social conformity.

There are ‘hotspots’ where more antibiotics are prescribed. However, the fact that these places tend to be some of the most deprived areas of the country strongly hints that there are underlying socioeconomic factors at play that cannot be solved with a nudge or prod. Research indicates that community socioeconomic variables may play a significant role in sepsis-attributable mortality, for example.

Social problems such as poverty and inequalities in health arise because of unequal distributions of wealth and power, therefore these problems require solutions involving  addressing socioeconomic inequality. As it is, the government is unprepared to spend public funds on public services to redistribute resources. 

The behavioural study did not include any consideration of socioeconomic variables on rates or severity of infection, or types of infection. 

The idea that ‘changing the prescribing habits in hospitals’ and GP surgeries will impact on antibiotic resistance is based on an assumption that doctors over prescribe antibiotics in the first place. There is no evidence that this is the case, and it’s very worrying that anyone would think that targeting doctors with behaviourally-based remedies will address antibiotic resistance and assure us, at the same time, that antibiotics are actually prescribed when appropriate, and tailored, ensuring the safety and wellbeing of the patient, rather than being prescribed according to arbitrary percentage norms distributed by behavioural economists.

The trials did not include sufficient data regarding clinical detail or diagnostic uncertainty that might justify antibiotic prescribing in individual cases.

One of the nudge unit team’s key aims is to design policies which reduce costs. They say: “The solution to the problem of AMR is not just to produce new and better drugs – that takes time, and a great deal of money. We must also reduce our use of antibiotics when they are not needed. Sadly, it seems that they are used unnecessarily twenty percent of the time in the UK”.

The various Nudge Unit reports on behavioural strategies that target doctors don’t mention any follow-up research to ensure that the reduction in antibiotic prescriptions did not correlate with an increase in the severity of infections or poor outcomes for patients. In fact one report highlighted that those who were admitted to hospital because their condition deteriorated were excluded from the trial, as they no longer met the inclusion criteria. That effectively means that any adverse consequences for patients who were not given antibiotic treatment was not reported. And that matters.

The authors say “We as the authors debated at length as to whether we should emphasise the fact that 80% of the prescriptions are being used in necessary cases.” 

There is no indication of how ‘necessary cases’ are determined, and more to the point, who determines what is a ‘necessary case’ for antibiotic treatment. Furthermore, the report uses some troubling language, for example, doctors prescribing antibiotics ‘above average’ were referred to more than once as the “worst offenders.” However, as I’ve already touched on, patients needs may well vary depending on a range of variables, such as the socioeconomic conditions of their community, and of course, complex individual comorbidities, which may not be mentioned in full when doctors write up the account for the prescription.

Sepsis, which may arise from any kind of infection is notoriously difficult to diagnose. It is insidious and can advance very rapidly.  It’s even more difficult to determine when a patient has other conditions. For example, sepsis can arise when someone has flu. That happened to me, when I had developed pneumonia without realising that I had. It’s standard practice for paramedics to administer a broad spectrum antibiotic and intravenous fluids to treat suspected sepsis and septic shock. This can often save lives. Sepsis kills and disables millions and requires early suspicion and antibiotic treatment for survival.

Once the causative agent for the infection is found, the IV antibiotics may then be tailored to treat it. The wait without any treatment until a firm diagnosis is potentially life-threatening. But the biochemical tests, such as CRP, and X-rays take time. 

Treatment guidelines call for the administration of broad-spectrum antibiotics within the first hour following suspicion of septic shock. Prompt antimicrobial therapy is important, as risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics. This time constraint does not allow the culture, identification, and testing for antibiotic sensitivity of the specific microorganism responsible for the infection. Therefore, combination antimicrobial therapy, which covers a wide range of potential causative organisms, is tied to better ‘outcomes’. 

In the trial, behavioural economists referred to medical notes, and if there is no diagnosis, the necessity of the prescription is then questioned. Knowledge of complex medical histories may also influence doctors’ decisions, and this may not have been mentioned on medical record. A cough and breathlessness is a common symptom influenza. However, a patient with a condition that compromises their immunity, or someone who needs immune suppressants, for example, is rather more at risk of developing bacterial pneumonia than others, and someone with COPD or asthma is also at increased risk.  

If a person dies because treatment was not given promptly in high suspicion cases of severe infection and sepsis, who is to be held accountable, especially in a political context where treatments are being rationed and prescriptions are being increasingly policed?

It’s also worth bearing in mind that massive doses of antibiotics are added to livestock feed as a preventative measure and to promote growth before the animals are slaughtered and enter the food chain. Using antibiotics during the production of meat has been heavily criticised by physicians and scientists, as well as animal activists. The pharmaceutical industry is making billions annually from antibiotics fed to livestock, which highlights the perverse incentives of the profit motive and potentially catastrophic impact on humans. It is estimated that between 70 – 80 percent of the total of antibiotics used around the world are used within the animal farming and food industry. No-one is nudging the culprits. 

The potential threat to human health resulting from inappropriate, profit seeking antibiotic use in food animals is significant, as pathogenic-resistant organisms propagated in these livestock are poised to enter the food supply and could be widely disseminated in food products.

Antibiotics used on farms can spill over into the surrounding environment, for instance through water run-off and slurry, according to a report from the UN’s environment body, last year, with the potential to create resistance to the drugs across a wide area.

In 2013, researchers showed that people who simply lived near pig farms or crop fields fertilized with pig manure are 30% more likely to become infected with methicillin-resistant Staphylococcus aureus bacteria.

Cash for care – rationing referrals to hospital consultants and diagnostic testing

It was announced in April this year that General Practitioners (GPs) across England will be able to “better manage” hospital referrals with a “digital traffic light system” developed by the Downing Street policy wonks. This nudge is designed to target the ‘referral behaviours’ of GPs.

GPs are being offered cash payments as an ‘incentive’ to not refer patients to hospitals – including cancer patients – according to an investigation by Pulse, a website for GPs. 

Furthermore, a leaked letter sent by NHS to England to Clinical Commissioning Groups (CCGs) and seen by Pulse magazine last year, asks that all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals.  

A “clinical peer review of all referrals from general practice by September 2017”, will be required, the letter said. 

To ‘incentivise’ the scheme, the letter said that there will be “significant additional funding” for commissioners that establish peer-led policing schemes. It added that it could reduce hospital referral rates by up to by 30 per cent. NHS England said that they want to introduce the “peer review scheme” whereby GPs check the referrals of one another to ensure they are ‘appropriate’. However, experts warn this increasingly Kafkaesque layer of bureaucracy could lead to more problems and possible conflict with patients’ safety and standard of care. 

In a trial of the nudge scheme, four NHS clinical commissioning groups (CCGs) have been using “profit share” initiatives to ration care, to help them ‘operate within their budgets’. Clinical Commissioning Groups hold the budget for the NHS locally and decide which services are provided for patients. 

Through this scheme, GPs are told they will receive up to half of the money that is saved by fewer patients going to hospitals for tests and treatments.

