NHS privatisation

In case anyone has any remaining doubt that the aim is to abolish our NHS, there is an interesting report about the service in Northern Ireland, prepared by Mckinsey, who are management consultants and who seem to have a finger in every privatisation pie, for no very obvious reason.

www.dhsspsni.gov.uk/2010-hsc-spendi...mplications.pdf

The introduction includes the usual warm words, serving to disguise the actual intent. It talks about


and


I hate the way these people always talk of "Vision" and "Improvement", when they mean cost cutting and dismantling.They seem to have some small awareness of the impact of those words because they actually bother to say what they mean by some of them. Except that it is not what they mean: but hey ho.

In the executive summary it says:


Well there is an interesting sentence which illustrates what I mean. Is it likely that there will a growing demand for care by 2014 (that is next year) so big it is going to mean that there is not enough money next year? Hardly. That is just smuggling in the narrative of demographic timebomb into this paper and you are not supposed to notice it is nothing to do with this at all. They suggest that the "ageing and growing population" accounts for about 1.5% growth in demand
Hmmm. They say that more than half of the increase will be in people over 65: so what? 65 is not even the retirement age any more. and "less than half" are presumably working age people who will contribute to the tax base available. There is no mention of the upside of that growing population: they are portrayed solely as a cost increase, and that is no accident either
Even if you accept that narrative it is at best disingenuous here.

Similarly, "inflating costs" is interesting. Why is that, then? I wonder if it could be to do with the increasing involvement of private sector players in the NHS, like, to take a random example, McKinsey? Of course not: it is due to things like the working time directive which increases costs by reducing the hours staff are allowed to work (no mention of the productivity increases which may accrue from the fact that your doctor is awake); the availability and use of new drugs which were not available before (no mention of any substitution of cost nor of any productivity improvement from more effective care); and better diagnosis of conditions which were previously missed (no mention of the cost savings attendant on earlier intervention, which, curiously, are often promoted in other parts of the forest) It is always worthwhile, when reading propaganda, to try to have a think about what is NOT there. To be fair they also include
So there is acknowledgement that increased private provision, which we introduced because it was supposed to be cheaper,increases cost. Again that is the opposite of what is claimed in other parts of the forest and again it is put forward as an act of god and not as the political decison it undoubtedly is. If Tesco can employ in house pharmacists and opthalmologists for profit "we" can keep them in house for less money even if we pay them more, I suspect.

But most important is the constraint in the growth of the spend: like that was an act of god and not a political decision. All of those are blithely presented as inevitable. Of course the last is justifiable given that the government has stated it is going to cut spending, and if this executive summary is designed as recommendations for a pragmatic response to that reality fair enough: but the other two elements do not tend to support that interpretation.

So how to bring the costs down? No surprises there. They want "better management of long term conditions".That is a good idea because they say it will improve overall health and reduce the need for costly treatment. Sadly it does not say how, and that is typical of this outfit: for they are not medical people, they are management consultants.

They also blithely say that reducing hospital stays will save money. They always say that. The assumption is always that community based healthcare will expand to meet the need and that hospital stays are often too long or wholly unnecessary. I have touched on the reality of that in another thread in discussing another report about the elderly who stay too long in hospital, and this is codswallop, in the real world. But don't take my word for it. As Private Eye reported in its latest edition, McKinsey also drew up a report for the wider NHS in 2009, which forms the basis of the £20 billion cuts called "efficiency savings" currently being demanded. It also says that cutting hospital stays will save money and also assumes that community health will be cheaper and just as safe. There is no evidence for that at all in the report, and it is interesting to learn the reason for that. At a workshop on Community-Based Care, for health professionals a McKinsey partner called Penny Dash admitted "There isn't very much evidence base about models of community care". But that does not deter them from saying


Nor are there any firm and costed plans about those services which are to replace the hospital stays, though you might think that would be pretty much essential if you were producing a report of this kind, in order to make your case. Never mind: it must be so cos McKinsey says so: over and over again, no matter what they are considering: and they get paid for saying it every time too.

Then there is the proposal for "co-payments". There is a clue in that label: it is a term I have only come across in American arrangements. It is the antithesis of the principle on which our system is based "free at the point of need".

Cutting staff wages is in there too: quelle suprise!

They do acknowledge that this would require a "significant" change from current policy and principles (my bolding). Damn right it would. They acknowledge that what they are proposing is a different kind of health service altogether: they do not say it is american, preferring to focus on european models: but it is amusing to note that this report refers to "we" throughout: in such phrases as "where are we now" McKinsey do not, so far as I know, live in Northern Ireland nor do they use the health service. It is cute.

The breathtaking arrogance of these people is neatly illustrated in this sentence:


Remember it will become unaffordable because the government has the political will to cut the funding on the basis of a McKinsey report which says that they should: and now the Northern Ireland service will be unaffordable because of that decision. I do not think "unaffordable" means what they think it means.

