The NHS Debate (Merged threads)

[Alfie Taylor]

I was about to post "someone will be along shortly to tell you that, despite you and your wife's lifetime of experience working in the NHS, you don't know what you're talking about." But I had to nip out for a few minutes before I got the chance and it seems I've been beaten to it. ^^

Are the Kings Fund lying?

Do you have the true figures to show how much the Labour party and it's voters handed over to millionaire friends of the Tories?

[Griff9of13]

Are the Kings Fund lying?

Do you have the true figures to show how much the Labour party and it's voters handed over to millionaire friends of the Tories?

 

I have now problem with non-clinical functions being contracted out if a genuine case can be made for improving the service; as I've spent most of this year working on supplying IT functionality to the NHS I'd be a hypocrite not to. 

[ckn]

Are the Kings Fund lying?

Do you have the true figures to show how much the Labour party and it's voters handed over to millionaire friends of the Tories?

Right... I was going to ignore you but you're persisting and acting like a toddler who has learned one phrase and using it wildly out of context.  What is happening in the NHS is that the government is "outsourcing" the profitable services and leaving the unprofitable ones to survive on lower and lower budgets.  It's a carbon copy of what happened to Royal Mail, the government "deregulated" the lucrative and profitable services and left the unprofitable last-mile postal services regulated to the Royal Mail until it became too tough to keep publicly owned.

 

If you go to a private hospital for an outsourced NHS operation and suffer a heart attack the doctors will call 999 and expect the NHS to come rescue you from them.  For free.  If you have major complications that are beyond their care then they'll call 999 and expect the NHS to come rescue you from them.  For free.  If they screw up your health then they expect the NHS to fix it.  For free.

 

Look at the services that have been outsourced, it's the health services that the private companies can make a profit from.  Health services are largely not profitable therefore there isn't a huge pool of it to go before the services those profitable services bankrolled, such as A&E, mental health acute care and so on, become "financially unviable".  This is where the current NHS deficit really comes from, people, especially Tories, point to the increased NHS funding but fail to realise that all the money does is cover the money lost that once went to cover the tough services but now is going into paying private companies.

 

That's when the government pretends that it's all come as a massive surprise and decides that they have to call in private companies to "rescue" the NHS from its own inefficiencies.  It's a massive con trick that people ignore by sticking their fingers in their ears and either pretending it isn't happening or by pointing at extra funding coming without realising that it's really just covering the losses to the private industry.

 

The NHS is expected to make £32bn worth of efficiency savings by 2020 as part of the deal that the Tories will give them £8bn extra.  That's a net efficiency saving of £24bn over five years.  The reason for that £24bn is nearly entirely down to the loss of the easy to do and relatively financially sound services that have been outsourced that the NHS now has to pay for.  In the past, a service that was simply cost NHS staff wages and NHS internal costs now costs private staff wages and private costs plus profit to shareholders.

 

Did that help understand the context of 10% of the NHS being privatised?  Also does it help you understand that the figure plucked out the air of 15% would mean the next 5% most profitable services gone that the NHS would then have to pay for?  Privatised does NOT mean it becomes miraculously lower cost and efficient, it simply means that someone else is now managing it for a profit while the NHS gets none of the follow-on benefits.

 

I was involved in a care-flow meeting last month where there were example pathways used, as soon as private companies became involved in the pathway timescales and waiting trebled.  If you are taken to hospital and it's all in-house then you typically go from speciality to speciality, jumping queues depending on your clinical needs.  If a private company becomes involved then you have to stop the NHS service, move them to the private service then back again.  I saw one pathway where a patient had NHS surgery, private physiotherapy and private home care, the bureaucracy from the private companies was shameful, as was the "admin" bill to pay for it, all while the physiotherapist bill per hour came to more than the consultant surgeon's real cost to the NHS.

[ckn]

I have now problem with non-clinical functions being contracted out if a genuine case can be made for improving the service; as I've spent most of this year working on supplying IT functionality to the NHS I'd be a hypocrite not to. 

