I’ve been confused about what’s happening about the coroners’ service for some time, so I appreciate a House of Commons Research briefing which explains what’s going on.

It seems to have been a right lash-up. The present proposal is to have an Office of the Chief  Coroner as part of the Department of Justice, without having a chief coroner, whose functions will be spread around various senior judges. The previous government legislated, and most people involved supported it, to reform the system for doing coroners’ inquests in the Coroners and Justice Act 2009. The present government cut an important aspect of the reform, having an Office of the Chief Coroner, on what seem to have been mainly financial grounds – they also have some objections in principle. The House of Lords, set onto this issue by Baroness Finlay – good old Ilora – is there anyone else in the House of Lords that concerns themselves with death and dying issues? – put a stop to this by re-writing the government’s proposals. The government is now making new proposals to fit in with this which seem to involve doing as little as possible. The junior minister, Jonathan Djanogly, is trying his best to make sure that change will be as little and cost as little as he can achieve. He is still facing more or less universal opposition from everyone who actually knows anything about it.

Why is this minor issue so important that it has achieved a government reversal in the House of Lords and a general outcry? It seems to be informed mainly by a cost-cutting mentality rather than actual governmental ill-will. Djanogly is a rich man revealed by the Guardian as having a conflict of interests in cutting legal aid, since it might potentially make even more money for his insurance interests. This is because it would mean that people have to enrich the insurance companies by insuring themselves against the need to take legal action to enforce their rights. It also means stopping poor people from having the chance to go to law to stop rich corporations and the like from oppressing them. The Guardian report here: http://www.guardian.co.uk/politics/2011/sep/16/conservative-mp-legal-aid-cuts, but they’ve been harping on about it over the weeks as they find out more about Mr Djanogly; you can find a small item about him most days in the Guardian it seems, often linked to Dr Fox and his demise as a cabinet minister for conflicts of interest. However, as with the coroners’ service, his main aim seems to be saving money on legal aid; just the same with coroners reform.

There also seems to be a bit of a ‘what do we need to enforce all these rights for?’ mentality, too.  Being mainly very rich men (and not having very many women who have to deal with the realities of life even in rich men’s families’), Cabinet members cannot quite get their heads round the fact that people who don’t have public school accents and friends in high places often have problems in getting big corporations and governments to do the reasonable thing. While I don’t suspect actual antipathy to coroners, I think there is a coherent attitude within the present government that says all regulation of what big corporations and governments do is just trouble-making red tape and better got rid of. And you can’t help noticing that coroners have occasionally been critical of government actions, for example in Iraq and Afghanistan. It is noticeable that in transferring some chief coroner functions to the Lord Cief Justice (who is expected to delegate them – beneath his notice presumably) that the immediate training needs mentioned about about sevrice personnel. Perhaps the coroners can be trained into doing what the government wants. Having most of this function within the Ministry of Justice, alongside people whose main job is supporting the government view on things, is hardly creating independent judicial review in a service that looks at how people have died when they die in suspicious circumstances. You may have forgotten that this slow-moving reform has partly come about because for a long time nobody noticed Dr Shipman killing an awful lot of his patients.

Checking that there is no funny business in how someone has died is, or should be, very important to everyone; and the government too. And palliative care social workers will be only too well aware that bereaved people often value the public review of the death of their loved one as a way of setting them on the path to renewal of their lives after what is for them often a very difficult experience.

As Baroness Finlay pointed out, making coroners more efficient and giving them training ought not to be a big thing, indeed it’s rather obvious. But the previous government planned to put them into a Ferrari administration at vast expense, rather than the old banger of an administration that most palliative care social workers experience. One understands that being an independent judicial officer requires good administration around you, because you have to respond competently to problems. However many millions for setting up the office does seem a bit over the top.

You can get to the briefing paper here: http://www.parliament.uk/briefing-papers/SN05721; it shows you how to get in touch with the campaigners if you should want to, and it shows you what a Ferrari administration can do in supporting people; would that we all had a House of Commons library to help us in knowing what is going on.

And I’m back to the publication of my new book in the US by Lyceum Books (UK next year from Policy Press):

Citizenship social work treats older people as equal citizens with everyone else, not as irritating past-its dependent on care from others. That means age-proofing universal services, such as leisure centres, so that older people can use them comfortably, and mainstreaming older people into all sorts of other provision from which they are excluded. It means a working so that creative personal development is still possible even for older people and we do not take for granted that they are a burden on the young.