So to clarify, surgeries are being offered financial ‘incentives’ for not sending patients to hospital to save money, that is then reinvested in part to implement further rationing of healthcare. The move has been widely condemned as a “dereliction of duty” by the community of medical experts and professionals. Referrals to consultants often involve important diagnostic procedures, therefore there is often no way of knowing for sure in advance of the referral whether or not it is “warranted”.

The NHS has had ‘referral management centres’ in place for many years.  However, last year they were at the epicentre of a scandal when it was revealed that the use of these centres has increased 10-fold over recent years. Furthermore, the centres are privately run and extremely expensive to employ, diverting funds that could simply be spent on patient care.

Moreover, those who were reviewing the referrals were also found to have varying levels of clinical knowledge, and so were not always able to correctly identify which referrals were ‘necessary’. They were also extremely inefficient as patients were forced to wait a long time for appointments. 

The Pulse investigation into referral incentive schemes being run by NHS clinical commissioning groups (CCGs) across England found some regions offering GPs as much as 50 per cent of any savings they can make. The “profit-share” arrangements mean practices stand to benefit financially by not sending patients for treatment or to see a specialist.

Hospitals are paid for operations and other activity, so by sending patients to cheaper services run by GP practices – such as diabetes and pulmonary clinics – or by keeping them out of hospital altogether, practices can increase the size of savings. GPs are not paid per procedure. Rather, they receive a single payment when each patient is registered with them. 

Currently, when doctors are referring patients for appointments with hospital consultants, the nudge – in the form of a “Capacity Alert System” – operates by displaying a red light next to hospitals with lengthy waiting times, and a green light next to those with more availability, on the system. 

The system underwent two trials in north-east and south-west London over the winter. During these pilots the number of referrals made to overburdened hospitals was reduced by 40%, while those made to hospitals with ‘spare capacity’ rose by 14%, according to NHS England. There was no comment made regarding the impacts of the scheme on patients’ health.

GP leaders have also said it is “insulting” to suggest doctors are sending patients to hospital arbitrarily, and raise significant conflicts of interest.

“Cash incentives based on how many referrals GPs make have no place in the NHS, and frankly, it is insulting to suggest otherwise,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs.

Of course, it’s important to take measures to ensure that GP referrals are appropriate and high-quality, but payments to reduce referrals would fly in the face of this, and erode the trust our patients have in us to do what is best for them and their health.” 

The NHS has been squeezed for increasingly drastic ‘efficiency savings’ in the past eight years. It’s absurd, however, that a huge amount of money is being spent on restricting access to healthcare, rather than on simply adequately funding healthcare provision.

Dr Peter Swinyard, chair of the Family Doctor Association, said the profit-share schemes were “bizarre”, adding: “From a patient perspective, it means GPs are paid to not look after them.

“It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.”

Meanwhile, NHS Barnsley CCG has identified a £1.4m funding pot to pay its practices if they achieve a reduction in referrals to specialties, including cardiology, pancreatic surgery, and trauma and orthopaedics.

The CCG said the 10 per cent target was “ambitious but achievable”.

Last year it was discovered that the NHS has to spend £1.5 billion in legal costs when patients don’t get what the standard of care expected and pay for from their healthcare providers. In 2015/16, there was a 27% increase in the number of claims and a 72% increase in legal cost, which amounted to £1.5 billion.  With the amount of money that the NHS is spending on legal costs for medical blunders, the NHS could have paid for the training of more than 6,000 doctors. Or eased the rationing of essential healthcare provision.

The purpose of the NHS has been grotesquely distorted: it was never intended to be a bureaucratic gatekeeping exercise that rations healthcare. The purpose of all public services is to provide a public service, not ration provision. Such is the irrationality of the government’s ‘market place’ and ‘profit over human need’ narrative. 

Dr Eric Watts, a consultant haematologist for the NHS, says that the British government couldn’t care less about the fall of the NHS. He said, “This is a triumph of secrecy and implacable lack of care about the NHS by a Government determined to watch it fail then fall.” 

One CCG told Pulse“Ensuring treatment is based on the best clinical evidence and improving historical variation in access is essential for us locally.

“Financially, it is an effective use of local resources which will improve patient experience and outcomes and increase investment in primary care in line with the Five Year Forward View commitments.” Those ‘commitments’ are the increasing implementation of cuts to healthcare provision and funding.

Cuts to care may well improve financial ‘management’ but it cannot be claimed that healthcare rationing “improves health outcomes” for patients. That flies in the face of rationality.

NHS England also said last year that funding will be available for CCGs to start “peer review schemes”, where GPs police each other – checking that their colleagues are referring ‘appropriately’, but it is not clear what it thinks about direct payments linked to cutting referrals.

The “Cash for Cuts” investigation, by GP publication Pulse, asked all 207 CCGs in England about their processes for cutting referrals. Of the 180 who responded, 24 per cent had some kind of incentive scheme aimed at lowering the numbers of referrals. 

This included payments for getting GPs to “peer review” each other’s referrals or other strategies. 

Dr Chaand Nagpaul, from the British Medical Association (BMA) has  also criticised the nudge scheme. He says “It’s a blunt instrument which is not sensitive to the needs of the patient and is delaying patient care. 

“It has become totally mechanistic. It’s either administrative or not necessary for the patient. It’s completely unacceptable. Performance seems to be related to blocking referrals rather than patient care.”

The CCGs have defended the schemes, saying that at the time they were pushed through, the NHS was struggling through the worst winter ever in its history and had not been able to hit target waiting times since 2015. The CCGs have said that the scheme is only to help reducing ‘unnecessary referrals’ and therefore improve outcomes for ‘genuine patients’, and not to reduce numbers overall. Who decides which patients are ‘genuine’, and on what criteria? 

Dr Dean Eggitt, who is the British Medical Association’s GP representative for Barnsley, Doncaster, Rotherham and Sheffield, also disagrees with the scheme. 

“The scheme is unsafe and needs to be reviewed urgently,” he said. 

The BMA’s GP committee have said that it had raised concerns nationally where CCGs have set an “arbitrary target” for reducing referrals. 

Before Christmas, Jeremy Hunt, the Health Secretary, announced that he wanted hospitals to find another £300m in savings on basic items like surgical gloves and bandages, and a long-awaited pay rise for nurses is contingent on staff boosting “productivity”.  

A Department of Health and Social Care spokesperson said: “Patients must never have their access to necessary care restricted  – we would expect local clinical commissioning groups and NHS England to intervene immediately if this were the case.” 

I’ve asked NHS England whether it would be reviewing cases where GPs stand to profit financially for not referring patients, along with others, but I have had no response at time of this publication. 

The NHS was founded on the principle of free and open access to healthcare provision for everyone. The nudge schemes I’ve outlined have introduced ‘perverse incentives’ that prompt GPs to ration health care. I have argued elsewhere on many occasions that nudge and the discipline of behavioural economics more generally is technocratic prop for a failing  political and socioeconomic system of organisation – neoliberalism. Rather than review the failures of increasing privatisation and ‘competition’, the government chose to deny them, applying increasingly irrational ‘solutions’ to the logical gaps in their ‘marketplace’ dogma. 