There are definitely some things that you wonder why the NHS does, that's where the big consultancy firms actually do earn their money while saving the NHS money.  Key things such as system-wide consultancy, adding really high-end knowledge or transformational expertise.  Where it doesn't work so well is in the more transactional things where all a private company does is take the low-cost NHS staff and turn them into private staff with private costs and profit.  I've seen the stuff you do and it's stuff we can't do easily at all within the NHS, we'd be daft to try to in-house that.

[Griff9of13]

There are definitely some things that you wonder why the NHS does, that's where the big consultancy firms actually do earn their money while saving the NHS money.  Key things such as system-wide consultancy, adding really high-end knowledge or transformational expertise.  Where it doesn't work so well is in the more transactional things where all a private company does is take the low-cost NHS staff and turn them into private staff with private costs and profit.  I've seen the stuff you do and it's stuff we can't do easily at all within the NHS, we'd be daft to try to in-house that.

 

Indeed. One of the cost savings we were able to offer was negotiating a trust wide deal on software significantly reducing the cost on buying it on a trust by trust basis. 

[WearyRhino]

According to the Kings Fund from 19th March this year.

"About 10% of NHS spend on health services is no non NHS providers which includes for profit, local authorities, social enterprises, charities and community interest companies.

There has been growth in non NHS provision of care, but THERE HAS BEEN NO WHOLESALE PRIVATISATION OF THE NHS"

 

It's nice to see you quoting and being so enthusiastic about the King's Fund, as someone who has worked with them in the past I share your enthusiasm.  You quoted selectively from the King's Fund's website Q&A 'The Kings Fund Verdict' section dated 19 March 2015. However, as you are now so enthusiastic about the King's Fund, I am sure you will concur with their Press Release on the same date:

 

 

Commenting on the latest financial figures from the NHS Trust Development Authority, Chris Ham, Chief Executive of The King’s Fund, said:

‘Today’s figures show another significant deterioration in NHS trust finances. When combined with Monitor’s most recent figures for foundation trusts, NHS providers are currently forecasting an end-of-year deficit of more than £800 million.

‘It is clear the next government will inherit a health service under huge financial pressure, with deficits among hospitals and other providers likely to continue rising in 2015/16. While there is still scope to improve efficiency to close some of the gap, this will leave new ministers facing an unpalatable choice between increasing NHS funding to restore financial stability, or allowing patient care to deteriorate as staff are cut and waiting times rise.’

 

Surely, THIS is the crux of the matter?

[Saintslass]

Do you only read the bits of posts that you agree with?  The NHS was in recovery under Blair/Brown, now it's back in the ICU.  You lot really are deaf and blind aren't you?  The NHS is in a mess and will rapidly be back where it was in 1997, a basket case.   Gideon may be fixing the roof but it's the foundations that are crumbling.

We don't listen to the leftwing propoganda.  The healthcare professionals just like the teaching professionals all start to complain once a Tory government is in power.  The NHS is no different now to what it was under the last Labour government.  It's still inept in the ways it was inept back then and still good in the ways it was good back then.  The only difference now is that a Tory government is in power and so everyone starts shouting about PRIVATISATION and other stuff that is political hogwash.

[Saintslass]

It's nice to see you quoting and being so enthusiastic about the King's Fund, as someone who has worked with them in the past I share your enthusiasm.  You quoted selectively from the King's Fund's website Q&A 'The Kings Fund Verdict' section dated 19 March 2015. However, as you are now so enthusiastic about the King's Fund, I am sure you will concur with their Press Release on the same date:

 

 

Surely, THIS is the crux of the matter?

You think that NHS Trusts have only just started to declare deficits?

[ckn]

You think that NHS Trusts have only just started to declare deficits?

 

In 2012/13 there was a net surplus in the NHS of £2.1bn.  That's £2.1bn underspent and returned to the Exchequer.