There are lots of practice things that you can do with older people to help them be fuilfilled human beings. If only 20% in their 80s have some dementia, it follows that 80% are not mentally frail. Why not act as though all older people are capable of self-fulfillment?

Readers in the Americas can get it from the publisher: http://lyceumbooks.com/CitiznshpSclWrkwOldrPpl.htm

Readers in the UK, Europe and the Commonwealth will eventually be able to get it from Policy Press early next year (I’ll remind you when):

http://www.policypress.co.uk/display.asp?K=9781447301271&sf1=contributor&st1=Malcolm%20Payne&m=4&dc=6

I’m back after working abroad for a few weeks, and I notice that the Department of Health website now has a tag cloud: see the picture:

So you see ’social care’, let alone ’social work’ there? Or ‘palliative care’? Or ‘end-of-life care’? Or ‘older people’? Clearly none of that bothers the DH.

A local newspaper reports on compensation for people with learning disabilities cared for by a Cornwall healthcare trust: £6.5m for the institutional abuse they suffered, added to £1.47m they were awarded a while ago because the Trust (strange word for it in the circumstances) misspent their personal money on its own activities. Things are better in those services after five years, say the Trust, and the deal means that it won’t go to a big trial which would cause further delays. However, you still have to ask why it has taken so long to come up with compensation and why it was not obvious immediately that the people concerned were being mistreated and cheated and therefore that such costs accumulated.

What is the moral compass of people who are working in care services? Why does it so often seem to require scandals, inquiries and compensation to lead to improvements and change? A generation or two ago, there were many scandals about ill-treatment in long-stay hospitals, leading to a development in community care. A while later, there were scandals about people not being properly cared for in the community. It seems that wherever vulnerable people are being cared for, abuse arises.

Does vulnerability in people always lead to their exploitation? Perhaps not inevitably, because my experience in social work is that many people care amazingly well and selflessly for their family and friends. But it seems that some abuse will always arise, because there is a long-term history of abuse by parents and carers. Does having care services always mean a proportion of people will be abused? If it seems so, what can we say about human beings? Can we assume that caring is integral to humanity? The example of the development of hospices and more recently trying to improve end-of-life care perhaps suggests that it is. But it seems to be a constant struggle to preserve caring for people when they are vulnerable, so is exploitation of vulnerability also a commonplace characteristic of humanity? More so than caring?

I suppose many religions have always said that achieving good is always a struggle for human beings individually and collectively. Why is that? And if it is true, how should we structure caring services to deal with that?

The newspaper story: http://www.thisiscornwall.co.uk/NHS-abuse-victims-win-pound-6-5million-pay/story-13342698-detail/story.html

The recent Report by the National Audit Office on personalisation and social care provides lots of useful information, and also a thoughtful critical review of the issues in the developing social care sector. Its main focus is whether local and national oversight is sufficient to ensure that needs are met and personal budgets are not misused. It comes to the conclusion that the government doesn’t have much in the way of levers to manage situations that go wrong, and there are insufficient resources to move in and take over if a major supplier goes bust. It was also hard to find care providers who could deal with very complex needs and getting advice and support for care users in setting up and managing their care was also difficult.

This bit includes a brief study of the collapse of the main national private provider of care homes, Southern Cross, recently. It confirms what we already knew, that this was mainly because its private equity owners sold its property and leased it back a few years ago.  This is a typical manoeuvre by private equity companies, whose job is to squeeze the assets of the companies they own to get as much money out of them as possible. It has led to the downfall of a lot of retailers because they have too much debt to cope when market conditions get tough. The report makes the point that care homes and the care sector generally are not good candidates for this, because they have high fixed costs anyway, and if there are fewer people using them (because local authorities and other funders won’t pay or they come up with other options, which they will because this is policy), there will be more competition with other providers, fees will go down, and losses start to accumulate. Will we see less private equity involvement in the care sector? Don’t bet on it if there is money to be made: this should be restricted in the cause of quality care.

Another feature of the social care system that makes a market system a poor way of providing is a comment made on p 28:

From a consumer perspective, the care homes market has some characteristics of an inefficient market:
Entry into a care home is often unplanned and can be made in response to a specific event (such as a hospital admission or the death of a spouse).
By definition, switching rates (choosing to switch care home) are very low, and consumer research commissioned by the Office of Fair Trading suggests that it is considered to be a last resort by most residents (it can often adversely affect residents’ health).
As is the case with most care services, buying a care home place is inevitably an ‘experience good’, meaning that the consumer cannot really tell their satisfaction until it has been experienced.