Yet it is blindingly clear that citizens needs and their human rights are being increasingly sidestepped by the absolute prioritisation of the private profit incentive. 

Nudge isn’t about ‘economics theory and practice adapting to human decision making’, as is widely claimed. It isn’t about remedying ‘cognitive biases’. It isn’t about people making ‘flawed decisions’.

It’s about holding citizens responsible for the problems created by a flawed socioeconomic model. It’s about a limited view of human behaviours and potential, because it frames the poorest citizens in an increasingly unequal society as ‘failed entrepreneurs’. Those members of the public who need to access public services are increasingly being portrayed as an economic ‘burden’. As such, nudge places limitations on and replaces genuine problem-solving approaches to public policy.

Nudge is about authoritarian governments using a technocratic prop to adapt human perceptions, behaviours and expectations, aligning them to accommodate inevitable  catastrophic social outcomes. These outcomes are symptomatic of the failings and lack of rational insights of wealthy and powerful neoliberal ideologues, who are determined to dismantle our public services. Without the consent of the majority of citizens. 

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The NHS was never safe in his hands. The company he keeps has made sure of that.

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Rationing and resource gatekeeping in the NHS is the consequence of privatisation

People march through London to mark 70 years of the NHS

People march through London yesterday to mark 70 years of the NHS.

Gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith. 

In the NHS, even the resource gatekeepers have gatekeepers, those receptionists standing sentry at the end of the telephone, and in general practices, who ration access to the GPs so assiduously we patients often get better before we’ve managed to arrange an appointment. Or ended up at an Accident and Emergency Department.

Only a service dedicated to keeping the public and service providers apart could have devised a system so utterly demeaning. It turns patients into supplicants and receptionists into bouncers who make decisions they are unlikely to be qualified to make, neither being roles to which any of us aspired.

Now, it has been decided that the NHS needs to scrap more medical procedures, including injections for back pain, surgery to help snorers and knee arthroscopies for arthritis, which form part of an initial list of 17 operations that will be discontinued completely or highly restricted by NHS England as many of these problems “get better without treatment.”

I can assure you that arthritis of the knee, or anywhere else for that matter, doesn’t tend to get better. Medical interventions can help patients with ‘managing’ the condition, however. 

Varicose vein surgery and tonsil removal also feature on the list of routine operations to be axed as part of NHS England’s drive to cease “outdated” and “ineffective” treatments.

The latest round of rationing is hoped to save £200m a year by reducing “risky” or “unnecessary” procedures. Patients are to be told they have a responsibility to the NHS not to request “useless treatment.”

However, complications from varicose veins, for example, include leg ulcers which require more costly specialist treatment to help them heal. 

Steve Powis, the medical director of NHS England, said: I’m confident there is more to be done”, adding that the list of 17 operations formed “the first stage” of rooting out futile treatments that are believed to cost taxpayers £2bn a year.

“We are also going to ask ‘Are there other procedures and treatments we should add to the list?’. Additions could include general anaesthetics for hip and shoulder dislocations and brain scans for patients with migraines.

Hip and shoulder dislocations are notoriously excruciating, as is the process of having the joint relocated, though the latter is short-lived. It’s particularly brutal to leave patients without pain relief, and especially children.

The reason why brain scans are often very important when people develop migraine symptoms is that they can determine whether the severe headaches are caused by something more serious, such as a subarachnoid haemorrhage (which happened to me) or a tumour (which happened to my mother). Sometimes ‘migraines’ are something else.
Powis added: “We have to spend taxpayers’ money wisely. Therefore, if we are spending money on procedures that are not effective, that is money we could spend on new treatments that are clinically effective and would provide benefits to patients. It’s absolutely correct that, in getting more efficient, one component of that is to make sure we are not undertaking unnecessary procedures.”

The rationing comes as the government prepares to raise taxes and ditch an increase to the personal income tax allowance to pay for NHS funding plans. According to proposals, £20.5bn of extra funding would be set aside for the health service by 2023. In a speech at the Royal Free hospital in London a fortnight ago, Theresa May said tax rises were inevitable.

However, there doesn’t seem to be any indication that this additional measure will ensure the public has value and adequate health care for their money. 

The prime minister said: “As a country, taxpayers will need to contribute a bit more.But we will do that in a fair and balanced way. And we want to listen to people about how we do that, and the chancellor will bring forward the full set of proposals before the spending review.”

Here are the 17 treatments NHS England may axe

Four procedures will only be offered at the request of a patient:

  • Snoring surgery
  • Dilation and curettage for heavy menstrual bleeding
  • Knee arthroscopies for osteoarthritis
  • Injections for non-specific back pain

A further 13 treatments will only be offered when certain conditions are met:

  • Breast reduction
  • Removal of benign skin lesions
  • Grommets for glue ear
  • Tonsillectomy
  • Haemorrhoid surgery
  • Hysterectomy for heavy menstrual bleeding
  • Removal of lesions on eyelids
  • Removal of bone spurs for shoulder pain
  • Carpal tunnel syndrome release
  • Dupuytren’s contracture release
  • Excision of small, non cancerous lumps on the wrist called ganglia
  • Trigger finger release
  • Varicose vein surgery

Some of these procedures do improve the quality of people’s lives. I’m wondering how this sits with the government’s drive to push people with disabilities and medical conditions into work.

Although it was announced recently that the NHS is to hire 300 employment coaches to find patients jobs to “keep them out of hospital.” It’s what the government probably calls the ‘two birds and one bullet’ approach.

A man with a birthday placard as thousands of people march to mark 70 years of the NHS

Yesterday, tens of thousands of people marched through London to mark the NHS’s 70th anniversary and demand an end to government cuts and further privatisation of the health service. Bearing placards reading “Cuts leave scars”, “For people not profit” and “Democracy or corporate power” demonstrators moved down Whitehall on Saturday afternoon to the chant of “Whose NHS? Our NHS”.

The protesters stopped outside Downing Street to demand Theresa May’s resignation en route to the stage where they were greeted by a choir singing “the NHS needs saving, don’t let them break it”. Shortly after, Jeremy Corbyn addressed the crowd – organisers said there were about 40,000 people present – demanding an end to privatisation, the closure of the internal market, for staff to no longer be subcontracted to private companies and for social care to be properly funded.

Corbyn said: “There have been huge attacks on our NHS over many years,” he said. “The Tories voted against the original legislation and have always sought to privatise it and continue an internal market.

“Paying money out to private health contractors, the profits of which could and sometimes do, end up in tax havens around the world.

“Think it through, you and I pay our taxes because we want a health service for everybody, I don’t pay my taxes for someone to rip off the public and squirrel the profits away.”

I absolutely agree. 

A brief history of the travailing NHS under Conservative governments

The government has failed to adequately fund the NHS since taking office as part of the coalition in 2010, and has overseen a decline in the once widely admired public health service, as a way to privatise it by stealth. 

