Vital decisions about the structure of our NHS are increasingly being taken with little or no evidence to back them up, writes JOHN LISTERTHE brutal face of so-called “Devo-Manc” proposals to integrate healthcare with what’s left of social care budgets in Greater Manchester has been exposed by the decision to strip emergency surgery from six hospitals — Wythenshawe, Tameside, Wigan, Bolton, Bury Fairfield and North Manchester.
These cost-driven cuts follow on the downgrading of Rochdale Infirmary and Trafford General, and raise questions over the future of A&E and maternity services at all six hospitals — potentially the biggest round of A&E closures ever in the NHS.
The Manchester hospital cuts are just one of a number of almost identically argued schemes that have taken shape in England — across London, Leicestershire and many other areas.
All of them have their roots in the aftermath of the banking crash of 2008, which threatened an end to a decade of yearly above-inflation increases in NHS spending.
The Labour government turned in 2009 to US-based management consultants McKinsey for proposals to on how to bridge a projected cash “gap” of up to £20 billion by 2015.
However any discussion of the potential huge savings of billions from scrapping the bureaucracy of the new competitive market system in the NHS, ditching private providers and tackling the various rip-offs in the private finance initiative was, predictably, excluded.
Instead McKinsey came up with a “report” consisting of 124 PowerPoint slides, which offered no coherent argument but a series of assertions, few of which were backed up by evidence, and none of which were seriously analysed to show potential costs and disadvantages.
A major focus, now to be found in every local plan for cuts, was the call to reduce demand for healthcare by keeping people healthy, tackling factors that can lead to chronic health problems such as obesity and smoking — none of which can produce short-term savings.
Today’s NHS England boss Simon Stevens is a fan of these ideas — but George Osborne has other ideas. He just slashed £200 million from an already pathetically small budget for public health services, making health promotion an even less likely route to savings.
McKinsey also proposed shifting health services out of hospitals to “lower cost settings” — which it claimed could save £2.7-£4.1bn.
A shift to self-care and chronic disease management was expected to save up to £2.5bn, while “reconfiguration within local health economies” (hospital closures) was said to save up to £1.6bn, plus up to £600m from “estates optimisation” (flogging off the vacated buildings).
All of these figures appeared to have been simply made up, with no explanation of how these changes were to be achieved.
Despite the vagueness of the proposals, NHS managers — egged on by McKinsey and other management consultants and assisted by Department of Health and external spin doctors — have since produced plans based on many of the same flawed assumptions.
Back in 2012, McKinsey director Penny Dash admitted at a “community-based care workshop” that “there isn’t very much evidence based about models of community care” — the very models McKinsey has been urging local health bosses to adopt.
In fact the evidence is stacking up to show that all of the big ideas being promoted by those trying to create a McKinsey-style “compelling story” and present a “case for change” share three important qualities — they lack any substance in reality and offer little if any cash saving. But all of them offer years of lucrative work for management consultants.
The first, and biggest, deception is the idea that by switching services out of hospitals it’s possible to make big savings.
One of the most advanced schemes of this type is the so-called Shaping a Healthier Future project in west London, which aims to close four A&E units and two whole hospitals (Ealing and Charing Cross).
It was initially promoted in 2012 as a £190m scheme to help save £1bn from spending. Since then the scheme’s cost has already escalated five-fold to £1bn — with no clear explanation of where the money might come from, or what the final plans might be.
There’s equally little evidence for David Cameron’s pet project — seven-day working in the NHS.
Recent experiments in the provision of seven-days-a-week access to GPs have resulted in schemes costing up to three times more than they claim to “save.”
In Manchester, just 65 per cent of the extra GP appointments were taken up, and the extended service reduced A&E attendance by a feeble 3 per cent — all of them minor cases.
Elsewhere 7/7 pilot schemes have cut back on extended evening access to GPs and some have closed Sunday sessions completely after finding far lower than expected patient demand.
The evidence that cost savings come from developing out-of-hospital initiatives in primary care and community health services is very limited.