There are also difficulties in getting new entrants to the care market, for three reasons:

Providers struggling to recruit staff to cover isolated and sparsely-populated rural areas.

High rent costs in some urban areas.

The challenging nature of care work, often unsocial hours, and relatively low levels of pay. (p 31)

To deal with this they recommend:

Subsidising adviser posts in voluntary sector advice and support providers.

Helping new small providers and social enterprises to enter the market by making local authority tendering and contracting processes more flexible and less burdensome for small providers.

Providing advice and in some cases limited financial support to help new small-scale care businesses enter the market.

Of course, they could come to experienced high-quality care providers like hospices, and get them to enter the social care market; this is happening in some areas.

Interestingly, an ADASS report on how things were developing suggests that most of the development is not in direct payments (the government’s and enthusiasts’ preference for the future of user control) but managed budgets (you get allocated a budget, but the local authority or some friend of the local authority – their tame voluntary organisation – manages it for you. This may be realistic, but it may signal the end of the shift to giving people government cash for care. Or it may mean there is going to be a hiatus while people get the confidence to move on again.

One of the things to ask is why the government is so keen on giving away its money in cash – generally treasuries don’t like allowing real people to get their hands on government cash; it means things can get out of control. The answer is two-fold: the politicians like it because people like the flexibility and control, so there is positive feedback in social care, an area that often gives problems rather than positives to government, local or national. The other answer is that the present political elite would like to have a functioning system of vouchers or something like to show that it can work. In most other areas where it is politically important to right-wingers to displace publicly funded services (health and education) vouchers have been shown not to work. So here the treasury (local and national) view may accord with the political view: by developing managed budgets, they can hang on to control while offering the semblance of giving user control. I’m a bit doubtful whether, in the long-term and covering every service user across the country, managed budgets will give real user control. The advisers and managers of the budgets will not have the incentives in the local government system (where not giving out money for any purposes if at all possible is totally ingrained) to be creative in getting imaginative ideas from service users and implementing them. They’ll fall back on standardised responses. So much more convenient and manageable.

The Report doesn’t get stuck on whether user choice is desirable and is actually enhanced; in general it follows government policy in thinking that it is. However, there are different views in different sectors of the population who might use personalised social care. Older people are less enamoured, although in general a majority of all sorts of service users thought that their mental well-being was improved and they achieved support that met their needs.

The Report at: http://www.nao.org.uk/publications/1012/oversight_of_care_market.aspx?dm_i=4O5,JGIK,UF1K0,1L8WB,1

National Audit Office (2011) Oversight of user choice and provider competition in care markets: Report by the Comptroller and Auditor General (HC 1458). London: TSO.

In an interesting literature review on citizen participation, Paul Sanderson implies a lot of thoughtful criticism of the ‘participation at all costs’ brigade. His work suggests that we have to be careful of assuming that citizens participating in official decisions is always a good thing. It depends on how you organise it and what they are participating in. There’s a bit of a critique of the Arnstein ladder of participation, presented as the way to understand participation in a lot of social work literature. This puts ‘citizen control’ at the top of the list, and ‘therapy’ near the bottom alongside manipulation as a form of non-participation. This is simply silly: they are different things to be used for different purposes, and Sanderson accurately reports the criticism that its use represents a political preference for particular forms of participation.

Sanderson distinguishes, in the context of the Conservative ‘Big Society’ policy between participation (like clients sitting on a committee to write a new social work course), co-production (being involved in delivering services, like clients being involved in training social workers) and ‘co-regulation’ (being involved in checking that services are OK – like clients being involved in validation of social work courses). Sanderson points out the ‘democratic deficit’, that increased efforts to get citizen participation in all sorts of activities is going alongside a marked reduction in people taking part in elections and voting, which you might call full democratic participation. Democratic systems are obviously not working, so we look for other forms of participation. There is then a problem about representativeness, but this also exists in elections. As societies get increasingly diverse, broad elective mechanisms are never going to get at the potential range of interests. People interested in politics tend to bemoan reducing involvement in political activity, but in my view this reflects the reality that traditional politics no longer represents and interests people. So what do you do?