2013/14 there was a net surplus in the NHS of £722m.

2014/15 there was a net deficit of £671m

2015/16 is expected to be £2.2bn net deficit.

 

Official government figures as released by the National Audit Office except for 2015/16 which uses NHS official figures to the end of November 2015 and projected to end March 2016.

[Saintslass]

In 2012/13 there was a net surplus in the NHS of £2.1bn.  That's £2.1bn underspent and returned to the Exchequer.

2013/14 there was a net surplus in the NHS of £722m.

2014/15 there was a net deficit of £671m

2015/16 is expected to be £2.2bn net deficit.

 

Official government figures as released by the National Audit Office except for 2015/16 which uses NHS official figures to the end of November 2015 and projected to end March 2016.

A decent article here from the BBC about how the NHS has to change the way it operates as there just isn't money in the system to fund whatever it wants whenever it wants it: http://www.bbc.co.uk/news/health-34353408

 

I knew I'd heard of NHS deficits before, see here for example (prior to the coalition government - and note what Labour are saying!): http://www.theguardian.com/society/2009/oct/13/nhs-deficits-heatherwood-wexham-park

 

It seems that the current deficit is the result in part of numerous NHS trusts not managing their money whereas previously it was a relatively small number of them getting into trouble.  There are of course external pressures too.  Addressing things like the ridiculous over-reliance on agency staff could help (what happened to bank staff?) but fundamentally the NHS needs to change wholesale.  It is unrealistic to continue thinking there is a bottomless pit of public finance for either the NHS or welfare.  There just isn't and there wouldn't be no matter which shade of government was in power.

[ckn]

A decent article here from the BBC about how the NHS has to change the way it operates as there just isn't money in the system to fund whatever it wants whenever it wants it: http://www.bbc.co.uk/news/health-34353408

 

I knew I'd heard of NHS deficits before, see here for example (prior to the coalition government - and note what Labour are saying!): http://www.theguardian.com/society/2009/oct/13/nhs-deficits-heatherwood-wexham-park

 

It seems that the current deficit is the result in part of numerous NHS trusts not managing their money whereas previously it was a relatively small number of them getting into trouble.  There are of course external pressures too.  Addressing things like the ridiculous over-reliance on agency staff could help (what happened to bank staff?) but fundamentally the NHS needs to change wholesale.  It is unrealistic to continue thinking there is a bottomless pit of public finance for either the NHS or welfare.  There just isn't and there wouldn't be no matter which shade of government was in power.

Ah, no.  Your article in your second paragraph is ONE trust.  Individual trusts could go into deficit and still be bailed out by the overall NHS surplus.  Now, it's a damnably rare NHS trust that will show a surplus.  See my lengthy post above for why the NHS now operates at a deficit rather than surplus, lucrative stuff has been stripped out and given to private companies meaning the surplus that they generated just goes into shareholders pockets rather than fund A&E and other never profitable services.

 

Edit: You NEED a surplus in the NHS to cope with extremes.  Your budget should assume the worst case scenario then be happy about money coming back in when it doesn't happen.  For example, if there's an extreme winter, or summer, or major terrorist attack, or a hospital is flooded and becomes unusable.  There's nothing in the kitty any more for anything other than fairy-land healthcare optimism.

[Griff9of13]

NHS discharge delays hit record levels

[Saintslass]

Edit: You NEED a surplus in the NHS to cope with extremes.  Your budget should assume the worst case scenario then be happy about money coming back in when it doesn't happen.  For example, if there's an extreme winter, or summer, or major terrorist attack, or a hospital is flooded and becomes unusable.  There's nothing in the kitty any more for anything other than fairy-land healthcare optimism.

Isn't that the same principle the government is trying to operate under by bringing down the deficit?  Surely that is simply good financial management, to operate a surplus so that you have something in the kitty for when the going gets tough?