The Tories have utilised a spin technique that carry Thatcher’s fingerprints – it’s called ‘don’t show your hand.’

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Jeremy Hunt and the Conservatives insist the NHS is ‘safe in our hands’

Chris Riddell 16.08.09

The direction of travel was set 25 years ago by the NHS review announced by Margaret Thatcher on the BBC Panorama programme in January 1988. The Conservatives have a poor track record with the NHS. Thatcher ushered in the NHS internal market, the mechanism that introduced what many in the health service still revile: competition.

Health authorities ceased to run hospitals but instead “purchased” care from hospitals who had to compete with others to provide it and became independent, self-governing trusts. The stated aim was to ‘increase efficiency’ and ‘eliminate waste’ through competition. Yet by the time John Major was prime minister, we saw the crisis deepen, with the postcode lottery and patients parked on hospital trolleys in hospital corridors for hours on end, waiting to see a worn out, overworked doctor.  

In order to assess the impact of Thatcher’s legacy on healthcare, it’s essential to appreciate that NHS market reforms began on her watch. Even the apparently relatively minor step of outsourcing hospital cleaning services was to cast a dark shadow over hospital care decades later. Putting cleaning services out to competitive tender meant that the job of cleaning wards went to the lowest bidder – often to companies that used casual, untrained staff, supplied by job centres. The contrast between the high quality of surgical treatment and the dirtiness of wards became notorious. The level of hospital-acquired infections grew steadily, including those caused by  ‘superbugs’  including MRSA. 

A study published by the Health Service Journal laid the blame for the rise of antibiotic resistant infections on poor hygiene standards; finding hospitals full of rubbish, uncollected left-over food in canteens and dirty linen strewn over bedroom floors. The impact outsourcing has had on cleaning services has been a constant source of tension since those early reforms. While trade unions and medical professionals have consistently argued against it, business leaders have always rejected any connection between outsourcing, infection rates, and declining standards.

Public sector outsourcing is central to the present government’s ideological strategy, despite the evidence that is now stacked against it being genuinely ‘competitive’. Since 2010, the number of large contracts awarded has increased by over 47% with tens of thousands of workers in various sectors – health, defence and IT – being transferred to corporate employers like Serco, Capita and G4S. The UK’s public sector has become the largest outsourcing market in the world, accounting for around 80% of all public sector contracting in Europe. These multinationals are not particularly interested in competition; they’re interested in profit and being in a monopoly position where they can dominate the market. Despite the wake of scandals that follows these companies, growth in the public sector outsourcing market shows no signs of slowing and the government shows no signs of learning from these events. 

Thatcher wanted to introduce even more radical changes – such as a shift to an insurance based healthcare model, with ‘health stamps’ for the poor – but in a busy decade, it seems that her battles with trade unions and left-wing Labour councils took priority.

It was under Thatcher’s administration that the climate of austerity began within the NHS. 

Then there was the Black Report into health inequalities, published in 1980 after a failed attempt by the  Conservatives to block its publication, noted that health inequalities in the UK were linked to socio-economic factors such as income, housing and conditions of work. The government rejected the report’s findings and recommendations.

Conservatives published a policy book called Direct Democracy in 2005. It claimed that the NHS was “no longer relevant”, and a system was proposed whereby patients were funded “either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice” – with the poor having their contributions “supplemented or paid for by the state”. The authors included the current health secretary Jeremy Hunt. 

Against a backdrop of austerity and public cuts, healthcare facilities are continuing to contract out their facilities management and clinical services. But, the practice remains deeply controversial and the consequences are becoming more visible. 

Thatcher’s competitive tendering was introduced for cleaning, catering and other ancillary non-medical services, and were extended by the Tories in the ’90s under the NHS and Community Care Act – the first piece of legislation to introduce an internal market into the provision of healthcare. This was followed by the Private Finance Initiative (PFIs) in 1992 under the Major government.  Lansley’s reforms – premised on ‘increasing the diversity of providers in the management of the NHS’ – represent only the culmination of this legacy.

A centrally funded health service has demonstrated its a major contribution to reducing health inequality, by permitting healthcare practitioners and policy makers to design services and deliver care based on need, not the profit incentive. An increasingly privatised NHS has simply led to rationing and inadequate healthcare.

The biggest single contribution to health inequality is social inequality, a problem that has deteriorated significantly in the wake of the Conservative agenda of combined economic austerity and welfare reform.

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Image courtesy of Robert Livingstone 

 

Related

The Coalition has deliberately financially trashed the NHS to justify its privatisation

Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper

Private bill to introduce further charges to patients for healthcare services is due for second reading today

Labour challenge government about ‘shocking’ rise in coroner warnings over NHS patient deaths

 


I don’t make any money from my work. I am disabled and don’t have any paid employment. But you can contribute by making a donation and help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.

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Labour challenge government about ‘shocking’ rise in coroner warnings over NHS patient deaths

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Coroners have a statutory duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. 

The Labour Party, who compiled the figures, has said the increase is due to the government’s austerity policies. Shadow health minister Justin Madders responded to the finding, saying: “This shocking rise in austerity-related deaths in the NHS shows yet again the devastating impact of Tory underfunding. Jeremy Hunt has claimed patient safety as his watchword, yet the truth is that more deaths are being blamed on a lack of resources in the NHS.

If the government doesn’t provide the health service with the funding it needs there is a real danger that services just become unsafe for patients. Ministers must take action now and give the NHS the resources it needs to keep patients safe.”

There were 42 ‘prevention of future death’ reports (PFDs) relating to issues such as lack of beds, staff shortages and insufficiently trained agency staff in 2016 compared with 30 in 2013. 

Within the 42 PFDs relating to lack of resources, eight were specifically concerned with resourcing of mental health services, double the number from 2013. Labour said the resourcing of mental health services was of particular concern, with deaths related to issues including the lack of mental health in-patient beds or shortages of trained staff.

In 2017, a damning PFD sent to the Department of Health after the death of Christopher Fairhurst in December 2016 said a shortage of GPs put patients at risk and placed unmanageable workloads upon those GPs who were in post. 

At the inquest into Christopher’s death, the court heard that the GP practice where Christopher was a patient serves 14,000 to 15,000 patients, but has been operating for the past few years with four or five GPs. Coroner Lisa Hamshi recorded a conclusion of misadventure, but Fairhurst’s family claimed he was often ‘twentieth in the queue’ when he tried to book a GP appointment.

The coroner claimed the ‘knock-on effect’ of the NHS funding crisis is seen ‘day in and day out’ in courts like hers. Hamshi said that she was satisfied with the care provided by doctors at Edenfield Road Surgery, but said she was concerned about the strain on surgeries – and a critical shortage of GPs across the country.

A Guardian investigation published in March found that coroners in England and Wales served PFDs relating to 271 mental health patients between 2012 and 2017. The NHS ombudsman also warned that mental health patients are suffering serious harm, and in some cases dying, because of “serious failings” in their treatment. 