Why do citizens get involved? Sanderson says this is for a variety of reasons. People who are keen on participation will tell you it is because they want change: maybe, but some forms of participation also give people advantages, and they get involved for that reason. It’s often said that the reason why complaints systems are important in health and social care is that it allows people to contribute to improvements in the services that they have experienced. This is self-serving managerial nonsense, although you sometimes hear it from self-justifying reports about people complaining about their local hospital ‘nobody should experience again what we went through’. The reality is that, like me, most people dine out on hair-raising stories of incompetence – it gets good laughs – but think the shambles is probably unreformable, because of all the barriers in the way. The way to get change in our society is to attach money to it. You get your money back if the train is late; you get compensation if you can prove they made a mess of it. That is the real way of getting managers moving: their budgets are suffering. This is why you get all this government whining about the ‘compensation’ culture; it puts  a bit of pressure on to change.

Sanderson is all very rational and evidence-based, and what he makes clear is that you have to think who you want to be involved, how you can do that, what yopur aims are and what their aims are – do you want them to describe their experience and express their views? Or do you want them to take part in some deliberative process that can contribute to your policy? My experience of health and social care is that politicians think only they have the right to make policy, but increasingly the democratic deficit means that their right is leaching away. And a lot of managers would rather be waterboarded that have real people involved in suggesting to them what they might do (let alone getting involved in regulating their outcomes).

And sometimes with good reason. One of the very useful points that Sanderson makes is that you have to decide on the role of research evidence, professional expertise and knowledge of the full situation in making decisions. Frankly, a lot of the time, citizen opinion is just plain wrong, based on inadequate evidence, unworkable and participation is timewasting. So the message of this report is to think very carefully what and how, and with what useful outcomes, you are going to encourage citizen participation, and plan accordingly. You also need to look at how you are going to balance the different types of people involved and their influence on the final decision. It is also worth thinking about whether it is important to engage with the stakeholder in a decision (who may be self-interested), or with people who are not very affected by it (who may be more independent, but are less likely to be bothered to get involved – as the government is finding in its desire to pass planning decisions on to local groups – they say why should we do a planning official’s job for them?). And also that the evidence that it is useful in achieving the objectives that people set for it is a bit thin, although decisionmaking, service quality, and sense of community are all enhanced by at least some forms of participation in some circumstances.

Sanderson, P. (2011) The Citizen in Regulation: A Report on the Evidence Base for The Local Better Regulation Office. Cambridge: Centre for Housing and Planning Research University of Cambridge.

On the internet here: http://www.lbro.org.uk/docs/citizen-in-regulation.pdf

The National End-of-life Programme newsletter caught my eye by looking at end-of-life care and the environment. There’s a new publication, also involving the King’s Fund:

National End-of-life Care Programme (2011) Routes to Success in end of life care – achieving quality environments for care at end of life. London: Department of health.

http://www.endoflifecareforadults.nhs.uk/assets/downloads/RTS_Environments_final.pdf

It identifies five elements to think about: natural environment (there should be lots of it; that means wood and leaves), first impressions (should be good), comfort, privacy and dignity, spiritual spaces, spaces for relatives and friends and facilities for dealing with a death when it occurs.

So far and so obvious, although it does spell these out in more detail which might give you some clues about how to go forward. Then there are case studies, for example an overpromoted garden shed with nice chairs and lighting in some hospice’s yard: it also does help you with making the best of an unfortunate starting point. The result, looking at the pictures, is nice, in the way that my very traditional English teacher would not have wanted me to use the word ‘nice’.

Actually, the overpromoted shed reminded me of an innovation from Southern Rail in my home station, Sutton. Not content with the slotted metal seats we usually sit on, even indoors, to reduce vandalism, it has introduced three wooden seats built out of wooden lego, in a circle and out in the open. All its other seats are under cover. I have yet to see anyone sitting on this structure, even at rush hour. I can only think that this ‘quality environment’ is designed to compensate for the waiting rooms that they have turned into offices and store rooms for their vanishing staff in recent years; I’m not sure whether they are truly vanishing, or are they just vanishing into the offices?

The connection in my mind is the strange architectual belief that bizarre wood structures make for nice. Not, I think, necessarily. This further reminds me of Sutton Council’s refurbishment of our main street: sensible, but what I’m sure any landscape architect would describe as old-fashioned. seats – they actually had armrests at each end – were replaced by an architect-inspired version of a seat: a log on two short legs with a metal bar a third of the way along as an armrest. When one of our older citizens sat on an early version (they’ve had to be redone) the log came off the legs and rolled away, central Sutton being somewhat hilly, the citizen being carted off to hospital. These are not comfortable, and any person with a normal-shaped bottom could tell they’re not comfortable. Why do the landscape architects want us to put up with them?