 

What I'd like to know, the fact and not the political propoganda I mean, is why all of a sudden, when the cuts have been going since 2010, but the NHS has been a ringfenced budget throughout (acknowledged by all but keyboard warriors of a certain political persuasion) almost all NHS trusts are apparently now running massive deficits?  I find it strange that these claims of deficits have coincided with the first Tory government in 20 years AND when that same Tory government has just lobbed in yet another multiple million pound boost to help the behemoth through the winter.

 

I smell a rat, personally, and I'd very much like to see some impartial, objective and accurate figures.  I'd also like to know more about how Trusts and individual hospitals are managed because I suspect it is in the management where the problems mainly lie - like in the wholesale use of ridiculously expensive agencies to cover gaps in service provision when the much cheaper old fashioned approach of bank staff would have been a far wiser means of covering shortfalls (and now that there is a cap on agency spend that should assist in bringing one area of ridiculous spending under control - just a pity the government had to intercede).

[Robin Evans]

I can't validate this... but I was talking to an HR gadgy.... He told me that to pay me a bank contract... where pension and enhanced hrs apply etc.... is more expensive than pulling in agency staff on flat rate.

I don't work any extra duty btw... bug ger that.

[Saintslass]

I can't validate this... but I was talking to an HR gadgy.... He told me that to pay me a bank contract... where pension and enhanced hrs apply etc.... is more expensive than pulling in agency staff on flat rate.

I don't work any extra duty btw... bug ger that.

Given that agency staff in the NHS are paid more than their permanent counterparts then I'd be skeptical of that claim.  And bank staff weren't employed on extra duty.  They were employed as bank staff, so the same rate as other permanent staff, ie less than agency staff.

 

Teaching has the same predicament but obviously on a less intensive level as fewer teachers are required to run a school than nurses are to run a hospital but the principle is the same.  A school spends a fortune on agency staff, who earn more than permanent teaching staff, to cover staff sickness, etc.  Had I chosen to be an agency teacher I could have earned £100 a day just as an NQT and I qualified five years ago.  (However, I had one day as an agency teacher and hated it so never did it again)

[Robin Evans]

But bank rate attracts emplyer pension contributions and other add ons where agency doesn't. Not that I'm that ar sed about labouring the point

Personally I think when all is considered there is little difference as far as the impact on the balance sheet goes.

[ckn]

I've explained WHY there's a deficit and what caused it.  It's fact.  It's supported by the government's own figures, as pointed out repeatedly.  I've shown where the government have given official statistics on how many beds they've cut, fewer services offered and fewer core treatments given.

 

I was at a meeting on Monday with a Head of Immunology where they've been told by NHS England that they have until April to "transition" their service to GPs.  In other words, NHS England are cutting the service that provides basic immunisation to a large area of around 1m people and hoping that GPs will take the slack for no extra money.  Again, that'll show in 2016 in lower levels of immunisation and from 2018 onwards in higher levels of herd immunity failings, probably resulting in critical avoidable illnesses for children.

 

On the agency staff line, here's the official framework for NHS staff agency pay (Excel file).  If we need to go outside of that then we need to justify it to NHS England.  This matches the equivalent cost of a permanent member of staff plus employment costs (employer's NI, pension, etc) against a daily rate.  Column C is the permanent pay rate, column D is equivalent maximum hourly for an agency worker, column E is the maximum daily rate for an agency worker.

[Saintslass]

But bank rate attracts emplyer pension contributions and other add ons where agency doesn't. Not that I'm that ar sed about labouring the point

Personally I think when all is considered there is little difference as far as the impact on the balance sheet goes.

That is contrary to evidence.  Permanent staff attract employer pension contributions, etc, and yet agency staff still get paid more so I reckon just employing more permanent staff but in a bank would cost hospitals less because there would be no agency fee to pay.  Given the amount of agency staff that every hospital uses, that could work out to be a tidy sum saved on the balance sheet.  I would suggest the government thinks along similar lines as they have now capped agency worker pay.