But there is a bright side


I wonder who will get the contracts for the PR and the IT? Do you think it might be private sector management consultants and IT firms like the ones who have a proven track record in failure when providing public sector IT systems? I think it just might. They estimate the cost of that at £0.3 billion this year: and £0.1 billion a year thereafter.

Moving on, I am struck by the way these people spin things throughout this document. To give one example:

1. They say that Northern Ireland spends less than the same service in England. It rather undermines their credibility to see that they have only a very hazy idea of how much less - between 7% and 16% per head, they think, which translates to between £250 million and £600 million a year.

2. They acknowledge that this leads to worse outcomes
3. They conclude it is necessary to spend less

I can't see the logic of that, but then I am not a management consultant.

It is also interesting to see what they consider to be "efficiency improvements" Once again there is no evidence at all to support their interpretation and this is in line with many such reports. For example, they say that the length of stay in hospital is coming down and that this is an example of better productivity. They do not show why that is a good thing, that is taken as read. But in order to demonstrate that you would have to show that readmission rates have not risen; that the care the people discharged receive is safe and appropriate; and probably a lot of other things which would come to me if I was writing the report and spent some time thinking about it. They say nothing on those issues, so far as I can see. " Productivity" is not a simple thing: if you wish to improve the care of patients it is not at all obvious that cutting the number of nurses will achieve that, and there is reason to suppose it will not. But a productivity measure will show an improvement if one nurse is looking after 20 patients where there used to be two. I am not persuaded that one can do as good a job as two, if you happen to be interested in actual nursing (including the intangible things such as time to talk to patients): but you can't measure those things very easily and if you are a McKinsey you will not even see why you should, I suspect.

The report points to some innovations which have already proved effective and which they claim give high patient satisfaction. Except that is not really true either, at least not in all cases. One instance is the "telemedicine" approach to long term conditions such as diabetes: said to reduce the need for in patient treatment; to reduce the length of hospital stay when that is required; and to have had very positive feedback from patients. All of that might be true and wholly positive: but it is based on pilot studies and
. It is a little premature to imply this is established: pilots, in my experience, tend to be better resourced than nationwide versions of the same service, and it remains to be seen what happens when the change is made on the bigger scale. I do not wish to be seen as dismissing the benefits of innovation: some of these things will be better. But it seems to me that the development and evaluation of such things should be independent of cost: that is a consideration which should be addressed after the pilot has demonstrated its worth in other terms.

Yet they conclude that since funding is not going to increase
They use this conclusion to justify dismantling the NHS on explicit grounds of TINA.


(my bolding). And this is in context of a report which says that

There follows some recommendations, which again sound positive if you don't think about them too hard.

1. They advocate better management of long term conditions. Who could disagree? Only it rests on the idea of improved community care, which is neither evidenced nor implemented, as already discussed: and it says it rests on increases support for "self care" (ie. no care at all) and carers (who are having the support they receive cut as we speak)

2. Decommissioning of ineffective or non essential treatments: fine so long as that is determined by research and by doctors and their patients. I am not aware of the expertise which allows management consultants to say that "potentially cosmetic" ear/nose/ throat surgery is "actually" cosmetic and I do not think that surgery to correct truly disfiguring conditions is demonstrably ineffective or non-essential.

3. Prevention: it is absolutely true that promoting healthy lifestyles would save money in the long term: which has nothing whatsoever to do with cutting spending and does not belong in this report: but it is always handy to demonise the victim wherever opportunity arise

4. Managing referrals/reducing variations in assessment.


Well "we" cannot be surprised if management consultants want more management. But that will not necessarily be cheaper, though that is the implication. It is just as likely that those doctors who make more referrals have better outcome in terms of health than those who make fewer.


5. Optimising urgent care. Fine: but once again the instance they mention depends on spending elsewhere, eg in "fall prevention support of elderly people". If that can be done well and good: we should do it if it does not entail restrictions on the quality of life of those people etc. But it is nothing to do with cutting the costs of health care directly. Less use of A&E is also in this section through, for example, better use of minor injuries units: do they exist? I am not aware of them. If someone is injured, and going to the GP is not enough or is not possible, they do not go to A&E because they insist on that: what they do is go to the hospital and the only place you can be seen without an appointment is A&E. It is for the triage nurse to decide priorities and presumably to decide which department as well. I infer that these minor injuries units are not available routinely and that is something that could change if it is cheaper and equally effective to put them in place.