OK, I don’t mind nice and St Christopher’s has been working hard at modern nice for a while now with some smart but possibly not altogether person-shaped consequences, but most people die at home, with pressurised relatives and inadequate domiciliary care (they’re not home helps any longer, so it might not be cleaned), with not a lot of space and if you live in the centre of most cities, not a lot of nice.

Let’s not talk about lovely hospices and leafy walls, let’s talk about how most people can die not in grotty general hospital wards or their corridors and how their dying environment in their own homes can be made nice, because a lot of the homes I’ve visited as a social worker are not nice and cannot be made nice. We’re perhaps a bit too keen on supporting people’s wish to die at home. When home is a studio flat in Southwark, some hospice nice is a good move; a point which  perhaps the palliative care world (which does nice quite well) should make a bit more firmly.

This post looks at the House of Commons discussion about the Health and Social Care Bill on 6th September. As usual, a lot of what was going on was detailed technical stuff, but the first day of it was mainly about privatisation and competition, including the removal of the ‘private patient cap’ (the limit on the proportion of income-earning private patients a Foundation Trust could have). This is relevant for social workers because if the critics are right, poorer people who only have access to the NHS rather than the cash to buy what they need, or a job that gives them health insurance, are likely to find it slower and longer to get their healthcare than they have become used to in the last few years because priority will be given to privatecare and money-earning

It is relevant for palliative care and social work  for the main reason that the debate was not about what is most important. Most important are the increasing number of older people who are getting more frail and approaching the end of life, and have other long-term conditions. All this debate was mainly about political views about whether increased competition and increased private providers will be good for more effective care. No doubt there will be more private providers and and more competition if the Bill in its present form passes, because everything about the government’s and the Secretary of State’s attitude suggests that this is important to them and it will therefore happen by hook or crook. This is what happens in our poitical system: the people in power get their way by swinging the system slightly in favour of the things they want; not that increasing the private contribution was much less important to Labour’s health tsars during the period of the last government.

It does not seem that there will be much protection for the increasing population of older frailer people and others who will need longer term care. The debate did not address that directly. Therefore we can expect their position to worsen; care for them will slow up and go missing. Any amount of coordinating less money will not solve that. The likelihood is, however, that what one minister said will also be true: most long-term health providers will not be doing a lot of private patient stuff so nothing much will change for most people with long-term care needs. They will be getting the best they can out of a slowly-deteriorating system that does not take much priority political notice of their needs, while the whizzies with their acute care will be making money from the people who can and who want to pay, for the people who want to get more money for being involved in healthcare.

Some of the debate was about balancing competitiveness with collaboration; critics think the government has still not ensured that collaboration is more important than competitive markets. And that’s really important for palliative care patients and social work service users who also need a good NHS service

Most of the huffing and puffing frankly sounded like old-style political skirmishing over very little, rather than transformational change for the people palliative care and social work deal with: see what you think [my comments in square brackets].

The first group of amendments were about the vexed question of whether, to what extent and in what ways the government’s aim was to privatise the NHS. You can see this debate at:

http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm110906/debtext/110906-0001.htm#11090649000003

It was tetchy. The Secretary of State discussed five main changes about this. The first issue was what would happen if a service (such as a foundation hospital) went bust.

First, the Bill puts clinically led commissioning at the heart of securing high-quality services for local populations. It is therefore right that commissioners should have a leading role when continuing access to services is threatened. Our amendments therefore strengthen the role of commissioners. For the first time, commissioners will have an explicit role in working with Monitor to agree plans to secure continuity of services. [Continuity of services means carrying on with providing somehting if the healthcare provider - eg the local hospital - collapses in debt or for some other reason.]

Secondly, commissioners will need to be supported in acting with providers to ensure that they have access to the scope, quality and choice of services they need. It is about promoting high-quality, effective and integrated services, as set out in clause 58. This will be the task of Monitor. If need be, when continued access to services is threatened because of failure occurring in a particular provider, Monitor will have a range of actions it can take. For example, it could take action to secure sustainability of essential services by adjusting prices. This would be necessary where a provider is otherwise unable to cover the costs of essential services—for example, because of lower patient volumes in more remote areas of the country.