 

During my present short term employment I have chatted with an agency nurse on the bus in a mornings.  She is going home after night shift.  She expressed disappointment that her earnings were going to drop to those of permanent staff now that the government's cap has been introduced. 

[Saintslass]

I've explained WHY there's a deficit and what caused it.  It's fact.  It's supported by the government's own figures, as pointed out repeatedly.  I've shown where the government have given official statistics on how many beds they've cut, fewer services offered and fewer core treatments given.

 

I was at a meeting on Monday with a Head of Immunology where they've been told by NHS England that they have until April to "transition" their service to GPs.  In other words, NHS England are cutting the service that provides basic immunisation to a large area of around 1m people and hoping that GPs will take the slack for no extra money.  Again, that'll show in 2016 in lower levels of immunisation and from 2018 onwards in higher levels of herd immunity failings, probably resulting in critical avoidable illnesses for children.

 

On the agency staff line, here's the official framework for NHS staff agency pay (Excel file).  If we need to go outside of that then we need to justify it to NHS England.  This matches the equivalent cost of a permanent member of staff, employment costs (employer's NI, pension, etc) against a daily rate.  Column C is the permanent pay rate, column D is equivalent maximum hourly for an agency worker, column E is the maximum daily rate for an agency worker.

On agency staff, I am quite sure all hospitals will have justified their pay rates to agencies with NHS England whenever they have needed to.  I know it to be a fact that agency workers are paid more than permanent NHS staff as I have known a number of nursing agency workers.  They used to be paid more.  They will not be in future because the government's cap has now come into play.

 

As for immunology, are you talking there about things like booster jabs?  Because to be honest I have only ever had them either at school or at my GP.  When I was going to visit Africa I had my immunisations at my local GP practice, and that was in 2007.  So if we are talking about the same service then this is the first I have known about such services being offered outside of GP surgeries!

[Robin Evans]

Back in the day when I used to do bank shifts... I got paid much more than agency...

Largely due to the supply & demand economics.

Few people on agency are LD & up to date with C&R.... so I used to cover on bank but only at my own pay grade....

More than agency.

Like I say.. that was back in the day...

It's bin a long while.

[Saintslass]

Back in the day when I used to do bank shifts... I got paid much more than agency...

Largely due to the supply & demand economics.

Few people on agency are LD & up to date with C&R.... so I used to cover on bank but only at my own pay grade....

More than agency.

Like I say.. that was back in the day...

It's bin a long while.

Well yes, that's it.  The same applies to agency workers.  Supply and demand.  The agencies could basically charge what they wanted, which they did, and the hospitals went along because they either had no choice (because they needed cover) or they weren't creative enough or managed well enough or a combination of those or other factors.  The government has stepped in though and asserted control which it had to do because things were getting ridiculous.  People should not be earning more than permanent staff and nor should private companies be making profits out of those earnings at taxpayers' expense.  At least with the old banking staff tradition the people earning the extra were already permanent staff but a contemporary scheme may simply employ roving nursing staff which probably couldn't cover all areas of nursing as some are more specialised obviously but it might help.  Either that or maybe better staff management is needed. 

 

Either way, and to bring this discussion to a close from my POV, capping the rate of pay for agency workers across the board can only be a good thing for hospital budgets.

[ckn]

On agency staff, I am quite sure all hospitals will have justified their pay rates to agencies with NHS England whenever they have needed to.  I know it to be a fact that agency workers are paid more than permanent NHS staff as I have known a number of nursing agency workers.  They used to be paid more.  They will not be in future because the government's cap has now come into play.

 

As for immunology, are you talking there about things like booster jabs?  Because to be honest I have only ever had them either at school or at my GP.  When I was going to visit Africa I had my immunisations at my local GP practice, and that was in 2007.  So if we are talking about the same service then this is the first I have known about such services being offered outside of GP surgeries!