Repeated studies have shown there is no substance to claims from McKinsey and others that hospital admissions could be reduced and costs cut by the superficially attractive idea of concentrating extra resources on patients at high risk (cynically dismissed by NHS bureaucrats as “frequent flyers” because they are often admitted to hospital).
In fact high-risk patients make up less than 2 per cent of hospital caseload. Focusing resources on them diverts GPs and other staff from other patients’ needs — and leaves the needs of the 98 per cent unchanged.
A Nuffield Trust study last year came to similar conclusions. The BMA is calling for other costly pilot projects on reducing hospital admissions through such measures to be scrapped since they are doomed to fail.
The buzzword of the moment — the call for “integration” of health and social care, trumpeted by ministers, Labour politicians and by Simon Stevens — has come under scrutiny. Again there is no evidence it can deliver the expected efficiency savings.
Last year, for example, the Commission on Hospital Care for Frail Older People, set up by the Health Service Journal, concluded it was a “myth” that measures such as the “integration” of health and social care and improved services in the community would reduce the need for hospitals or bring cash savings for the hospital sector.
Agreeing that improving community services was desirable, the report argues that this could only delay rather than avoid the need for hospital stays.
“The commonly made assertion that better community and social care will lead to less need for acute hospital beds is probably wrong.”
Better social care is perhaps an even more remote prospect than better community health services. Social service spending has been battered by the huge cuts that have cut local government budgets by 45 per cent since 2010, and is set for similar-sized cuts in the next five years.
Indeed there is little in the way of social care left for the NHS to integrate with. What remains is restricted to the patients with the most severe problems, leaving nothing to support those with moderate needs or provide preventive support to those with lesser problems.
Numerous studies have also challenged the core McKinsey/government argument for the “consolidation” of A&E services into fewer “major units,” leaving only urgent care centres, offering limited hours and services.
Studies by primary care specialists have concluded that most of the people who attend A&E do need to be there, shooting down the assertion that the majority are inappropriate attenders or simply minor cases.
A 2009 report commissioned by the Department of Health from the Primary Care Foundation specifically challenged “widespread assumptions that up to 60 per cent of patients could be diverted to GPs or primary care nurses,” and argued that the real figure was as low as 10-30 per cent.
A report last year for the King’s Fund also concluded that “a proportion of A&E attenders can safely be seen in community settings, but there is little evidence that developing these services in addition to A&E will reduce demand.”
In any case, the cost savings from diverting A&E patients to other services are negligible. Care in other settings is only marginally cheaper — and requires investment.
The NHS spends less than 3 per cent of its budget on A&E, so even closing all of the remaining units would go nowhere near to solving the NHS cash crisis, which stems not from excess use of A&E but the political decisions of Osborne to cut NHS spending as a share of GDP.
In practice A&E cuts serve a different purpose, as a prelude to hospital cuts and closures.
Shifting care out of hospital to expanded primary care or community healthcare has also proved impracticable — there is a national shortage of GPs and practice nurses, worsened by 2010 cuts in training places.
Primary care budgets have been squeezed even more tightly than hospital budgets.
There is no funding available, no plans and no serious commitment to develop expanded community services — and even if there were, it would not save any money.
As the picture of chaos grows, the deliberate effort to undermine confidence in the NHS has been intensified by Jeremy Hunt’s outrageous attack on hospital consultants.
The constant, complex reorganisations and policy initiatives are fragmenting the efficient, publicly owned and run NHS into a myriad of piecemeal contracts, while the pressure to “integrate” with social care poses a major threat of the introduction of charges for care and the erosion of our NHS free at point of need — now the Secretary of State no longer has any duty to provide healthcare.
It’s never been more important to fight back against every cutback, every closure and every privatisation. The next few years will be crucial in the battle for the NHS, and for its reinstatement. We need to build the biggest, strongest campaign to make sure we have a chance to win.
John Lister is director of Health Emergency.
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