Thirdly, if a provider gets into significant difficulties, we have provided Monitor with powers to be able to try to turn around the provider. The aim would always be to support the recovery of the provider, wherever this was possible. Specifically, the amendments require Monitor to maintain an ongoing assessment of risk to the continued supply of NHS services. Monitor must then intervene proactively to help a provider to address problems and, where necessary, agree contingency plans with commissioners.

Fourthly, we have put in place provisions to deal with the rare event of a provider no longer being sustainable in its current form. In that instance, the priority must be to secure continued access to the services patients need. [But not, you notice, continuation of the present provider, so if my local Hospital goes under they can call someone else in; possibly one of their private friends] This protection is particularly important in relation to foundation trusts, which of course are the principal providers of acute, emergency and specialist hospital services.

Fifthly, it is essential that political accountability runs through what hon. Members will all know is central to our responsibilities to our constituents. Our plans therefore strengthen political accountability at both the local and national level. At a local level, the amendments enhance democratic legitimacy by extending local authority scrutiny to all NHS services [this could in the end, if the local councillors and their, mainly social care, advisers do a good job of demanding a health service that is locally responsive and integrates with social care - they could push NHS people to respond to local social care need better, rathre than accepting this constant winge that social care does not help meet NHS objectives]. That is in contrast to previous proposals, where only designated services would have been subject to such scrutiny. At a national level, we will establish a process for the Secretary of State to veto proposals, in individual cases relating to unsustainable foundation trusts, if he decides that they do not secure continued access to NHS services and, as a last resort, to intervene where he believes that the NHS commissioning board or Monitor has failed to discharge its functions.

This is the comment from Frank Dobson, the former Labour Health Secretary:

To ask the essentially collaborative health care system in this country to turn over to being competitive is a bit like asking the Meat and Livestock Commission to promote vegetarianism: it is simply not what people want to do; it is not their approach and nor should it be. It remains the case that Monitor is still rigged in favour of promoting competition. Let me point out…that clause 58(3) states:

“Monitor must exercise its functions with a view to preventing anti-competitive behaviour in the provision of health care services for the purposes of the NHS which is against the interests of people who use such services.”

However, it does not say that “Monitor must exercise its functions with a view to preventing competitive behaviour in the provision of health care services which may be against the interests of the people who use such services”. Apparently, then, there is a basic, intrinsic and fundamental assumption that competition must be beneficial and non-competition must be harmful. If the Government say that Monitor is neutral, it should be given a neutrality in respect of competition and non-competition. …the unfair competition of some of the independent treatment centres was harmful to and threatened the services provided by neighbouring NHS hospitals. There is clear evidence here of problems within the private sector.

I recall that, a few years ago, United Health—a subsidiary of the US United Health—took over three GP services in my constituency. It bid that it could provide the range of services for less than the local GPs, so it got the contracts. It has not complied with all the conditions that were set, but in the end, the primary care trust decided that it could not take it to court because it would be such a lengthy and expensive exercise and it feared that the PCT might not win. Not content with that, United Health recently announced that it was selling the franchise to another private outfit. It did not consult the staff. It did not consult any elected local representatives—neither myself nor councillors. Above all, it never consulted the patients. These private sector outfits regard patients as part of the chattels that they can dispose of to maximum benefit and maximum profit.

That illustrates the fact that if we are to have contract-based provision of services, a huge amount of lawyer effort will be put into trying to draw up watertight contracts. What one lawyer thinks is a watertight contract, another lawyer will make a leaky contract by puncturing a hole in it, and we will go over to the system in the United States, where zillions of dollars are spent on court challenges or settlements with the providers of health care.

Furthermore, there is virtually no major American supplier of health care that has not been indicted for defrauding federal taxpayers, city taxpayers, state taxpayers, doctors or patients—and sometimes all five. I thus asked the Secretary of State whether he would rule out giving any NHS contracts to any organisation that had been indicted for defrauding people in another country. He gave me about a page-long answer, which could be summarised as, “No, he would not rule them out.”

We are thus talking about the possibility of European competition law being used to force our Secretary of State to allow people to give contracts to American companies whose greatest claim to fame is that they have defrauded innumerable Americans. I think that that is intolerable. I would have thought that all these anti-EU Conservatives would have found it rather embarrassing to think that European law was going to be used to allow fraudulent Americans to get contracts working in our national health service. All those things, however, will be possible under the system proposed by the Secretary of State.