It's one thing that the current government are trying to stop, the rather silly agency rate inflation.  All Chief Executives will have had face-to-face meetings with NHS England where they will get increasingly tough meetings the more agency staff they have outside of Framework rates.  It is something that I know that there are league tables comparing like against like for non-Framework contractors as a ratio of total staff in each organisation.  If you're in the bottom half of the list then you're getting the tougher meetings and a few have been put on official performance warnings because they're not fixing the problem fast enough.  The CEs that have tried to beat the system have all been found out and appropriately "managed".  I know the contractor returns I have to do each month for my service and it's a real PITA of a system but I fully support it.

 

On immunology, this is the service that chases the herd immunology targets for entire areas.  Pushing schools, nurseries, religious groups and so on.  This is the service that will tell your GP when your children are due their innoculations and chase them to do it.  This is the service that looks at long-term trends and tries to fix them.  Without this service, your GP will only do the basic stuff, if they remember and if you're a good patient who goes along when they're told.  This is something that a GP surgery would never be able to do because they're largely a reactive service, relying on outside stimuli for virtually everything they do.

[Saintslass]

On immunology, this is the service that chases the herd immunology targets for entire areas.  Pushing schools, nurseries, religious groups and so on.  This is the service that will tell your GP when your children are due their innoculations and chase them to do it.  This is the service that looks at long-term trends and tries to fix them.  Without this service, your GP will only do the basic stuff, if they remember and if you're a good patient who goes along when they're told.  This is something that a GP surgery would never be able to do because they're largely a reactive service, relying on outside stimuli for virtually everything they do.

Presumably then the government is going to make GP surgeries accountable for ensuring immunisations are undertaken?  I didn't know about this plan but certainly on the surface it seems like a logical plan.  GP surgeries, along with schools, are the key places where immunisations take place - and at least I now know we weren't talking about the same thing! - and so it seems perfectly sensible to make the places where the service is provided accountable for providing the service?  Or am I missing something?  (Probably!)

[Trojan]

Given that agency staff in the NHS are paid more than their permanent counterparts then I'd be skeptical of that claim.  And bank staff weren't employed on extra duty.  They were employed as bank staff, so the same rate as other permanent staff, ie less than agency staff.

 

Teaching has the same predicament but obviously on a less intensive level as fewer teachers are required to run a school than nurses are to run a hospital but the principle is the same.  A school spends a fortune on agency staff, who earn more than permanent teaching staff, to cover staff sickness, etc.  Had I chosen to be an agency teacher I could have earned £100 a day just as an NQT and I qualified five years ago.  (However, I had one day as an agency teacher and hated it so never did it again)

But the "ringfenced" budget has not been growing at the rate it should have done to keep up with demand and with health inflation.  You can say what you like, under Labour health spending, rightly or wrongly increased and the service got better - immeasurably better, under this government in real terms health spending has at best stood still and the NHS is declining.  All this deficit guff is just that.  We've run a deficit in this country for years under governments of both parties.  It goes down in good times and up in bad, that's how things should be.  This government under the pretense of reducing the deficit is actually shrinking the state.  That's what they believe in.  Now I don't agree with that policy, but fair enough if that's what they want to do why can't they come straight out and sell it to the voters instead of pretending?

[ckn]

Presumably then the government is going to make GP surgeries accountable for ensuring immunisations are undertaken?  I didn't know about this plan but certainly on the surface it seems like a logical plan.  GP surgeries, along with schools, are the key places where immunisations take place - and at least I now know we weren't talking about the same thing! - and so it seems perfectly sensible to make the places where the service is provided accountable for providing the service?  Or am I missing something?  (Probably!)

Yes.  The GP contract has immunisation written into it, it has had this for a long time.  As a passive service.  GPs can remove patients from their list who won't give their children innoculations.  That completely misses the point of having a proactive service that goes into all the little community groups, drives peer pressure, drives the GPs to get their patients served rather than abandoned.  It's what has the herd immunity of the country at the level it is and this will fail.