In a report analysing more than 200 complaints about NHS mental health care, John  Behrens – the ombudsman – highlighted “failings that have occurred, and continue to occur, in specialist mental health services in England, and the devastating toll this takes on patients and their families”.

His findings came just two weeks after the Guardian revealed that coroners had issued NHS providers of care with legal warning notices over 271 deaths of mental health patients that occurred in England and Wales between 2012 and 2017 following failings in the treatment they had provided.

The report identified five “common failings” by mental health trusts that can lead to patients suffering distress or harm or dying avoidably. They include inadequate assessment of the patient’s risk of suffering harm or committing suicide and poor communication between health professionals and the patient or their family.

The report is a dossier of detailed but anonymous cases which, in some cases, led the ombudsman to conclude that patients were subjected to care so poor that it was “injustice [that was] shocking and tragic”. The failings illustrate how far the NHS has to go if it is to improve care in the dramatic way that ministers and health service bosses have promised in recent years.  

For example, a Ms J died after she had a life-threatening reaction, called neuroleptic malignant syndrome (NMS), to being prescribed an antipsychotic drug for a psychotic episode she was having. Doctors dismissed the physical symptoms of her condition.

“Had doctors identified NMS, it is likely that Ms J would have received the appropriate treatment and survived. As such, we concluded that Ms J’s death was avoidable,” the report said. Her death illustrated “the human cost of service failures”, Behrens said.

In another case, a mental health professional decided that a Mr O was suffering from an episode of psychosis for the first time. However, the worker breached National Institute of Health and Care Excellence guidelines by not assessing the patient for signs of post-traumatic stress disorder. The NHS trust’s risk assessment “was too brief and inadequate”, the report said.

Among the mental health-related deaths attributed to resource issues in 2016 was that of Wendy Telfer, 44, who died after taking an overdose. The PFD to Royal Devon and Exeter NHS foundation trust said: “It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.”

A 2017 PFD sent to the Department of Health after the death of Christopher Fairhurst in December 2016 said a shortage of GPs put patients at risk and placed unmanageable workloads upon those GPs who were in post.

The peak month in 2016 for deaths identified by coroners as being linked to a lack of resources – whether mental health-related or otherwise – was December, with eight. The NHS is always most overstretched in winter, with staff shortages and high bed occupancy rates.

Regular winter crises are a consequence of increased demand for services without a corresponding increase in funding. In four weeks in the run-up to Christmas 2016, 50 of the 152 English trusts were at the highest or second-highest level of pressure, according to a Nuffield Trust analysis commissioned by the BBC.

A Department of Health and Social Care spokesman said every preventable death was a tragedy. He said: “When coroners recommend specific steps to prevent future tragedy we expect NHS bodies to act without delay. 

“As well as making mental health services a personal priority, both the prime minister and the secretary of state have committed to a long-term plan with a sustainable multi-year settlement for the NHS, which will be agreed with NHS leaders, clinicians and health experts.”

That clearly isn’t adequate.

Mental health is an integral and essential component of health. Those groups with high rates of socioeconomic deprivation also tend to have the highest need for mental health care, but the lowest access to it.

People with mental illnesses are also vulnerable to abuse of their human rights. Scarcity of available resources and inequities in their distribution pose major obstacles to better mental health. 

Research by the Royal College of Psychiatrists (RCP) found that the income of mental health trusts across the UK had fallen since 2011, after taking account of inflation.  

In England, 62% of mental health trusts reported a lower income at the end of 2016-17 than they had in 2011-12. Only one trust saw their funding rise in all five financial years, according to official figures.

The RCP reports that the total amount of income that mental health trusts received in 2016-17 was £11.829bn – £105m less than in 2011-12 at today’s prices. 

Parity of esteem – the requirement to treat mental and physical health equally – was enshrined in law in 2012 and became part of the NHS Constitution in 2015. Yet ddespite legislating for parity of esteem, the government has failed to adequately fund it. The lack of resources is exacerbated by the fact that mental health funding is not ring-fenced and can be diverted by the NHS to plug gaps in other areas.

“It is totally unacceptable that when more and more people are coming forward with mental health problems, trusts are receiving less investment than they did, in some cases, seven years ago,” said RCP president Professor Wendy Burn.

It’s totally unacceptable that a government which has contributed to a rise in mental ill health in the first place by designing policies that widen inequalities, implementing cuts to public services that are both avoidable and immoral, continues in failing to recognise the psychological costs of austerity for individuals, communities and wider society.

Careless cuts cost lives.

Related image

 


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The Healthcare Nudge Tax – Hubert Huzzah

Mary Seacole was a British-Jamaican business woman and nurse who set up the British Hotel in the Crimea during the Crimean War. Not as well known as Florence Nightingale, she essentially spent all of her fortune tending to the British Wounded. She was Florence Nightingale’s copay. There are a wide range of reasons why Seacole ended up going from successful Businesswoman to Poverty but the cost of nursing care was a significant contributor.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is seen, on the Left, as introducing something new to the National Health Service: co-funding and co-payment. This is untrue: whenever someone pays for spectacles, dental treatment or a visit to the chiropodist, that falls, broadly into co-funding-co-payment. There is no need to legislate for these things. What the Bill is seeking to create is something a lot more than simple co-payment.

Seacole paid for treatment and facilities for British Soldiers in Crimea. She lacked the social connections in Britain to do anything other than pay the full economic costs for her efforts. The important point is that Seacole was co-funding and co-paying the Healthcare provisions of Florence Nightingale. Lacking the connections of Nightingale, Seacole was obliged to pay in full, up front, the market price of nursing care. Unlike Nightingale, Seacole was not economically supported in delivering nursing care. When the Crimean War ended, Seacole came to Britain and was both well known and sympathetically received but poor. Her fortunes were only really restored by patronage and public subscriptions to her.

Sir Christopher Robert “Chopper” Chope OBE son of a Judge, pioneered the sale of Council Houses – with such aggression he became known as Chopper. As Chairman of Conservative Way Forward he has been vocal in promoting the extremes of Thatcherism even to the detriment of his own Party. As a Private Landlord, in 2014, Chope filibustered a Liberal Democrat bill, with cross party support, seeking to make revenge evictions an offence. Again, in 2015, he filibustered a private member’s bill seeking to restrict car parking charges on Carers at hospitals. His vision is resolutely Thatcherite: he steered the Poll Tax through Parliament; and, his chosen tool is the Private Members Bill. Which helped to ensure the Referendum on European Membership took place. What he does not like he talks into the ground.

Which all begs the question of why a Thatcherite former vice-chairman of the Tory Party would be presenting a bill for co-payment and co-funding since the NHS already operates a co-payment system. Indeed, why would a Member of Parliament waste time on something that already happens when there are so many other issues demanding attention. Across Europe there are a variety of ways in which Healthcare is funded. All involve some degree of co-payment.