Liz Kendall (Labour) made some related points:

The Bill establishes Monitor as an economic regulator, modelled on the same lines as those for gas, electricity and railways. The explanatory notes make this explicit. Page 85 states that clauses in part 3 are based

“upon precedents from the utilities, rail and telecoms industries”.

Indeed, in an interview with The Times earlier this year, David Bennett, the new chairman of Monitor, confirmed that that was the Government’s plan, saying that Monitor’s role would be comparable with the regulators of the gas, electricity and telecoms markets.

Labour Members have consistently argued that such a model is entirely wrong for our NHS. People’s need for health care is not the same as their need for gas, water or telecoms. There is a fundamental difference between needs, ability to benefit, the complexity of services and the fact that they are far more interlinked. The NHS is not a normal market. It is not like a supermarket, or like gas or the railways. There are much more important issues at stake.

…The Bill will guarantee that the NHS will be treated as a full market, and the providers of services will, for the first time, be treated as undertakings for the purpose of competition law. The Secretary of State said that the Bill would not increase the applicability of competition law, but the Minister of State confirmed it when he told the Committee:

“UK and EU competition laws will increasingly become applicable…in a future where the majority of providers are likely to be classed as undertakings for the purposes of EU competition law, that law…will apply.”––[Official Report, Health and Social Care Public Bill Committee, 15 March 2011; c. 718.]

Andrew George (Labour) talked about some of the amendments he had proposed:

That said, the purpose of my amendments…is primarily to ensure that Monitor’s role to ensure that anti-competitive behaviour is kept in its box is balanced by looking at the impact of competitive behaviour that might undermine the ability of NHS services to collaborate. The underlying purpose of amendments 1207 and 1208 is to neutralise or balance the new duty on Monitor to prevent anti-competitive practices that are against the interests of the people who use the services—in other words, patients—by also applying a duty to prevent anti-collaborative practices that would have the same effect.

…we need to ensure that we sustain the essential services. …certain services clearly need to integrate. An example is acute emergency trauma centres. If the orthopaedic, paediatric or ophthalmology services were removed from such essential centres, their ability to deal with a wide range of emergencies would be fundamentally undermined. They serve populations of between 250,000 and 500,000 people—sometimes more—and they are absolutely essential. We must ensure that we do not end up with a regulator that allows them to be undermined by imposing a duty on them not to act in an anti-competitive manner.

The House then went on to discuss the private patients’ cap. Emily Thornberry (Labour) made the crucial point:

…Baroness Williams…wrote an article…in which she says:

“One thing that remains…is the decision to lift the cap on private beds in foundation hospitals. Not only could that mean that many of our finest hospitals would gradually become private, it also means that inevitably foundation hospitals would be subject to European and British competition law.”

…the argument is about whether we should have a cap or not. If the House votes tonight to lift the cap, our constituents will ask how it can be that their representative has voted for a clause that allows private patients to fill up the national health service hospital paid for by those constituents’ taxes so that they will be pushed out of it.

The Health Minister Simon Burns defended the proposed change:

The cap is arbitrary and unfair. Several NHS trusts that are not subject to the private patient income cap have private incomes well in excess of many foundation trusts. Last year, four of the top 10 private income earners were NHS trusts—that is, without a cap. A few FTs have high private incomes simply because they did a few years ago. The cap locks FTs into keeping private income below 2002-03 levels and means that last year about 75% of FTs were severely restricted by caps of 1.5% or less. Meanwhile, patients at the Royal Marsden benefit from its cap being 31%, and it has consistently been rated as higher performing by the Care Quality Commission [part of the reason for this is that the RM does a lot of research and the cap allows some research and other activity].

…FTs will retain their principal legal purpose—to serve the NHS. This means that the majority of their income will continue to come from the NHS. With no shareholders, any profit they make will have to be ploughed back into the FT, and so will support that purpose of caring for NHS patients. The vast majority of FTs have little, if any, potential to increase private income, never mind the desire to do so. For them, NHS activity will remain the overwhelming majority of the work they do, if not all of their work. It is extremely unlikely that even the most entrepreneurial FTs with international reputations would seek to test the boundaries. Their commissioners, public and NHS staff governors would hold them to account in fulfilling their duties and serving their NHS patients.