6. Social Care improvements. Already addressed in this thread and elsewhere. This is just a wish list, with the additional recommendation of more "co-payments"

7. Shifting to lower cost settings: this means apparently that folk should go to the GP rather than outpatients because the GP can treat them if he has sufficient specialist support in many cases. I expect GP's are just sitting about waiting for work. That is an assumption that management consultants often make about people who are not management consultants

8a. Reducing average length of stay in hospitals: already addressed
8b. Increasing staff productivity:


This is just drivel in a context of reducing staff numbers and reducing the numbers of managers and administrators. But it is just what one would expect from management consultants

9. Optimising the use and procurement of drugs. Fair enough

10. Optimising the use and procurement of other supplies. Fair enough

11. Making better use of our estates


Don't know about Northern Ireland nor about the general situation over the country: I do know that my mother's friend was in hospital for a few days last week and that people were kept waiting for a bed to become vacant because the place could not meet the need. I would need detail of this unnecessary space: to me this just looks like closing hospitals which are fully utilised: might be wrong

12. Seems to be specific to NI but is better procurement again

13. Renegotiate or reprocure private services for less money. Great idea, given that care homes cannot make a profit at current rates, according to what they are saying. GP's and pharmacists and opthalmologists will obviously welcome a cut in their wages as well. That is all this is: wage cuts for other people (and profit erosion for those private care providers who are there because they are so efficient and cheap)

14. Optimising management and admin costs. Already been done, they say, so I don't know why it is there. Probably because McKinsey always put it in when they produce these lucrative off the shelf reports

There is a curious sentence further down in the report


That is not because they are pish, of course: it is due to


I am sure you can translate that in terms which fit your background views: I know I can.

The most important part of this report is section 4, where they go on to look at more radical solutions should the wish list not be enough. This is the meat of the proposals and it seems to me it is the heart of the privatisation agenda.

They want fewer acute hospitals because of reduction in hospital stays, yet an increase in local hospitals. That looks odd until you notice that "local hospitals" is in quotes. It remains to be seen what they actually mean for they say those local hospitals will provide complex and urgent care and medicine; intensive care units and "paediatric ambulatory treatment services" It looks like an A&E unit with some outpatient service for kids, and a small amount of inpatient facility, for example for those who have broken a hip and can't go home immediately; and an intensive care unit. It is once again short on rationale and short on detail so it is not easy to grasp the "vision" they say they have. Anyway that is to be combined with putting all the GP's in one place and the development of "integrated care centres" which will also provide urgent care: not clear if they are the same as the "local hospitals" or something different.

As the report says, none of this is new or original. Make me wonder why we pay these people, but I often wonder that. And in case you missed the TINA, the reiterate


If you are talking rubbish it never hurts to repeat it.

Then the detail: 350 fewer hospital beds then "we" have at present. 30% fewer outpatient hospital appointments. Balanced by 20% more GP consultations (because they are just sitting about) and 15% more community contacts (because health visitors and social workers and district nurses have nothing to do). In case you doubt that, it is specifically stated that


though in fact I see no such plan at all: I see an assumption with no underpinning outline of how this is to be achieved. Hey, they are "big picture" people! If you doubt that they say so:


Despite the fact there is no plan they say 1000 fewer staff will be needed: as against the extra 10,000 needed by next year if "we" do nothing. Does that look plausible to you? But never mind: we need 1000 fewer staff but we need a lot more "enablers" who will "champion" the "reforms" You may not be aware but this word "champions" is now quite widespread. I first came across it when working in child care some years ago. It was a source of great derision and considerable embarrassment for those required to adopt the title: just as the content was because the people who got the role did not actually believe in it quite often. This is just more "off the shelf stuff" But the "enablers" are really another tier of management: what is not to like? Especially since they will need to be trained in "leadership": I wonder who will do that?

Oh and "we" need "incentives" for the staff to improve their "productivity". So it seems that they are not expected to agree this is improvement. We need to influence
Since doctors and nurses and physiotherapists and pharmacists are already graduates or at least have tertiary professional education, I think we can be sure that this is more bean counters. Either that or we are going to have graduate hospital porters.

"We" also need to sell the case for all of this: and "we" must get our skates on.
It is true that policy made in haste tends to be rubbish: but this is an emergency!! Again you will be able to translate that in line with your wider views: I read it as, if we don't get this through before 2015 the government might change and it won't happen at all. Where will our pals get their profit from then????

There is also discussion about extending co-payment beyond bringing that into line with what is in place in england; reducing the service and restricting the availability of treatment: eg. refusing hip replacement operations to those who need them if they do not meet other criteria: like you have to be over 80 to get one; introducing means testing for all; etc. They acknowledge those types of changes are probably illegal: but that can be dealt with, presumably. It also acknowledges that they might indirectly increase costs in the long term: but can we rely on government to take that into account?

This post is too long: but I think it is important and I should say that it was marked as not intended for release to the public. That tells you something, I think

Edited by FionaK - 15/1/2013, 15:54