1. No co-payments: The Netherlands and Malta.

2. Flat-rate co-payments: Austria, Italy.

3. Implied ceiling flat rate co-payment (prepayment certificate): UK.

4. Percentage rates co-payment: Belgium, France, Greece, Estonia, Latvia, Lithuania, Poland, Portugal, Slovakia, Slovenia and Spain.

5. Percentage rate co-payment with annual ceiling: Finland.

6. Uniform percentage co-payment: Cyprus, Germany, Norway.

7. Co-insurance, with percentage decreasing with accumulated expenditure over a given period and with a ceiling: Denmark and Sweden.

8. Deductible co-payment: Ireland, Sweden.

9. Many countries have explicit exemptions for certain products, as well as for some patient and socio-economic groups.

The only places with zero co-payments are the Netherlands and Malta. Co-payment is the usual European model. Co-payment intrinsically limits the amount paid and allows for exemption. Even in Belgium, France, and so on, the percentage co-payment is open to reduction by negotiation, prepayment or even poverty. Importantly, co-payment takes place at the point of delivery. There is always a way to avoid the refusal of treatment with co-payment. The Economists explanation of co-payment is that it provides an entry cost into the Healthcare Market for the Healthcare recipient which avoids moral hazard. Moral hazard occurs when someone increases their exposure to risk when insured because they are insured. It is the accusation placed against the Banks in 2007. When there were claims Banks were ‘too big to fail’, the claims of moral hazard disappeared. Moral hazard only applies if you are, economically, small, according to policy makers. Fundamentally, co-payments across Europe have been about ensuring equity that is fairness not avoiding moral hazard.

Co-payment as a mechanism for ensuring fairness have always been viewed with suspicion by health economists because co-payment leads to value based pricing of healthcare. Value Based Pricing is distinct from Cost Based Pricing in placing a price onto goods or services based on the value to the purchaser not the cost to the provider. Cost Based Pricing determines how much the time and materials a service or goods cost, a profit margin is applied and the buyer charged.

Buyers of Cost Based Pricing products can always push prices down towards cost. The slogan Think like a patient, act like a taxpayer is being repeated, mantra-like, by close friend of Boris Johnson and former president of United Health Group Inc. – an American commercial health company – as the head of NHS England. It is intended to justify the moving of 36 treatments out of the NHS into a purely co-funded basis. Unlike co-payment, co-funding is never waived. Co-funding ensures that there is a fundamental shift in the relationship between Doctor and Patient.

Since 1948, the NHS has operated on the basis that a Doctor makes a decision about the treatment for a Patient and the Patient receives that treatment from the NHS. The decision involves no third parties. Under a co-funding healthcare model – the decisions about the value of the therapy are made by the Third Party Payee. That Third Party Payee both determines the pricing and the availability based on assessments of value. The Third Party explicitly shapes prescribing decisions through various guidelines and incentives. This is the general system that operates in the US where people think like a patient and act like a premium payer – because the tax paid is a premium paid to an Insurer. The difference between the experience of Florence Nightingale and Mary Seacole is the difference between co-payment and co-funding.

Florence Nightingale could decide on any treatment she wished to give to the Troops. When she did so, she could appeal to sponsors and donors to pay for those treatments. Mary Seacole recommended the treatments that she was experienced with which were particularly around communicable diseases such as cholera. Unless she could find an approving donor, she was obliged to pay out of her own funds. Lack of social connections and her acceptance of the need for Soldiers to have a social existence kept donations at a distance.

Both Nightingale and Seacole were operating on a cost based pricing model and the outcome for both were, economically, different. Both Nightingale and Seacole were accepting payments from those they treated but Seacole would waive fees for those who could not pay or if it served the health of others around that person for them to be treated. She was forced into co-funding of treatments because failing to treat cholera simply because someone cannot pay promotes the spread of cholera. It was that utilitarian compassion that made Seacole a national hero. It was also the success of her approach – that of broadly socialised medicine – that helped to galvanise the Far Right of the Conservative Party into demanding Seacole was removed from the national curriculum and to rabid opposition to her statue being erected as a memorial on NHS Property.

Legitimately, there are those who point out that the Tories are racists who have a problem with Black People from the Caribbean in the Health Service. That point is hugely important but ignores that Seacole was obliged to be a completely commercial healthcare provider which bankrupted her. The fundamental problem was not simplistically racism but that private healthcare simply fails to work. Which illustrates the kind of smokescreen that the Tories adopt: nudging people into an argument about one thing when the real issue is elsewhere: talk about racism and lose the NHS or talk about the NHS and suffer racism.

There is no mistake in saying that the Cosmopolitan nature of British society outside Whitehall and the Establishment is what created the NHS, and that Mary Seacole was an important step along the path to the 1948 Act; but, that distracts from what the National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve.

Mary Seacole illustrated what happens when co-payment and co-funding coexist: someone goes bust. Co-payments are limited and, despite being almost universal in their enforcement, can be waived. Poor people should not die because they are not poor. Introducing co-funding ends the capacity to waive a co-payment. Co-payment is a gateway to full co-funding. Co-payment establishes a threshold price and the result is a shift from Cost Based Pricing to Value Based Pricing. Healthcare co-payment, connected to co-funding, nudges policy from Cost Based Healthcare to Value Based Healthcare by claiming that a Value Based Price should be “largely consistent with the values and preferences of the vast majority of the insured population”.

Value Based Pricing sets a prices according to the value of a product or service to the Payer rather than according to the cost of the product to the Seller. There needs to be no connection to cost based prices or even historical prices. The aim is simply to increase profitability without a need to increase sales volumes. Which is essential in commercial healthcare where successful treatment reduces the need for treatment and failed treatment removes customers from the market.

Value Based Pricing principally works in to the benefit of the Seller. It relies on the perceptions of the Buyer which leads right back to Nudge Theory. For Value Based Pricing the single most valuable emotion is not desire but fear. Realistically, it is Fear Based Pricing that relies on the Buyer being in fear of not obtaining the product. Co-payments create low level fear yet co-funding not only creates low level fear in the short term but reinforces that fear in the longer term. Which creates the environment for perpetual nudge. Value Based Pricing leads to such things as Surge Pricing as operated by Gig Economy Apps such as Uber. Surge Pricing raises price when there is higher demand because there is higher fear of not being able to obtain the service. For the Health Service that kind of Surge Pricing would be apparent around “flu season” or communicable disease outbreaks.

Value Based Pricing is not only about maximising profit but also acknowledge to be associated with high levels of fraud. Co-funding creates a purely Value Based Pricing market place, meaning that co-payments are, at best, a loss leader. With the current Co-payment system in place, it would be possible for a Pharmacist to look at a prescription and tell the Patient that a cheaper over the counter alternative exists. The same would be possible with a General Practitioner: it would be possible for a General Practitioner to recommend a box of generic paracetamol at twenty pence instead of a prescription at three pounds eighty.

Under a system where Co-funding and Co-payment are both present, it is normal for both General Practitioners and Pharmacists to be contractually unable to give any pricing advice whatsoever. Indeed, the American Medical Association, found that 28% of prescriptions for generic drugs included an element of overpayment and 6% of branded drugs included an element of overpayment. The prescription has become, for a good many Americans a nudge into purchasing. The General Practitioners and Pharmacists have terms and conditions dictated by a third party: which is the outcome of marketplace healthcare.