Caroline Lucas made the ideological point:

I find it unacceptable that taxpayers’ money has ever been used to allow private patients to jump the queue and use NHS facilities. The history of the cap was all very interesting, but the bottom line is that it serves an important purpose, which is why it should stay. The Government argue that income from private patients is put back into the NHS and ultimately benefits the health service, but the reality is that when people become ill and need treatment, it is hard to justify asking them to wait longer because capacity in our NHS hospitals is being taken up by private patients. The bottom line is that an NHS hospital has to treat NHS patients, and I do not believe that we have adequate spare capacity sloshing about in the system to justify private queue-jumping into NHS hospitals.

…It is often argued that foundation trusts are about choice, but I would argue that such private treatment should be offered only when there is surplus provision in the system. It is one thing to talk about a choice of general goods and services, but it is enormously inefficient and massively costly to apply that kind of mentality to the health service. Now, we see the present Government trying to use the model introduced by the previous one to allow foundation trusts to do as they please, and lifting the cap on the income that can be derived from private sources.

The hundreds of constituents who are contacting me about this do not want private queue-jumping; they want NHS services paid for from taxation. The future of the NHS should be about developing whole systems, not isolated institutions, and private health care in the NHS should be phased out. The NHS needs to be about building networks across professional and institutional boundaries, not about creating new barriers. It needs to be about IT and information sharing, not reducing connectivity, and about getting more people treated in the community and in primary care.

Chris Leslie made an important follow-up clarification:

Long waiting lists matter because they are also the lifeblood of the private medical industry. We need only look at the advertising slogans of many private medical insurers to see how people with promises of “speedy service” and “getting your health situation sorted out quickly”. This, however, can happen in the context of NHS hospitals.

What we must do is ensure that we put the needs of NHS patients first. My worry about removing the private patient cap is that it changes the incentives relating to how the foundation trusts will work, putting revenue generation ahead of patient treatment. The allure of revenue will, of course, be there, but keeping waiting lists high is, in a sense, part of ensuring that revenue continues to come in. I want to see trusts focused absolutely and completely on reducing waiting times.

And just so you don’t think I only go on about what the government does, I’ll say something about social work next. I looked at the NCPC and Help the Hospices websites to find something to write about there, but they all seem to have been on holiday. I hope that doesn’t stimulate a response from either or both telling me about loads of things they’ve done recently; it’s not obvious from the websites, guys.

You’ll have gathered that I have not been on holiday. It’s the conference season, and I have five lectures and two papers to give this month, which is why posts from me have been hard to find recently. In preparation, I’ve been looking at a book published (in America) for the ‘Global partnership for transformative social work practice, education, and inquiry’. Sounds great until you realise that it has two papers not from north America, both from senior white academics, Nigel Parton from the UK and Mel Gray from Australia, previously South Africa. Both significant ‘thought leaders’ but hardly signifying a ‘global partnership’ (Sorry about that, it’s a new bit of jargon I’ve found in an American book review).

You have to wonder whether the Americans have found Africa, Asia and Latin America yet, in spite of the claim of their educational validating body (CSWE) that social work courses in the US have a ‘global perspective’ and the proliferation of American texts on some variety of international social work.

I won’t dignify the book by a citation. Perhaps they need to recognise that there are some thought leaders elsewhere in the world.

The Department of Communities and Local Government caught my eye by issuing its ‘best value document’, even though it’s in auterity black and white, having chopped a load of lengthy documents from the previous government. This tells us that if local authorities want to cut voluntary organisations they should consult them early, give them three months notice of the actual cut and incorporate their ’social value’ in their decision. It mentions the national and local compacts, which regular readers know I think aren’t worth the paper the government emailed them on.

This is the definition of ’social value’:

…social value is about seeking to maximise the additional benefit that can be created by procuring or commissioning goods and services, above and beyond the benefit of merely the goods and services themselves.

Under the page on objectives (actually there’s 100% more on their objectives and 50% more on a smarmy message from the Minister than the actual text of the guidance) it says:

We want to encourage public agencies and civil society to collaborate more, including greater involvement for voluntary and community organisations…

None of which leads me to believe that anyone commissioning anything from government will think of anything other than the financial interests of their own organisation. I wonder what the NHS policy is.

You can see the guidance here: http://www.communities.gov.uk/documents/localgovernment/pdf/1976926.pdf (but just you try quoting it to them as they cut you).