Overpayment at the point of dispensing is counted as healthcare fraud. The FBI estimates that Health Care Fraud costs American tax payers $80Bn/y. Of this amount $2.5Bn was recovered through the False Claims Act in the Financial year 2009-2010 at the cost of paying out $0.3Bn to whistle-blowers. Prescription fraud is not the only source of fraud. Wherever there is a mixture of co-payment and co-funding, there is an elevated level of fraud. This includes Billing for services not rendered, overcharging services and items through computer coding, duplicate charges for items, unbundling treatment packages and charging for individual items, excessive and unnecessary services as well as bribes and falsified medical records.

In fact, where there is fraud in any Healthcare System there is a reduction in life expectancy for Healthcare users. This is particularly evident where medical records are falsified for any reason. The single biggest source of fraudulent activity is around Third Parties being involved in the Patient-Doctor relationship.

The annual cost of Fit To Work assessments, in general, was expected to rise to £579m in 2016-17, it did so. Part of that rise was due to Atos walking away from a contract as Third Party to the Doctor Patient relationship for sick and disabled people. Each employment and support allowance (ESA) test had a price hike from £115 to £190 in order to continue doing them. This was hailed as being contracting out of public services when, in fact, it was the invention of a whole new service, already carried out by General Practitioners, in order to create a Third Party to the relationship between Doctors and Patients. The track record of that relationship has been abysmal – the majority of decisions based on the Third Party are overturned by an appeals process. The important thing is not to be distracted by the large, growing, literature and documentation of rising death rates, suicides and failed decisions but to focus on the entire Work Capability Assessment (WCA) being a government contract with Key Performance Indicators (KPI) that drive organisational behaviours.

By walking away from the contract, Atos demonstrated that the DWP were locked into a Value Based Pricing contract and so the 65% price hike from £115 to £190 is perfectly understandable. The simple reason that the Government paid up was that the assessment price was a co-funding arrangement.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve the institutionalisation of co-payment and co-funding into the NHS. Currently Co-payment exists but there is no lever to be pulled that can nudge Patients into behaving as Consumers. In articles about the frequency and magnitude of co-payments exceeding prescription costs, there is frequently expressed the concern that Consumers are prevented from knowing the full nature of the relationship between themselves and the Third Party. For example, Pharmacists and General Practitioners can be placed into a non disclosure relationship with the Third Party where they cannot be told of a better and cheaper treatment. Because the Third Party manages the relationship between Doctor and Patient. Surveys among US Independent Pharmacies indicate that, despite denials, this is common practice. Which makes perfect sense in an economy that is being pushed into Value Based Pricing even if it is reprehensible behaviour.

The promotion of Value Based Pricing into UK Healthcare is not simply about making a profit. It also seeks to promote behaviour change. To change the behaviour of all NHS Patients into being NHS Customers. Without institutionalised co-funding and co-payment as paired policies, turning Patients into Customers becomes an uphill struggle. Christopher Chope navigated the Poll Tax through the Commons, changing a property based taxation into a person based taxation. It turned out badly, yet neither he nor his opposition dwell upon the fundamental change of relationship between Electorate and Local Authorities that it created. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 has a far bigger impact.

Martin Shkreli, infamous for hiking the price of Tiopronin (trade name Thiola) from $1.30 to $30, caused outrage demonstrates the power of Value Based Pricing. In 2015, in Shkreli’s company acquired Daraprim: an out of patent drug with no generic version available. The price of a dose of the drug in the U.S. market increased from US$13.50 to US$750 per pill. In interviews, Shkreli explained that co-payments would be lower for patients as the new owner of the drug ensured many patients would get the drug at no cost, through a free drug program, and that it sold half of its drugs for one dollar. Which were all technically correct statements.

What they actually revealed was how dysfunctional co-payment becomes in the presence of co-funding. Co-funding introduces the Third Party to the Doctor Patient relationship. Which is already understood to be dysfunctional from the outcomes at the DWP. Importantly co-funding introduces a Choice Architecture into healthcare which makes future healthcare subject to the Libertarian Paternalism of Nudge.

Value Based Pricing is generally acknowledged to lack intellectual honesty. In reality it is a matter of charging what you can get away with not what the product or service costs. Organisations who deliver a product on a Value Based Pricing basis often push Cost Based Pricing onto their supply chain resulting in inflation of profits. In a commercial environment this is poor treatment but in a Healthcare environment it unsustainable poor treatment that kills the customer base as well as the supplier base.

Combined with co-funding, it locks new market entrants out and so ends the possibility of the NHS reducing costs. In that sense, locking co-payment and co-funding together is little more than an invitation to fraud. While Value Based Pricing is controlled by, for example, the National Institute Of Clinical Excellence (NICE), the advocacy is in favour of the Electorate. NICE might well make unpopular decisions but the are decisions that are rational and internationally respected. Passing Value Based Pricing decisions to a Third Party – as happened at the DWP – changes the advocacy to be for the owners of the treatment.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out in a deceptively simple amendment to Section 1 followed by an equally simple looking amendment to section 12E of the National Health Service Act 2006. The overall impact is to change the relationship between the NHS and the Patient:

the making and recovery of charges is expressly provided for by or under any enactment, whenever passed”

Allows the Government to introduce charging by Statutory Instrument. A process that takes a week or so. This would allow for charges to be put in places for any treatment, drug, appliance or activity of the NHS by placing a document with the preamble: “In exercise of the powers conferred on me by The National Health Service (Co-funding and Co-Payment) Bill 2018, I hereby make the following Order:” At which point any charge can be placed into effect. The Statutory Instrument simply needs to remain unchallenged for 40 days and it becomes Law. The last occasion that the House of Commons annulled a Statutory Instrument was in 1979. So, whenever a Statutory Instrument is passed into law, NHS Charges to the Patient could be changed. Which simply means that all that is required is an active Lobbying Group and any NHS Tariff could be amended or even new ones created.

Which is not simply about nudging people to eat less sugar or cease smoking. It is about nudging Legislators to slavishly implement Value Based Pricing decisions of a wide range of goods, products, services, treatments and activities of the NHS. While this seems localised to the UK, the truth is the pricing of Drugs and Treatments in the NHS affects purchasing decisions in 40% of the World’s Health Services. Value Based Pricing in a global market is easier if your product is being sold at a premium in an influential local market. The creation of an institutional nudge has immense, global, commercial value. Lobbying in the UK would avoid scrutiny in, for example, the US but the outcome would be the same: Value Based Prices could rise in America. By nudging Legislator rather than end Customer, the cost of nudging is significantly reduced and the impact is far greater. Not only is the nudge guaranteed to work but it has the force of law to prevent it being dismantled.

The NHS has one of the price drug regimes in the World. Co-payment already exists and needs no legislation to be introduced: it is as simple as asking a General Practitioner to prescribe and asking the price. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is not about kite flying or testing the waters or increasing choice for patients but about ensuring that Lobbyists are the Third Party getting between Doctors and Patients not only in the UK but right across the World.

What The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 will promise is more choice and better, cheaper care. The experience in the US where co-payment and co-funding is in place is that Health Tourism increases – people find it cheaper to travel to Canada to get a prescription filled – and fraud rises; but, much more importantly, Healthcare ceases to be about health and becomes a significant way for Third Party Investors to manage social behaviour. The biggest Nudge possible: locking everybody into your marketing plans.

In the same way as Martin Shkreli could claim a price rise was a price fall on the basis of complex Value Based Pricing calculations that are commercial secrets, The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 makes commercial secrets obligatory through Statutory Instruments, which not only ensures the NHS is privatised but that the Privatised NHS promotes healthcare cost rises across the planet.

It has been suggested that The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 should be filibustered into oblivion. That would not end the drive toward Privatisation. It would also not prevent the Bill from being presented again in a similar but different form. This is the experience of the Poll Tax: it was never popular but it was navigated towards legislation by careful use of procedure. Similarly the progress of the European Referendum was navigated by the careful use of Private Members’ Bills. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is simply another example of the well tried technique of Thatcherite MPs. This time it embeds nudge into a central Institution of Society: the NHS. The Bill should be utterly repudiated and, along with it, the underlying presumption that the entire population can be nudged and deceived and their health manipulated for profit.

Article by Hubert Huzzah

Picture: Statue of Mary Seacole (Grounds of Saint Thomas’s Hospital London). Martin Jennings 2016.

 

Related

Private bill to introduce further charges to patients for healthcare services is due for second reading today

 


 

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Private bill to introduce further charges to patients for healthcare services is due for second reading today

NHS charges

Christopher Chope, a Barrister and the Conservative MP for Christchurch, has proposed a private bill that would make provision for co-funding, and to extend the use of ‘co-payment’ – charges – throughout the National Health Service (NHS); and for “connected purposes.”

Though there are already some charges for health services such dental treatments, eye tests and prescriptions already, experts have warned that if the bill gains assent, it would open the floodgates to charging for a range of other services including GPs appointments and minor operations.

The National Health Service (Co-Funding and CoPayment) Bill would “make provision for co-funding and for the extension of co-payment for NHS services in England” and this will be the second reading of the bill.

MPs are set to debate the proposed bill today.

Recent changes to NHS prescribing guidelines has shown that the co-payment system is far from perfect. Controversial limits to the kind of conditions for which GPs can prescribe medication. Instead, patients will be given advice on what medications to buy from the pharmacy. 

Simon Stevens, Chief Executive of NHS England, said: “Across the NHS our aim is to: ‘Think like a patient, act like a taxpayer’. The NHS is probably the most efficient health service in the world, but we’re determined to keep pushing further. Every pound we save from cutting waste is another pound we can then invest in better A&E care, new cancer treatments and much better mental health services.” 

John O’Connell, Chief Executive of the TaxPayers’ Alliance approved the changes, adding that “It’s great news that NHS England will save a vast amount of taxpayers’ money by curbing prescriptions for basic items that are much cheaper to buy in the supermarket than they are to prescribe. Taxpayers should not be footing the bill for items like anti dandruff shampoo or athlete’s foot powder, so cutting out wasteful spending like this will mean that precious resources can be focused on frontline services. Patients too must remember that these items are not “free” – the money comes out of taxpayers’ pockets, so NHS England should be applauded for this move.”

However, someone should remind Stevens and O’Connell that everyone pays tax and national insurance. This kind of rationing is a steep and slippery slope to a health service that is no longer free at the point of delivery. 

However, NHS has always been free at the point of delivery – that’s one of the founding principles on which it was created. Millions of ordinary people rely on this principle. Under no circumstances must we permit the government to take us back to the time when had to sell their household belongings to see their doctor. Citizens in a civilised  and democratic society should not be penalised financially for being ill and needing NHS services.

Justin Madders MP, Labour’s Shadow Health Minister, said: “Once again we see the Tories’ true colours.

“At a time when the NHS is going through the biggest funding squeeze in its history and more than four million people are waiting for treatment, Tory MPs are proposing a two-tier system where those who can afford it get treated first.

“Labour’s first priority will be to give the NHS the funding it needs to protect an NHS free at the point of use for everyone who needs it.”

Chope has previously tabled a range of other controversial bills.

He was appointed as the Parliamentary Private Secretary to Peter Brooke, the Minister of State at the Treasury in 1986, before being promoted by Margaret Thatcher to serve in her government as the Parliamentary Under Secretary of State at the Department for the Environment later in the same year, where he was responsible for steering through the immensely unpopular “Community Charge” (best known as the Poll tax) legislation.

In June 2013 Chope was one of four MPs who camped outside Parliament in a move to facilitate parliamentary debate on what they called an “Alternative Queen’s Speech” – an attempt to show what a future Conservative government might deliver. 42 policies were listed including reintroduction of the death penalty and conscription, privatising the BBC, banning the burka in public places and preparation to leave the European Union. 

Chope helped to lead backbench support for the motion calling for a European Referendum. He has also been heavily involved in the use of private member’s bills to achieve this aim. Chope came under fire in January 2013 for referring to some staff in the House of Commons as “servants”. Parallels were drawn between this opinion and his views on the minimum wage – which he has called to be abolished.

On 28 November 2014 Chope, a private landlord, filibustered a Liberal Democrat bill with cross party support intended to make revenge evictions an offence.

In 2014 Chope along with six other Conservative Party MPs voted against the Equal Pay (Transparency) Bill which would require all companies with more than 250 employees to declare the gap in pay between the average male and average female salaries.

He came under criticism in late 2014 for repeatedly blocking a bill that would ban the use of wild animals in circus performances, justifying his actions by saying “The EU Membership Costs and Benefits bill should have been called by the clerk before the circuses bill, so I raised a point of order”.

You can read Chope’s latest controversial and draconian bill: The National Health Service (Co-Funding and Co-Payment) Bill here.

GP and NHS campaigner, Bob Gill, says:

Ever wondered why Government wanted to spend a fortune on the charging infrastructure for collecting relatively insignificant sums from illegal immigrants using the NHS?

Well that was the cover story. Reality is that charging was always intended to apply to everyone.

Here is the Bill to extend charging to all.”

Please tell your MPs to attend the debate and to argue and vote against it, whatever party they are.

Here is how to contact your MP.

Template emails are downloadable from the 999 Call for the NHS website.

Let’s not let the Conservatives get away with privatising our NHS by stealth.

Image result for MPs with a vested interest in NHS

 

Update

The bill did not get through the second reading, as it ran out of time. However,  the Conservatives have rescheduled the bill for another attempt, on Friday 15 June.

Related 

Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper: work as a “health outcome”.

 


I don’t make any money from my work. I’m disabled through illness and on a very low income. But you can make a donation to help me continue to research and write free, informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.

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